Winner | University Hospitals Case Medical Center | Cleveland

University Hospitals Case Medical Center has been on a nearly decadelong journey to achieve and sustain the highest level of quality and patient safety. Driven by senior leadership and a high level of board involvement, the 947-bed academic medical center fosters an environment of collaboration and respect among interdisciplinary teams. All employees know they have an active role to play in enhancing quality and patient safety and are empowered to innovate and enact change.

The organization has undergone a slow, yet deliberate, cultural transformation propelled by a shift to transparency, a focus on accountability and the development of an innovative quality program, among other things. "Transparency has led us to success," says William Annable, M.D., chief quality officer.

Cathy Koppleman, R.N., senior vice president and chief nursing officer, agrees. "We were an organization that did not share a great deal of quality and patient safety data outside of the administrative circle," she says. Quality and patient safety reports were presented to the board, but were not a top agenda item.

Bolstered by the adoption of a "just culture" and better incident reporting, transparency is now highly prevalent within the organization, and with the board and the community. Lessons learned and shared stories are critical components.

"When a patient shares their experience, it touches clinicians on an emotional level," says Koppleman. "It reminds them of their duty and commitment not only to provide care, but to be caring."

When the medical center began its quality transformation, the organization did not have a working definition of quality, and its management incentives were not based on quality-related metrics. Clearly defining quality was crucial — not only to develop accountability metrics, but also to build understanding and support within the organization. The description of quality as defined in the organization's Quality Improvement Plan mirrors the Institute of Medicine's Six Aims: care that is safe, effective, patient-centered, timely, efficient and equitable.

"Our goals are aligned so that from the employee's incentive plan up through the management incentive plan, 30 to 50 percent of the goals are based on quality," says President Fred Rothstein, M.D. "There is significant engagement opportunity for everyone. It really drives quality, safety and incentivizes change."

To lead the quest for quality, University Hospitals Case Medical Center established the role of the chief quality officer and consolidated the offices of the CNO and chief medical officer. Bringing these two offices together emphasizes the organization's multidisciplinary approach. "This really made a strong statement about the importance of the quality program," says Karen Boyd, director of the Quality Center.

Other keys to quality and patient safety include a more effective system to prioritize goals. "By trying to do too many things, we weren't able to accomplish what we wanted or sustain our gains," says Nathan Levitan, M.D., president of the Seidman Cancer Center and former system CMO. Quality scorecards are available at all levels of the organization so every employee has access to up-to-date performance measures.

Board oversight and involvement in quality and patient safety initiatives have played a significant role in the organization's transformation. Prior to becoming chief quality officer, Annable served 12 years on the board, including a stint as chair of the board quality committee. A trip to the Institute for Healthcare Improvement's National Forum on Quality triggered the realization that the board wasn't doing enough to drive quality and patient safety improvements within the organization. "The best boards expect transparency and disclosure and insist on data," Annable says. Effective boards also hold leadership accountable for the organization's performance.

All board meetings now start with a quality report, and board members are among the first notified if a sentinel event occurs. Board members also adopt a quality improvement project and follow its progress. And board members participate in leadership rounds.

One of the strengths of the organization's quality and patient safety program is the ability to identify a problem early on and quickly assemble teams to understand the root cause and develop solutions. "Change comes from the front line," Annable says. "Our employees don't hesitate. It's very rare for me to walk around the hospital without being approached with ideas and opportunities."

Employees have developed a level of confidence in the organization, particularly around quality and patient safety programs, notes Levitan. Joint Commission site visits no longer are cause for anxiety, but instead are viewed by staff as a learning opportunity and a chance to engage with outside quality experts.

Rothstein takes pride in the level of collaboration and respect within the organization. "Everybody's voice counts. We all embrace our responsibilities," he says, adding, "We listen to our patients as much as we do our employees."

The University Hospitals Executive Team
UH Case Medical Center believes transparency is a cornerstone to excellence in quality and patient safety. From the left, Jane Dus, R.N., vice president, medical-surgical services; Nathan Levitan, M.D., president of the UH Seidman Cancer Center; Karen Boyd, R.N., director of the UH Quality Center; William Annable, M.D., chief quality officer; Fred Rothstein, M.D., president, UH Case Medical Center; Kim Bixenstine, clinical risk management and patient safety, general deputy counsel; and Michael Anderson, M.D., chief medical officer.

Reaching out to a Struggling Area in both traditional and nontraditional ways

Finalist | Lincoln Medical and Mental Health Center | Bronx, New York

Located in one of the most diverse and economically disadvantaged communities in the United States, Lincoln Medical and Mental Health Center has developed a deeply embedded partnership with its community and exemplifies a patient-centered approach to care. The mission of the 335-bed public hospital in the South Bronx is to provide competent, culturally sensitive, high quality care in a safe environment with dignity and compassion regardless of ethnicity, nationality, religion or ability to pay.

The challenges in meeting the needs of the patient population are many: the largely immigrant community has a median household income of less than $14,000 and about half of the population does not have a high school diploma. Too often patients do not present themselves for care until they are in late-stage or end-stage disease. To overcome these obstacles, the health center focuses on offering convenient, efficient care and to provide that care out in the community whenever possible.

The organization hosts more than 400 outreach programs each year reaching 20,000-plus patients. The Taxi and Limousine Health Screening Program reaches drivers where they work, while the Lincoln Art Exchange allows local artists to barter their services for medical care. For every hour of service provided, the artist receives $40 in health credits.

"I'm really proud of the way we work with our community to ensure they have health care. We do it in traditional and nontraditional ways," says Iris Jimenez-Hernandez, the health center's executive director.

Other programs are designed to encourage individuals to seek diagnostic and preventive services early on. "Many of our patients are not accustomed to the concept of preventive care," Jimenez-Hernandez says. "They only see a physician when they are experiencing an acute episode." The key is convenience and getting test results back as quickly as possible.

"We do as much on-the-spot care as possible," says Melissa Schori, M.D., chief medical officer. For example, the emergency department provides rapid HIV testing and links patients to appropriate follow-up care. Walk-in appointments are available for mammograms. Patient navigators help high-risk patients receive necessary follow-up care.

An active Community Advisory Board identifies local health needs and links the hospital with community-based organizations. One such partnership established the "For You, For Life!" campaign to decrease disparities in the rate of colonoscopies among minority groups. Patient navigators were assigned to patients to encourage them to receive a colonoscopy. The program achieved a significant drop in the no-show rate for appointments, from 67 percent to 10 percent. The number of colonoscopies increased from 774 to 2,210.

Community collaboration extends to setting and prioritizing organizational goals. Priorities are set in cooperation with the community, senior leadership, the board, regulatory agencies, and middle and front-line management. The effort further ensures the organization is meeting the needs of the community and is deemed a vital component of developing an effective and accountable quality and patient safety program.

"The focus of the entire organization is on quality and safety and appropriate resource utilization," says Abdul Mondul, M.D., associate medical director and patient safety officer.

Physicians are very engaged in quality and patient safety activities, notes Carl Kirton, R.N., chief nursing officer. "It's hardwired within our culture," he says. "Physicians don't view quality and patient safety as a nursing issue. They want to be involved."

Collaboration among caregivers is critical to providing high-quality, patient-centered care, says Ray Mercado, D.O., chair of obstetrics and gynecology. Simulation and interdisciplinary crisis management are among the methods in place to facilitate collaboration across disciplines.

"Our biggest challenge is demonstrating value and carving out costs in the system in an environment in which patients have significant health needs," Jimenez-Hernandez says. "The work is challenging, but when we get it right, it is very rewarding."

The Lincoln Executive Team
Lincoln Medical and Mental Health Center has developed a deeply embedded partnership with its community. From the left, Abdul Mondul, M.D., associate medical director and patient safety officer; Iris Jimenez-Hernandez, executive director; Melissa Schori, M.D., chief medical officer; and Carl Kirton, R.N., chief nursing officer.

Giving staff and patients an Active Role in improving care

Finalist | UNC Hospitals | Chapel Hill, N.C.

Meeting and exceeding patient and family expectations is a top priority at UNC Hospitals, with an emphasis on eliminating unnecessary harm and providing a caring, compassionate environment. The 805-bed academic medical center's commitment to improvement focuses on achieving excellence in the organization's six pillars: people, service, quality, finance, innovation and growth.

A team of leaders is charged each year with setting and prioritizing goals for each pillar. The proposed goals are vetted through various internal committees before being presented to the board for final approval. Multidisciplinary Commitment to Caring teams are assigned to evaluate opportunities and develop action plans to help meet the goals, which align with the Institute of Medicine's quality aims.

Interdisciplinary leadership is used to facilitate process and performance improvement efforts throughout the hospital at the unit level. Teams, known as Triads, are led by a physician with support from a nurse and case manager. The Triads focus on challenges unique to the patient population. Projects and their outcomes are shared during various quality and staff meetings. Physicians are compensated for their time spent leading these quality initiatives.

"This process provides a systematic way of identifying problems and quickly designing solutions," says Tony Lindsey, M.D., chief of staff. "Our multidisciplinary approach has helped us make great strides in our quality improvement work."

The organization's success, however, is dependent on involvement from all employees. Everybody has a responsibility to do his or her job and do it better, says Larry Mandelkehr, director of performance improvement and patient safety. "Quality is everyone's responsibility. We work hard to engage our employees and medical staff so everyone understands what we are doing and why we are doing it."

All employees receive a copy of the organization's goals and employee performance and compensation are linked to their achievement. "The alignment of priorities is a good starting point for success," Mandelkehr adds.

UNC Hospitals is committed to providing a patient-centered care environment and believes a strong relationship between nurses and their patients and family members is essential to providing exceptional, compassionate care. The chief nursing officer leads a multidisciplinary effort to develop key staff behaviors that give patients and families a voice in the caring process. "Our nursing staff have changed the way they provide day-to-day care," Lindsey says. Nurses make hourly rounds, which has a significant impact on a patient's perception of care. "It helps them anticipate patients' needs and be more proactive with patients."

The organization continuously looks for ways to engage patients and families in the care process. "We don't take the traditional path," says Tina Willis, M.D., medical director of the pediatric intensive care unit. The organization doesn't rely on focus groups and advisory councils for input. Instead, patients and families are members of improvement teams. Several patients have received education and training in quality and patient safety activities. "It saves us a lot of time," Willis says. "Having patients be part of the team provides a unique perspective that can contribute significantly to the outcome of the project."

UNC Hospitals utilizes a multipronged approach to quality and performance improvement, including Lean, Six Sigma and rapid-cycle improvement. "A hospital is a complex place and we need different tools in our toolkit," says Brian Goldstein, M.D., executive vice president and COO. "We have to approach process improvement and patient safety from multiple directions."

President Gary Park is quick to acknowledge the critical role of the staff in quality and patient safety. "We have a dynamic culture that places focus on patients and families," he says. "We have made a commitment to challenge ourselves. We know we are going to make mistakes, but we have a very forgiving, supportive culture."

The UNC Hospitals Executive Team
Brian Goldstein, M.D. (far left), executive vice president and COO, along with, from left, William Roper, M.D., CEO of the UNC Health Care System; Tony Lindsey, M.D., chief of staff; and Gary Park, president of UNC Hospitals, are committed to providing a patient-centered care environment that not only meets, but exceeds, patient and family expectations.

Bold goals with a focus on Collaboration inside and out

Citation of Merit | Meriter Hospital | Madison, Wis.

Embrace excellence always. That's the mission of Meriter Hospital, and it's evident throughout the organization as it strives to achieve the highest level of clinical and operational performance. The journey is guided by a strong collaboration among senior leadership, governance and the medical staff. Meriter's definition of quality highlights the needs of the patient and reflects the Institute of Medicine's Six Aims: patients need care that is effective, respectful, safe, timely, efficient and equitable.

Continuous quality improvement is part of the underlying culture of the 448-bed community hospital. Central to the organization's quality and performance improvement efforts was the use of the Baldrige National Quality framework; Meriter was awarded the state's Governor's Level of Excellence award in 2006. Today the system's performance continues to be driven by critical elements of this framework. "We strive to be the best," says Kathleen Werner, R.N., director of performance improvement. To that end, the organization sets bold quality aims. They include zero health care-associated infections, achieving the top quartile in patient satisfaction with pain management, zero medication errors, and preventing potential harm or injury to patients. The aims are meant to be motivating and achievable, Werner notes.

The quality aims are set by the board's Quality of Healthcare Committee, which consists of five community representatives, six members of the medical staff and four hospital leaders.

Front-line staff also are involved in setting goals and priorities and are key drivers of process improvement.

The Nursing Shared Governance model, for example, empowers nurses to take charge of their own work as it relates to practice, competence and quality. The adoption of a "just culture" further empowers employees to acknowledge the potential for harm and seek continual quality improvement.

Meriter has strong ties to the community and works collaboratively with area health care providers, the city of Madison and community groups to identify and address population health needs and disparities. These organizations work together through the local Health Council to address community health issues such as access to care and primary care for the uninsured.

Meriter's Helping Educate and Link the Homeless Program seeks to eliminate barriers to health for the medically underserved, including literacy, inadequate housing, lack of insurance and access to primary care, lack of access to transportation and the prevalence of mental health and substance abuse issues.

"Access to quality care is critical," says Werner. "Meriter has always been a generous organization and supportive of the community."

Demonstrating value is also a top priority for Meriter, with a focus on cost reduction and enhancing operational efficiency. One of the biggest challenges is balancing the needs vs. the demands of patients, says Geoff Priest, M.D., chief medical officer. "We have a highly educated, insured patient population. We struggle with balancing patient expectations with cost management," he says. "There is still work to be done."

About the Award

The goals of the American Hospital Association–McKesson Quest for Quality Prize are, among other things, to raise awareness of the need for a hospitalwide commitment to highly reliable, exceptional quality, patient-centered care. The winner receives $75,000; two finalists receive $12,500 each. For full criteria, visit www.aha.org/questforquality.