Aiming to be ‘the Best at Getting Better’
Quality improvement is a strategic commitment at Cincinnati Children’s Hospital Medical Center. The 475-bed hospital and academic medical center seeks continuous quality improvement to improve patient safety, outcomes and experiences. Spurred by the Institute of Medicine’s report highlighting deficiencies in the health care industry, the organization embarked on its quality transformation in 2000.
“We recognized that we were asking good providers to function in an environment that was full of barriers and inefficiencies,” says Jim Anderson, president and CEO. In response, the organization overhauled its care processes, placing emphasis on patient-centered care and evidenced-based medicine. The strategic plan identified six improvement priorities that mirror the IOM quality aims: access, flow, patient safety, clinical excellence, reduced hassles and team well-being.
“We want to be the best at getting better,” says Lee Carter, chairman of the board. To that end, the organization adopted the Model for Improvement supported by the Institute for Healthcare Improvement to serve as a basis for all quality improvement activities. The model helps identify areas for change, set goals and determine the appropriate course of action. The organization is the only children’s hospital to receive a Robert Wood Johnson Foundation Pursuing Perfection grant.
Once an area is identified for improvement, a multidisciplinary team is created to pinpoint the problem, develop solutions and oversee the transformation process. Currently, there are 18 teams focusing on operational issues, such as supply chain management and family-friendly billing, and clinical issues, such as medication safety, access and nosocomial infections.
Each team is assigned a “cabinet champion,” a clinical leader or senior executive, who meets with the team on a regular basis and facilitates the process by identifying resources, eliminating barriers and sharing results throughout the organization.
The process promotes incremental change so that employees are not overwhelmed. But it also broadens the scope of quality improvement by involving individuals at varying levels within the organization.
“We’ve accomplished a tremendous amount of change, but we aren’t done by a long shot,” says Tom Boat, M.D., chairman of the department of pediatrics and the research foundation. “The difference for quality improvement is that you have to work as a team. It’s increased interaction and created a more stimulating work environment.”
The Business Case
In addition to adopting best practices from within the health care field, Cincinnati Children’s looks to other industries for examples. CEO Anderson does not have a health care background; previously, he worked as a business attorney in a large law firm and served four years at the senior executive level for an electronic manufacturing company. The latter experience, in particular, provided some valuable lessons.
“The culture placed a great emphasis on quality, taking cost out of the process and improving efficiency. The same principles can apply to health care,” he says. “These principles are essential for every high-performing organization to embrace.”
Cincinnati Children’s puts a lot of emphasis on making the business case for quality. “Obviously there’s a moral case for quality,” Carter says. “We believe there is a business case as well.” The finance department has a financial analysis unit, led by Anderson and Scott Hamlin, the senior vice president and CFO, that examines the economic impact of quality improvement projects. The results are used, in part, to help prioritize improvement projects.
“The market desires the highest value at the lowest price. I believe that’s our responsibility,” Hamlin says. “I can’t think of any other industry where you’d have to have the discussion about whether there’s a business case for quality. It’s absurd.”
As an example, he cites initiatives that affect a large percentage of the organization’s young patients, including those with respiratory illnesses such as asthma. Efficiencies and improvements in care not only can enhance patient outcomes and experiences, but also can reduce visits to the emergency department and hospitalizations. It also frees up resources so clinicians can research and treat rare, complex childhood diseases.
“You need superior outcomes to get patients to go to Cincinnati Children’s over other organizations,” Hamlin says. One indication that the philosophy works: In 2005, the medical center treated patients from 40 states and 37 countries, according to its Web site.
Family Matters
Ensuring a positive patient and family experience is a priority for Cincinnati Children’s. Pediatric care demands a high level of family involvement and the organization strives to meet the cultural, psychological and spiritual needs of a highly diverse constituency. Physicians and staff members confer with the youngster’s parents or guardians at all junctures of the process, and respect their decisions about the course of treatment.
Parents are encouraged to participate in family-centered rounds and can request a clinical care conference with the care team to discuss details and concerns about their child’s treatment plan.
The medical center also maintains a 24-hour-a-day visitation policy.
A 40-member family advisory council provides input on a variety of topics, including renovations, amenities, new service lines and patient care concerns. Finding volunteers is no problem.
“There are always more people who want to participate on the committee than spaces available,” says Bill Kent, vice president of patient care services. “Families want to feel that they are making a contribution to Children’s.”
Driven by Data
Good, solid data is the key to Cincinnati Children’s efforts to improve quality—and to demonstrate how well it is doing in key performance areas.
As part of the protocols they must follow, the process improvement teams research and choose evidence-based solutions to whatever particular issues they are working to resolve.
“One of our goals is to improve outcomes in care and to produce zero defects in care,” says Uma Kotagal, M.D., vice president of quality and transformation. “We use evidenced-based practices 95 percent to 100 percent of the time.”
Data also drives the medical center’s efforts to be more transparent both inside and outside the organization about the quality of its care. Benchmarking data is shared regularly with the board and throughout the organization.
Now the hospital is developing an Internet-based reporting system to share key performance measures with the public, including transplant outcomes and patient safety and satisfaction data.
“Transparency is necessary in order to be successful,” Anderson says. “It can be painful and awkward, but it’s an essential ingredient.”
Bronson Methodist Hospital, Kalamazoo, Mich.
Clear Goals and the Tools to Reach Them
At Bronson Methodist Hospital, quality is defined as providing excellence in every aspect of health care. The effort is driven by a thorough strategic planning process, the Plan for Excellence, that helps align individual and departmental activities with the organization’s goals.
The 343-bed hospital, located in Kalamazoo, Mich., has lofty plans: to become a national leader in health care and quality. Toward that end, it has set three strategic goals: clinical excellence, customer excellence and corporate effectiveness.
“In order to be the best, it starts with creating a culture that empowers employees to make the right thing happen,” says Frank Sardone, president and CEO. “It starts with education, setting up good processes and metrics to measure the results.”
The Plan of Excellence is designed to be accessible and applicable to all employees. Everyone receives a copy of it and it is displayed prominently throughout the organization.
Senior executives and organizational leaders work to translate the plan into actionable items for the individual and departments. “Everyone understands how what they do every day impacts the strategic plan,” Sardone says.
For example, the organization set a goal to eliminate ventilator-associated pneumonia. The measure became a part of department scorecards and all the appropriate employees were instructed about what they could do to prevent VAP from occurring in patients. Since the initiative, the organization has seen significant improvements in all of its ICUs; the pediatric ICU, in fact, hasn’t had a case for more than 18 months. Employees can earn up to $300 in gainshare bonuses each quarter when department and organization goals are met.
Proof that Bronson is well on its way to becoming a quality leader was its winning a 2005 Malcolm Baldrige National Quality Award. Bronson leaders say that the Baldrige criteria continue to guide their quality initiatives. “We want to set a very clear vision,” says Jane Janssen, director of clinical operations improvement. “That’s one thing we’ve done well.”
Katie Harrelson, vice president of patient care services and chief nurse executive, says the Baldrige program provides a solid framework. “When we started using the Baldrige criteria, it was like putting glasses on so we could focus and do what’s right for Bronson,” she says.
Measurement is a critical component in the Baldrige process and in Bronson’s quality efforts. “You manage what you measure, ”says Scott Larson, senior vice president of medical affairs and chief medical officer, and it’s a motto that the hospital’s leaders take very much to heart.
Bronson relies heavily on benchmarking and comparisons to pinpoint areas for improvement. “We have a very keen awareness of our performance and outcomes,” Larson says. The executive team, for example, reviews organizational performance scorecards on a weekly basis and tracks the number of atypical events that occur within the organization.
In addition to measurement, Bronson actively seeks input from its more than 3,000 employees to identify quality concerns and recommend solutions. Sardone and Harrelson hold quarterly open-office hours to encourage employees to tell them about their concerns. “Every time I have them, the day is filled with visits from employees,” Sardone says.
Harrelson says the open-office hours are “a great opportunity to personally connect with the individual. It provides feedback to the executive team about what’s going on in the organization.”
Employees can also express their concerns through a patient safety hot line.
In addition to using Baldrige criteria, Bronson participates in the Robert Wood Johnson Foundation’s Pursuing Perfection program and the Institute for Healthcare Improvement’s 100,000 Lives Campaign, and it seeks to address all of the Institute of Medicine’s quality aims.
One area the organization has designated for improvement is day-to-day input from patients and families. Bronson has an active family advisory council, conducts patient satisfaction surveys and asks patients and families during daily rounds whether or not their care has met expectations. “We want to identify every aspect that will help us provide the best care,” says Harrelson.
Bronson attributes its successes, in large part, to the commitment of its employees to quality improvement. “Whenever we realize gains in performance, we celebrate,” Larson says. “And, we face the facts when we don’t make our goals. We collaborate and raise the bar. It’s become infectious.”
Strong staff involvement is essential, Harrelson notes. “We’ve worked for a long time to create a sense of engagement and to demonstrate to our employees the value in providing quality,” she says. That includes better staffing ratios due to low turnover, better patient outcomes and satisfied customers, she says.
“Our employees, physicians and volunteers are what makes this place spin,” Sardone says. “They are our best asset.”
Baptist Memorial Hospital for Women, Memphis, Tenn.
First, Engage the Physicians
Engaging the medical staff in quality improvement efforts has been a priority at Baptist Memorial Hospital for Women since its inception. Even before the 140-bed facility opened its doors five years ago, physicians had been integrally involved in the planning process, including the design of the facility and what service lines should be offered. More than 20 multispecialty physicians participated in a committee that met monthly with the architect, hospital leaders and staff representatives. Hospital leaders, in turn, visited physician offices to share plans for the facility.
The result: The physicians have a powerful connection to the hospital and a commitment to make sure it achieves the highest quality of care possible. “I’ve been in the hospital business for 35 years and I’ve never seen a medical staff so willing to step up and take the lead in quality efforts,” says CEO Anita Vaughn. “They really feel a sense of ownership.”
It’s especially remarkable considering that all the physicians who work at the hospital are from private practice, notes Carol Thetford, R.N., chief nursing officer. “That’s a hard group to get engaged,” she says.
Doctors demonstrate their sense of ownership through their enthusiastic participation in department meetings and quality improvement initiatives. OB department meetings are generally attended by no fewer than 25 physicians, out of the 100 obstetricians who attend at the hospital. “At other hospitals, we’d see one or two physicians in attendance,” Vaughn says. “It’s hard to get business done and move forward without good attendance.”
Baptist Women’s defines quality as “the pursuit of process improvement and the attainment of best outcomes in clinical care, patient safety, customer satisfaction and the creation of an environment conducive to: no needless death, no needless pain, no helplessness, no needless waiting and no waste.”
The organization developed a “Quality Blueprint” that guides managers and staff in meeting the organization’s goals outlined in its strategic plan. All staff members are invited to participate in developing the strategic plan.
Clinical initiatives are linked to the Institute of Medicine’s quality aims. For example, participation in the Institute for Healthcare Improvement’s Transforming Care at the Bedside program is linked with providing equitable care. The hospital’s installation of a picture archiving communications system is linked with efficiency.
Patient- and family-centered care is evident throughout Baptist Women’s. The neonatal intensive care unit includes several sleeping rooms for parents so they can be close to their babies during critical times.
The unit also has a sibling visitation program. Patients’ brothers and sisters attend a class prior to visitation so they know what to expect. They also get a specially designed coloring book to help prepare them for the experience.
In the Comprehensive Breast Center, patients are assigned a nurse navigator when they receive an abnormal mammogram that will require a biopsy. The navigator helps the patient through the process, scheduling appointments and answering questions, and is present during the procedure. “The nurse navigators are there to hold the patient’s hand to guide them through the process,” says Cindy Beard, assistant administrator. “They help patients make decisions during a very difficult time.”
A patient diagnosed with breast cancer can have her case presented at a weekly, multidisciplinary breast care conference. The meeting is usually attended by between 15 and 20 physicians from chemotherapy, radiation and pathology, as well as other specialties. The physicians discuss each case that is presented and come to a consensus about an individualized treatment plan for the patient. Having so many physicians from so many areas review the particulars of her illness and how to treat it can be very reassuring to a cancer patient.
That sense of teamwork extends to the entire clinical staff. In a physician satisfaction survey conducted last year, 93 percent of physicians said they were satisfied or very satisfied in the level of nursing care provided at the hospital.
Baptist Women’s leaders agree that collaboration and involvement of the staff from all levels of the organization create a highly energized work environment. “Everyone is treated with respect,” says Joni Poynter, director of quality. “You don’t see staff walking down the halls avoiding eye contact, you don’t see administrators locked away in their offices. There’s a real sense of family.”
2007 American Hospital Association-McKesson Quest for Quality Prize® Applications
Applications for the 2007 awards are due Oct. 16, 2006 and can be found at www.aha.org/questforquality. For information, call (312) 422-2700, or e-mail questforquality@aha.org. The winner will receive $75,000 and two finalists will receive $12,500 each. Citations of Merit may be awarded recognizing other noteworthy programs. The awards are presented annually in July at the Health Forum and American Hospital Association Leadership Summit. The prize is supported by grants from McKesson Corp. and the McKesson Foundation.
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This article 1st appeared in the September 2006 issue of HHN Magazine.
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