The Robert Wood Johnson Health Network has demonstrated marked progress since doctors from its hospitals and medical school began meeting to share advice on the quality of care.
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| Andrew Greene |
In 1995, founders of the New Brunswick, N.J. - based Robert Wood Johnson Health Network decided that physicians would ensure the success of the network's quality agenda. The idea was that a group of doctors from member hospitals and the medical school would act as an expert resource, source of collegial support and springboard for new ideas. The result is the Physicians Coordinating Council, an all-volunteer, physician-led committee. Members of the council include:
The physician coordinating council (PCC) is one of three network governance councils that help the network's hospitals achieve strategic goals. A nurse coordinating council (comprising chief nurse executives from each member hospital) and a chief executive officer committee (represented by each member's CEO) provide additional clinical and administrative support. Network bylaws define physician coordinating council membership, officer elections, voting resolutions, primary responsibilities and the relationship to the other councils and the Robert Wood Johnson Health Network board of directors. The PCC elects a chairman biannually by majority vote and meets monthly in a network office conference room.
PCC members are rarely absent at meetings. Although each physician in the room represents a hospital that competes with those of other PCC members, the mood around the table is one of collegiality. Here, away from their own hospitals, physicians openly discuss current medical and administrative issues, as well as current topics in medicine, patient care and hospital policy. They work collaboratively to help others resolve or tackle emerging issues in their own hospitals. PCC members also identify ways that the network can support processes and hospital quality initiatives.
While information sharing proves useful to its members, the PCC's main goal is to direct the network's Clinical Integration Program. The program is a systematic approach to improving quality in clinical outcomes (mortality, complications, procedure rates and length of stay), processes of care (evidence-based protocols), patient satisfaction and patient safety. PCC physicians approve the program's study topics and monitor results quarterly--critically analyzing the data for significance. They evaluate the validity of the topics selected for review. As stewards of their hospital resources, they focus on topics that will have the greatest impact on the largest populations.
From the start, PCC members realized that they needed valid, reliable and severity-adjusted data for the program. If the PCC was going to encourage hospital physicians to make changes in the way they practiced, they needed to address the "my patients are sicker" arguments. They also recognized the importance of setting performance benchmarks to measure progress. So PCC members reviewed software and recommended a national performance measurement system at all member hospitals. The network's board of directors endorsed their recommendation, and the system was installed at hospitals not already using it.
Initially, the Clinical Integration Program's quality studies focused on clinical outcomes, but the program expanded in 2001 to include evidence-based care processes that have become the standard of care for patients with myocardial infarction, stroke, community-acquired pneumonia, heart failure and risk of surgical infection--the subject for both state and national hospital report cards. In 2003, the Nurse Coordinating Council influenced the PCC to add patient satisfaction to the program. All network hospitals use Press Ganey's patient satisfaction surveys, and network scores as well as national and regional benchmarks are reported quarterly. This year, the program added patient safety practices based on the National Quality Forum's Safe Practices for Better Healthcare.
One type of report reviewed at PCC meetings is found in the chart below. Individual hospital and network aggregate clinical outcome rates are captured and compared against the severity-adjusted expected rates and the New Jersey state rates. The PCC currently monitors 31 outcome indicators, keeping track of the network's high-volume DRGs and procedures as well as national report card topics. The network gives special attention to 18 severity-adjusted indicators for which it uses a methodology to calculate expected outcomes based on each patient's acuity levels. Data trended from 1997 demonstrate the Clinical Integration Program's positive impact: 94 percent of all 31 study topics had improved outcomes, and 89 percent of the 18 modeled study topics had rates better than the severity-adjusted expected rate in 2003.
| Robert Wood Johnson Health Network |
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Performance Significance |
Needs Improvement | In the Range | Best Performance | ||||||
| Medical | Myocardial Infarction Mortality Rate |
O |
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O |
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| Heart Failure Mortality Rate |
O |
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O |
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| COPD Mortality Rate |
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O |
O |
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| Ischemic Stroke Mortality Rate |
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O |
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O |
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| Pneumonia Mortality Rate |
O |
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O |
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| Aspiration Pneumonia Mortality Rate |
O |
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O |
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| OB/GYN | Primary Cesarean Section Rate |
O |
O |
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| Total Cesarean Complication Rate |
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O |
O |
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| Total Vaginal Birth Complication Rate |
O |
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O |
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| Total Abdominal Hysterectomy Complication Rate |
O |
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O |
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| Surgical | Inpatient Surgical Complication Rate |
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O |
O |
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| Surgical Cardiac Complication Rate |
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O |
O |
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| Surgical Respiratory Complication Rate |
O |
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O |
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| Surgical Urinary Complication Rate |
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O |
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O |
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| Inpatient Laparoscopic Cholecystectomy Complication Rate |
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O |
O |
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| Other Appendectomy Complication Rate |
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O |
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O |
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| Inpatient Post Operative Hip Replacement Respiratory Complication Rate |
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O |
O |
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| Inpatient Post Operative Mortality Rate within 48 hours |
O |
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O |
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| % by Category | |||||||||
| Network Ratings - 2003 | 6% | 28% | 67% | ||||||
| Network Ratings - 1997 | 50% | 22% | 28% | ||||||
The chart shows network performance on the 18 modeled studies. Hospital performance is rated as either "unfavorable" (needs improvement), "as expected" (in the accepted range) or "favorable" (best performance). The rating group thresholds are determined through standard statistical computations. Scores in the "unfavorable" and "favorable" groups are significantly different from those in the "as expected" group at the 95th percentile confidence level of statistical certainty.
The chart's results confirm the high quality of care provided at Robert Wood Johnson Health Network hospitals, as 67 percent of indicators have statistically significantly better than expected rates. The network's compliance ratings with evidence-based care processes exceeded the state's overall performance. Patient satisfaction scores are better than the benchmark peer groups and are still improving.
The PCC's goal is to move all indicator rates to the far right (or "favorable") column. It uses a spotlight approach to performance improvement: Physicians from hospitals with exceptional performance share best practice strategies, and those that need improvement create corrective action plans.
The PCC does not advocate a prescriptive approach to performance improvement. Each hospital determines the best strategy for its individual culture. One hospital convenes a physician group similar to the PCC, with representatives from various clinical departments; another's chief medical officer meets one on one with medical staff members. The network and the PCC support its members' activities by providing consultations on policies, procedures, coding and clinical practices. The medical school presents programs on state-of-the-art medical practices and the latest technologies.
The PCC works collaboratively with other councils and has the authority to convene committees to ensure grassroots involvement in improvement initiatives. A newly formed network patient safety committee (a PCC subcommittee) is reviewing the initial results from member hospitals' patient safety surveys. All reports are available on the network's password-protected Web site, and hospitals use the information to communicate findings within their own organizations.
Continuous improvement in quality initiatives at the network's member organizations can be attributed in large part to an unlikely source--a group of physicians from competing hospitals who have the dedication and commitment to work as one highly effective team. The Physician's Coordinating Council is the driving force behind the network's shared vision of exceptional health care.
Andrew Greene is chief executive officer, Robert Wood Johnson Health Network, New Brunswick, N.J.
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This article 1st appeared on November 16, 2004 in HHN Magazine online site.
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