AHA Awards
Quest for Quality Prize
2007 Winner I Columbus (Ind.) Regional Hospital
Resting on Laurels Is Never an Option
Columbus Regional Hospital’s goal is admirably immodest: “to be the best in the country at everything we do.” Executives and staff at all levels of the organization share the belief that there is always room to improve performance.
To that end, the 225-bed, county-owned hospital looks to national frameworks of excellence, including the Malcolm Baldrige National Quality Program and the Magnet status program of the American Nurses’ Credentialing Center.
“We want to measure against the best tools available,” says former President and CEO Doug Leonard. [In June, Leonard became president and CEO of the Indiana Hospital & Health Association, Indianapolis. He had been at Columbus Regional for 29 years, the last nine and a half years as president and CEO.]
Columbus Regional is the 2007 winner of the AHA–McKesson Quest for Quality Prize, which honors leadership and innovation in patient care quality, safety and commitment. The winner receives $75,000 and two finalists receive $12,500 each. This year, two citations of merit were presented.
Ten years ago, Columbus Regional’s senior leadership and physicians were engaged in a public dispute about the strategic direction of the organization. The hospital’s public image suffered and patient satisfaction scores fell from “average” to a low of 14 percent. When Leonard became CEO, his first priority was repairing the relationship with physicians and restoring the organization’s standing in the community.
He won over physicians partly through increased transparency. Doctors are now directly involved in the strategic planning process. The chief of staff attends every board meeting and at least one board member attends every physician executive meeting. “The board won’t meet unless the chief of staff is there,” Leonard says. “The physicians, and our nurses, know we are interested in things that are important to them.”
The improved relationships are sustained through a very structured process, says Thomas A. Sonderman, M.D., vice president, chief medical officer and patient safety officer. Physician leaders, board members and the executive staff attend a yearly leadership retreat to discuss strategic issues facing the organization.
The hospital formally adopted a mission that focuses on the patient and quality, and “that resonates with everyone,” Sonderman says.
To advance the mission, Columbus Regional embraces the Institute of Medicine’s six Aims for Improvement, which call for safe, effective, patient-centered, timely, efficient and equitable care. “We’ve been working for over a decade to build a platform for clinical quality excellence,” says Cherona Hajewski, senior vice president of patient care services and chief nursing officer. “We’re getting an understanding of best practice care.”
Education plays a big role. Among other things, a large group of employees each year—up to 25 at a time—attend the Institute of Healthcare Improvement’s National Forum. The group includes board members, senior executives, nurses and physician leaders. “It creates instant alignment,” says Sonderman. Everyone hears the same message and is able to meet and discuss the issues later. “It’s a team-building opportunity.”
Columbus Regional has invested heavily in technology, including implementing an electronic medical record, to improve efficiencies and patient safety. The information services department has grown from 13 employees in 1997 to 40 today. “IS exists to support the core business of patient care and our strategic objectives,” says Diana Boyer, R.N., vice president and chief information officer. All IT projects have a physician champion and an executive sponsor.
In 2006 and 2007, Colubmus Regional won Hospitals & Health Networks’ Most Wired Innovator Awards for an electronic medication reconciliation process and for a wireless communication and nurse call system, respectively. The medication reconciliation process improved timeliness, efficiency and patient safety by reducing the process from 42 to seven steps. The wireless communications and nurse call system allows patients, physicians and other care team members to contact nurses directly through portable phones. The system is integrated with an RFID tagging and bed turnover system. “We are really proud of the Innovator Awards,” says Leonard, “because they show how well our departments work together. There are no silos here.”
IT projects are no longer based upon what’s best for a department. “The first consideration is what’s best for the hospital,” says Ben Caughey, director of pharmacy services.
That’s generally the theme for all quality projects. “By taking care of the patient first, everything else falls into place,” says Leonard. Performance measures are shared throughout the organization, and evidenced-based processes and best practices are promoted to ensure an effective team approach to process improvement.
Since the dark days a decade ago, patient satisfaction scores have climbed above 90 percent. “We don’t accept status quo with the system,” says Kathy Wallace, director of medical quality management. Staff feel eencouraged to improve quality. “That assurance has led employees to provide innovative ideas to enhance patient care,” she says.
2007 FINALIST I Integris Baptist Medical Center, Oklahoma City
Transparency and Teamwork Drive Quality
The push toward accountability and transparency is driving quality improvement at Integris Baptist Medical Center. The 564-bed hospital is part of Integris Health, an 11-hospital system that posts quality, patient satisfaction and pricing data on its Web site for each of its facilities. “We are responsible to the community to be open about how we are doing,” says Stan Hupfeld, president and CEO of Integris Health. “We also figured out that what you pay attention to, you improve.”
Transparency has created a healthy level of competition within the system, Hupfeld says. Physicians see their performance scores benchmarked against their peers and each individual hospital sees how its results match up against others in the system. The incentives help achieve full buy-in from the medical staff, facilitate teamwork and keep things moving at a rapid pace, notes Charles Bethea, M.D., chief medical officer of Integris Heart Hospital, a part of Integris Baptist Medical Center.
Accountability is addressed, in part, through an internal pay-for-performance program. Compensation for senior executives, department leaders and managers is tied to clinical effectiveness measures. That program is being expanded systemwide so that every employee has a stake in quality performance. If each hospital meets its quality, patient satisfaction and financial goals, every employee will receive a bonus of up to 2 percent of their salary annually. “We hope to pay out every penny,” Hupfeld says.
Like every organization, Integris Baptist had to undergo a cultural transformation before it could achieve high performance. That involved a shift from a culture of blame to one of teamwork, built around evidence-based practices. James White, M.D., chief medical officer of Integris Baptist, helped create a “Framework for Approaching Patient Safety,” which outlined the steps in the organization’s pursuit of zero defects in patient care. The emphasis on transparency and accountability helped facilitate the process. “We were able to change the culture by showing what really matters,” says Bethea.
Quality initiatives, when appropriate, are built around disease management processes. That involves a thorough examination of the processes in place to identify ways to provide patient-centered care while also improving safety, effectiveness, timeliness and equity. The emergency department, for example, examined ways to better identify patients who are suffering heart attacks. Cardiac nurse specialists were assigned to the ED and patients presenting with chest pain now receive an EKG between five and eight minutes after arrival, down from between 12 and 15 minutes. The difference is significant, notes Bethea, adding that the change allows for faster intervention and will save one or two lives each year.
“That’s a strong motivation for clinicians,” he says. Based on the program’s results, the board supported hiring 4.5 full-time cardiac nurse specialists to provide round-the-clock coverage in the ED.
Integris Baptist has invested a great deal of time reviewing processes, and the work continues. The system is in the process of rolling out LEAN thinking to further improve efficiency and outcomes. The organization recently achieved Magnet status, which, according to Chief Nursing Officer Linda Merkey, has significantly improved nurse retention. Since the hospital first applied for Magnet status in 2003, nurse turnover has dropped from 14 percent to 8 percent, well below the national average of 20 percent.
A core aspect of quality improvement is continuous learning. In addition to education provided at the hospital and through attendance at seminars and meetings, employees can apply for six-month sabbaticals for extended education. The ED director, for example, attended courses at the University of Michigan to become certified in LEAN health care.
Despite its accomplishments, few employees would tell you they are satisfied. “We’ve worked really hard, but we always know we can do better,” says Susan Dragoo, vice president of quality and medical staff services.
2007 FINALIST I Cedars-Sinai Medical Center, Los Angeles
Departments Take the Initiative
To establish a culture of quality and safety, Cedars-Sinai Medical Center has adopted both a centralized and decentralized approach to process improvement. The 855-bed teaching hospital’s Strategic Plan 2006-2010 calls for superior quality, safety, service and value. Short-term goals are identified in the annual planning process and supported through rigorous data collection and analysis.
Hospital departments provide the background, data, analysis and skill sets to meet organizational goals, says Thomas Priselac, president and CEO. “Quality needs to be owned by the departments,” he says. “We have worked hard to make people see that quality is not the responsibility of the process improvement department.”
A comprehensive dashboard system helps executives monitor clinical outcomes and operational efficiency. All dashboard indicators have a dedicated owner who is responsible for review, assessment and improvement. The results are shared across the organization.
“We see process improvement as part of our work and what we do every day,” says Michael Langberg, M.D., senior vice president for medical affairs and chief patient safety officer.
The Data Provider Group, an interdisciplinary governing body, oversees data availability, integrity and usability. Data quality is assessed against eight measures: accessibility, believability, completeness, conciseness, and whether it is easy to understand, free of error, timely and value-added.
Crucial to the organization’s success is the so-called flattening of hierarchy that encourages all employees to generate ideas and participate in process improvement initiatives. “This is the only hospital that I know of where I can speak to the vice president of nursing on the same level,” says Dulce Baranda, R.N. “Every day, we see a member of leadership and we are encouraged to talk to them about our concerns.”
A team approach to care and process improvement is also encouraged. “Everyone who has to be in the room to make the right decision is in the room,” says Langberg. “The chain-of-command reporting process only creates problems.” Performance improvement initiatives are also carried out by multiprofessional teams. Clinicians participate in an MD-RN collaborative, deemed a best practice by the Institute for Healthcare Improvement. “There’s a wonderful, productive alignment between physicians, the medical staff faculty, nurses and other hospital staff,” says Mark Gavens, senior vice president for clinical care services and chief operating officer.
Cedars-Sinai received Magnet designation from the American Nurses Credentialing Center in 2000—the first hospital in California to do so. It’s also one of 13 hospitals in the United States to participate in the IHI’s Transforming Care at the Bedside initiative. The initiative taps front-line caregivers to identify and rapidly implement processes to improve safety and quality, care team vitality, patient-centeredness and value.
The systematic approach to process improvement is effective but flexibility is necessary to do what’s right for the patient. “We hold patient care in the highest regard,” says Priselac. “Some deviation is warranted. It reflects our desire to maintain personalized care.”
Citation of merit I Amarillo (Texas) VA Health Care System
Educating Patients
At Amarillo VA Health Care System, employees have a strong sense of duty to provide veterans and their families with quality care that is also compassionate, timely, efficient and ethical. “The reason we are here is because our patients have served our country,” says Andrew Stenhouse, M.D., chief of staff. “It’s an honor to take care of a lot of these heroes.”
The effort is bolstered by quality initiatives identified through the VA’s National Center for Patient Safety, including an electronic medical record and a bar-code medication administration system.
Patient education was quickly identified as an area of need. New enrollees and veterans new to the area are invited to attend patient orientation sessions designed to familiarize them with the system. The bimonthly orientation allows patients to meet face to face with patient advocates and staff from the pharmacy, administration and primary care. Staff provide an overview of services, answer questions and are on-hand for consultations. New patients are also presented with an orientation packet that provides information on eligibility, pain management, advance directives and privacy. “Our patients tend to be more prepared for their first inpatient visit if they attend the orientation,” says Barbara Moore, program specialist.
To further enhance patient education, Amarillo VA developed an electronic patient consent form that is being rolled out across the VA network. “It’s an outstanding tool for patients,” says Bruce Boland, clinical application coordinator. “It provides a thorough synopsis of what is going to happen and uses pictures to illustrate when applicable.” It also gives clinicians quick access to information, providing them more time for bedside discussions with patients.
Amarillo VA’s patient-centered care initiative also involves improving efficiency—for instance, discharge planning. A staff member visits the patient a day before discharge to review his or her status and determine if transportation is available, among other things, to ensure timely discharge. The teaching team conducts rounds each morning, starting with patients slated for discharge that day. Providing everything is in order, a team member signs the discharge order.
Citation of merit I McLeod Regional Medical Center, Florence, S.C.
Face to Face
Patient-centered care takes the spotlight at McLeod Regional Medical Center, through a data-driven quality-improvement process. When quality initiatives are selected, a root-cause analysis follows and physician-led teams identify and implement evidence-based practices.
The 453-bed tertiary and teaching hospital focuses on three to five improvement projects per quarter using the Six-Step Problem Solving Process, a precursor to Six Sigma. Outcomes are tracked and reported regularly. McLeod was one of seven organizations in the United States selected in 2002 to participate in the Robert Wood Johnson Foundation’s and Institute for Healthcare Improvement’s Pursuing Perfection initiative.
Senior leaders realized early how important it was for everyone to be involved in the pursuit of patient-centered care. Quality is considered a key business strategy and a top priority of the board and executive leadership. Quality initiatives are the first item on the agenda at board meetings and the discussion takes up half of each meeting.
Every day, a group of about 10 senior executives meets at 8:30 a.m. to conduct patient rounds. Each executive is assigned a particular area of the hospital on a rotating basis and visits three or four patients to discuss their experiences and their perceptions of quality. Afterward, the executives reconvene to discuss what the patients told them. The rotating schedule enables each executive to see the entire hospital within a two-week period. With an average length of stay of 5.5 days, half of all patients are visited by a senior executive during their stay. “It’s only in engaging and talking to patients that we can truly center our services around them,” says Donna Isgett, R.N., vice president of clinical effectiveness.
The process helps identify safety concerns and opportunities to improve patient satisfaction. For example, many patients complained about parking, so valets are now stationed at all entrances. Patients were also unhappy with food service. The dietary team now visits patients to review the menu and answer any questions.
The executive rounds also let senior executives see firsthand how employees are involved in quality management and listen to any concerns they may have. All employees are encouraged to report safety issues and share improvement ideas.
“We’ve spent a number of years working on quality improvement,” Isgett says. “We need to work on improving efficiency, which will only improve the safety and effectiveness of our processes.”
Prize Committee
Stephanie Alexander I Senior Vice President/General Manager, Premier Healthcare Informatics, Charlotte, N.C.
James Bagian, M.D. I Director, National Center for Patient Safety, U.S. Department of Veterans Affairs, Ann Arbor, Mich.
John Bluford I President & CEO, Truman Medical Centers, Kansas City, Mo.
Molly Coye, M.D. I CEO, Health Technology Center, San Francisco
Kathleen Jennison Goonan, M.D. I Executive Director, Center for Performance Excellence, Institute for Health Policy, Massachusetts General Hospital/Partners, Boston
Paul Hofmann I President, Hofmann Healthcare Group, Moraga, Calif.
Beverley Johnson I President and CEO, Institute for Family-Centered Care, Bethesda, Md.
Mary Beth Navarra, R.N. I Vice President and Patient Safety Officer, McKesson Corporation, Cranberry, Pa.
Eugene Nelson I Professor of Community and Family Medicine, Dartmouth Medical School, Hanover, N.H.
Jeffrey Selberg, Chairman I President & CEO, Exempla Healthcare, Denver
Ken Smithson, M.D. I Vice President Integration Services, Irving, Texas
Nancy Wilson, M.D. I Senior Adviser to AHRQ & CMS for Quality, Rockville, Md.
Staff
Gail Lovinger I Vice President, Association Governance, American Hospital Association, Chicago
Stephen Mayfield I Senior Vice President, Quality and Performance Improvement, American Hospital Association, Chicago
Kathy Poole I Director, Governance Projects, American Hospital Association, Chicago
This article 1st appeared in the September 2007 issue of HHN Magazine.
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