ABOUT THE AWARD
The American Hospital Association–McKesson Quest for Quality Prize seeks to raise awareness of the need for a hospitalwide commitment to highly reliable, exceptional quality and safe, patient-centered care, and to promote a systems-based approach toward improvements in quality of care. The winner receives $75,000; the finalist receives $12,500. For full criteria, visit www.aha.org/questforquality.
WINNER | VCU Medical Center, Richmond, VA.
At the Virginia Commonwealth University Medical Center, safety is “a very deliberate journey” that involves everyone from clinicians to maintenance staff, says hospital Chief Executive Officer John F. Duval. That journey began in 2008, when the hospital launched Safety First Every Day, a multiyear effort to “build the safest health system in America.”
The system had made some “remarkable” progress with quality safety initiatives beginning in 2003, says Duval, “but we weren’t making progress fast enough and broadly enough within the organization to reduce serious safety events.” Leaders began to look beyond core measures and health care-acquired infection rates, and realized a different approach was needed.
Safety First brought in best practices from two other industries highly focused on safety and reliability — nuclear power and aviation — basing its initiative on the science of safety to instill a culture of high-reliability health care. All hospital staff, from nurses and doctors to engineers and environmental service workers, now go through specialized safety training called Behavior Expectation for Error Prevention (BEEP). The four-hour training program teaches how errors and other safety events happen and ways to prevent them.
The hospital also began recognizing individuals on staff who stepped in to prevent serious safety events. Duval personally acknowledges each Safety Star’s contribution with a gold pin and a handshake, delivered on the floor where he or she works.
“Part of our behavioral expectation is to create what we call ‘situational awareness,’ ” Duval says. “The goal is to have 9,400 hospital employees looking out for things that might be serious safety events.”
They also began enhancing their common-cause and root-cause analyses, and sharing lessons learned from events more broadly. “We began internal transparency around serious safety events,” Duval explains.
Creating an environment in which employees feel comfortable reporting safety breaches is essential to VCU’s culture of safety. “We take the good things we do and the misadventures we have and hold them side by side, visibly across the breadth and depth of the organization,” says Ron Clark, M.D., the center’s chief medical officer. “We do that in a variety of ways, from posting infection rates and serious safety events on the walls of our clinical units to summarizing lessons learned from across the organization.”
Although “we’re all scientists in one way or another … accustomed to relying on data, numbers, trend lines — those sorts of things,” says Dale Harvey, director of performance improvement, “we found we had to really strongly supplement that with telling stories.”
They started with stories of incidents from other health care institutions, but “quickly moved to telling stories of things that went well and things that had not gone so well at our own institution,” Harvey says, adding that they did not name names “because we’re not focused on the individuals involved — this is about systems and processes and how we interact and work together. That’s really a key strategy for engaging people and helping them understand the why.”
The VCU Medical Center built in adult and pediatric early warning systems embedded in its electronic health record that signal the rapid response team to check a patient at risk. The systems use real-time clinical data from the electronic health records, look at a range of indicators and give each patient an overall score, which is then used to identify patients who require intervention and alerts the team to escalate care.
Safety First boasts significant successes. Since the program began, the hospital has tallied a 50 percent reduction in serious safety events, an 83 percent reduction in falls with injury, and a 35 percent increase in safety occurrence reporting. The health system also has seen an 88 percent reduction in infections overall in intensive care units in the past nine years. Rapid response team calls have increased from 25 during January 2010 to 144 for July 2013.
But safety isn’t the hospital system’s only priority. VCU is an inner-city tertiary care medical center, so equity of care among patients of different socioeconomic backgrounds is another important pillar of quality.
“We have a number of under- and uninsured patients who live within the shadow of our hospital,” Clark says. “For a decade, we have paid off our bottom line for those patients to have access to our community physicians who were close by our hospital so they could get primary care.”
A survey of the costs associated with Virginia Coordinated Care, the hospital’s program to serve 30,000 un- or underinsured residents, found that 10 percent of patients with significant health problems accounted for 80 to 90 percent of the cost of the program, Clark says. The hospital created a “complex care” program for 500 of the costliest patients, assigning each to a multi-disciplinary team that included a doctor, social worker and a clinical psychologist.
“The current model wasn’t serving them well at all,” he says. “We created something that hadn’t existed and were substantially able to improve their health and outcomes. The last couple of years, they’ve had dramatic reductions in hospitalizations and visits to the emergency department. It makes a huge difference in their quality of life.”
The health system partners with other organizations in the National Health Care for the Homeless Council. The Daily Planet Health Care for the Homeless provides a full range of health-related services to homeless persons in the greater Richmond area, and its Medical Respite program provides short-term residential care for these individuals so they can rest in a safe environment while accessing medical care and other support services.
VCU also has a strong focus on behavioral health for children, offering family navigators and open visitation, and bringing all parts of the community together to address children’s needs. Partnerships with clinics and other nonprofits help the system provide care for low-income and non-English-speaking patients.
Mindful that leadership should reflect the ethnically diverse population that the hospital serves, VCU has been working with the state legislature to increase diversity on its board. “We led out of the gate very deliberately with safety,” says Clark, “recognizing that today a lot of the things that happen don’t matter if you harm someone along the way.”
But it’s important not to be single-minded in the quest toward zero events of preventable harm. “Once safety was readily in place in people’s minds, we moved on to timeliness, effectiveness, efficiency, equity and patient-centeredness,” he says. “If you achieve constant excellence in all of those, you really do move toward a much more highly reliable care delivery model that defines excellence in the organization.”
Adds Duval, “We are halfway there, and in another decade, we will be halfway there,” as each success has brought increasing recognition of what is achieveable in a highly reliable organization.
The AHA-McKesson Quest for Quality Prize Finalist | Carolinas Medical Center–NorthEast
At Carolinas Medical Center–NorthEast, both executive and governance leaders are expected to be well-versed and hands-on in the day-to-day reality of hospital operations. For instance, each member of the hospital’s advisory board is assigned a month to go on rounds in a particular unit with which they are unfamiliar and then report to the group.
“I believe that the pace and the culture of the hospital around quality is set from our board and our senior leaders,” says Phyllis Wingate, division president for Carolinas Medical Center–NorthEast. “I think it’s very important for leaders to understand the goals and the aims, as well as to be visible and involved in quality.”
Strong partnerships between hospital administrators and medical staff leaders and specialists are also key, says Dan Hagler, M.D., the hospital’s chief medical officer. “We have nursing and medical staff members who are actively engaged, and that is woven into the fabric of the hospital — all the way up to our system board members, who are intensively focused on improving the quality and safety of care.”
Physicians are active in the decision-making process through an annual system-level quality goal-setting day and through the facility-level multidisciplinary service line teams, referred to as EAGLE (Executiving Actionable Goals Leading to Excellence) Councils. The councils comprise a physician champion and administrative leaders who look for gaps in service, and operationalize best practices in pediatrics, integrative medicine, cardiovascular, oncology, neuroscience, high-risk obstetrics, chronic disease management, sports medicine and orthopedics.
“There’s tremendous physician engagement here,” Wingate says. “That’s part of what’s unique about us, and also what drives our success. We give physicians a responsible role in the growth and development of the hospital in a structured way that management listens to.”
EAGLE Councils are unique to Carolinas Medical Center–NorthEast, but all 40 hospitals in the Carolinas HealthCare System share insights and innovations through QSOCs (Quality and Safety Operations Councils) and measure outcomes through Carolinas HealthCare System’s Dickson Advanced Analytics group and the CMS-authorized Hospital Engagement Network. “They are an internal learning collaborative where we learn best practices from each other across our system,” Hagler says.
For example, Carolinas Medical Center–NorthEast piloted a nurse-driven urinary catheter protocol developed by the Infection Prevention QSOC. The success of the pilot led to adoption by the Carolinas HealthCare System and helped to reduce the number of catheter-associated urinary tract infections systemwide. “There’s a lot of activity around quality and safety, and it’s heard across all of our organization,” he says.
According to Wingate, each EAGLE Council at Carolinas Medical Center–Northeast has made a contribution to the Institute of Medicine’s Six Aims. EAGLE Councils have made recommendations on everything from cardiac testing at night so that patients don’t have to wait for exams the next day, to implementing inpatient consult services and protocols that relate to improvement in care.
“Because physicians are so actively involved on these teams, they have broad knowledge about the clinical practice and where we should be working to make improvements in patient care,” Win- gate explains.
One EAGLE Council is focused on neuroscience. “We are a regional referral center for stroke, and the Neuroscience EAGLE Council has driven our stroke management and interventions to achieve top core measures and patient outcomes,” says Hagler. It is helping Carolinas HealthCare System to improve stroke network performance through early identification and prompt treatment for stroke patients.
Recommendations from the EAGLE Council led to the formation of a Family Advisory Council at CMC–NorthEast’s Jeff Gordon Children’s Hospital, part of Carolinas HealthCare System Levine Children’s Hospital network. Adding community members to the Family Advisory Council enables “us to get their views on how we are doing,” says Hagler.
Another example of where EAGLE Councils have had an impact is with the expansion of the hospital’s integrative medicine program. As a result, the hospital has employed an integrative nurse specialist, and the expanded integrative therapies have resulted in better pain management.
The implementation of Carolinas Medical Center–NorthEast’s Heart Success Clinic was prompted by a systemwide effort led by Sanger Heart and Vascular Institute to reduce health failure readmissions. In addition to their physicians, hospitalized patients are seen by a nurse practitioner, pharmacist, dietitian and nurse navigator, then set up for active outpatient visits and further management in the Heart Success Clinic. The program has reduced readmissions in that patient population by about 50 percent.
“Being part of the system brings us a lot of benefits,” Hagler says, explaining the medical center’s achievements in improving quality. Wingate agrees that Carolinas Medical Center–NorthEast benefits from the vast infrastructure of Carolinas HealthCare System, inlcuding its own Hospital Engagement Network, data analytics group and QSOC. “The high level of engagement from the local leadership helps drive quality at the bedside,” says Hagler.
Citation of Merit | University of Wisconsin Hospital and Clinics, Madison
At UW Hospital and Clinics/UW Health in Madison, the biggest quality leaps are happening around patient- and family-centered care. Patients and families are part of all major steering committees for big improvement projects, says Sue Sanford-Ring, vice president for quality and patient safety.
“We are currently working on a discharge improvement collaborative across all our general care units, and patient advisers worked with us in developing the approach,” Sanford-Ring says. “And now we’re rounding and they’re rounding with us. We’re talking with nurses and physicians, and patients and families to support the changes being made and to receive feedback on the impact. Our patient and family advisers are truly our partners — we can’t imagine it being any other way.”
One improvement that came out of the discharge collaborative was encouraging families to audio-record discharge conversations on their cellphones. “Our readmission rate is really good through the transitions of care work we’ve done, but we know discharge from the hospital is a really stressful time for patients and their families, and when they get home, they may not remember all of the details of what they need to do to care for themselves.”
A patient/family/staff steering committee spent many months making recommendations on the design of a new health care facility that’s scheduled to open in the summer of 2015 — from the size and layout of patient rooms and family areas to the parking structures and the grounds. “They’ve been involved in every aspect of the design of that facility,” Sanford-Ring notes.
The Health and Healing Committee includes staff, clinicians and patient family advisers — otherwise known as PFAs.
The committee successfully advocated for an outdoor healing garden, healthier food options and more integrative medicine offerings. Other accomplishments: health channels for television, Sound Health/Music as Medicine programs, a Health and Healing Resources website, quiet space for staff, a pet therapy program, an art therapy program, an annual Health and Healing Week and an effort to make inpatient units quieter.
PFAs are actively involved in a Teleheath Steering Committee, which is exploring new way to engage families remotely, and a shared decision-making work group, which aims to enhance patient and family roles in treatment decisions.
Citation of Merit | Medical University of South Carolina, Charleston
Developing a culture that encourages safe reporting, keeping clinical decision support tools up-to-date and leveraging academic resources form the foundation of Medical University of South Carolina’s substantial work around safety.
The results have been admirable: Since 2007, the hospital has seen an 84 percent reduction in central-line infections and a 52 percent reduction in ventilator-associated pneumonia.
The hospital began its safety work eight years ago. Early efforts centered on nurses, who provide 80 to 90 percent of direct clinical care, says Danielle Scheurer, M.D., the hospital’s chief quality officer. A nonpunitive workplace culture lets employees feel comfortable reporting their mistakes and creating behavioral standards to which everyone is accountable.
The hospital looks closely at not only how many safety reports it receives over time, but also what percentage are near-misses, and then tracks to see how the error occurred and how to prevent it in the future. “In a really good culture of safety, what you want is a high number of reports with a larger percentage of near-misses and a smaller percentage of patient harm,” Scheurer says.
For example, a near-miss might be when a nurse notices that the incorrect medication is in a patient’s medication drawer. “Nothing bad happened — she recognized it was wrong and the incorrect medication was never sent to the patient,” Scheurer explains. “But by reporting that, we track back. We consider that to be a very unsafe condition because on a different day or a different shift, that wrong medication might have gotten administered.”
Another priority has been patient-centered care. The hospital seeks advice from patient family councils on procedures, new initiatives, quality improvement tactics and patient education.
For instance, the councils recently were consulted on the hospital’s late-arrivals policy. It ultimately was amended so that clinicians rather than desk staff now make decisions as to whether to reschedule or see a late patient.
“We really lean on those councils to give us advice on what to do and how to do it,” says Scheurer. “I think we’ve made some impressive inroads.”
Citation of Merit | Richard L. Roudebush VA Medical Center, Indianapolis
At Richard L. Roudebush VA Medical Center in Indianapolis, improving the health status of veterans is a wide-ranging endeavor that reaches beyond the hospital walls, encompassing both the medical and nonmedical needs of individuals and enlisting a wide range of partners throughout the community.
Nearly 15,000 vets participated last year in the medical center’s telehealth program, which monitors chronic conditions remotely, adjusts treatments as needed and determines whether the person needs to be seen immediately.
The Tele-retinal Diabetic Screening program provides video consultations to clinicians who visit patients at home or in their local VA facility. The program is intended to decrease bed days and improve diabetes control. Veterans Services Organizations help individuals without access to the Internet to participate in telehealth services.
The medical center has been particularly proactive in meeting the needs of veterans who have behavioral health issues, are homeless or need a job. The annual Battlemind to Home Symposium, held in conjunction with the Military Family Research Institute at Purdue University, brings together local clinicians and first responders to increase community awareness of the challenges military families face when service members return home, and to educate them about mental health issues, along with legal options and other support available.
The Veterans Outreach program staffs two computer labs where 40 to 50 veterans a day receive training in computer skills, career planning and compiling resumes. The Operation Hire a Hoosier Veteran Career Fair lets Indiana businesses, veteran support groups and educational institutions spotlight employment and educational opportunities. And Homeless Stand Downs are one-day events that provide a variety of services, including hot meals, clothing, health screenings, VA and Social Security benefits counseling and referrals to both VA and community services.
In addition, the medical center operates a 50-bed Domiciliary Residential Rehabilitation Treatment Program for homeless veterans. Through the program, “we provide treatment and assist veterans in getting their health care needs and their personal goals back on track for independent living,” according to the award application.
The VA hospital gives veterans tools to be more engaged in their own care. For example, patient records are instantly available through My HealtheVet, the VA online personal health records. Patients even can access their current records during their hospital stay.