Quality improvement becomes second nature

Beth Israel Deaconess Medical Center was an early adopter of the Six Aims for Improvement and since then has made the Institute of Medicine's concepts a part of everything it does.

The board at 649-bed Beth Israel Deaconess acted quickly to adopt the Six Aims after they were introduced in the 2001 report "Crossing the Quality Chasm: A New Health System for the 21st Century." The Aims are a central part of the evaluations for the American Hospital Association–McKesson Quest for Quality Prize.

At its first meeting after the IOM report was unveiled, Beth Israel Deaconess' board subcommittee formally chose the Aims as the basis for its institutional philosophy and framework for defining and evaluating quality. "We've been looking at ourselves through that lens for a long time," says Kenneth Sands, M.D., senior vice president of health care quality for the medical center.

Since then, Beth Israel Deaconess has taken a number of steps to build a quality effort that is embedded in its organizational management, with quality improvement addressed in its decision-making across the hospital.

Sands says one reflection of that bottom-up organizational focus on quality can be found at a quality and patient safety symposium the organization holds each year. The symposium puts a spotlight on noteworthy quality improvement efforts taking place across the hospital, and they generally come from the units, not from management.

"There's no committee that organizes that work," Sands says. "We've really gotten to a place where [quality improvement] is a held value at the local level," he says.

In addition, Beth Israel Deaconess works to be transparent regarding its quality performance and, as part of that, posts quality data on its website. The hospital's performance relative to its chosen benchmark as well as a national average can be found for measures in the general areas of infection prevention and nursing care, as well as for the specific areas of heart care, pneumonia care, surgical care and patient experience. Beth Israel Deaconess also makes available its performance and its work to eliminate preventable harm. The medical center's accreditation report from the Joint Commission is posted on its site.

To get the patient's view on quality and other matters, Beth Israel Deaconess has about 100 patients and patient family members serving as advisers on four patient/family member councils, on hospital committees and on ad hoc projects, says Barbara Sarnoff Lee, director of social work and patient/family engagement. The advisers "deepen our understanding or help us think in a different way," she says.

The patient/family advisers are encouraged to be analytical, with a focus on the future and how to improve the hospital. "We are not a support group for people who have had a difficult experience," Sarnoff Lee says. "We're asking them to take a good critical look at the care. They are asking, 'What's going to move us forward? What's going to improve the experience?' "

Regarding the goals of the IOM's Six Aims, Sands says ensuring that care is provided in a fair manner across the spectrum of patient characteristics poses some of the biggest challenges. "Equitability is the hardest dimension in a lot of ways; the measures are more challenging," Sands says.

The organization continuously looks for ways to assess equity, including financial equity, and works with community health centers — including one it owns — to improve health beyond medical care and to look at the community as a whole.

Hospital officials also are prepping for the changes taking place in quality measurement and reimbursement. "Generally, we are anticipatingthe fact that the next emphasis is going to be on care across the continuum and on population-based care," Sands says.

As part of that, Beth Israel Deaconess received a grant for a federally funded project targeting quality of care in the post-acute care setting. The Center for Medicare & Medicaid Innovation-funded program, called Post-Acute Care Transitions, will deploy nurses, clinical pharmacists and a social worker to provide a bundle of interventions designed to prevent rehospitalizations.The medical center received a $4.9 million grant, and aims to reduce 30-day readmissions by 30 percent over three years, saving Medicare $12 million.

Beth Israel Deaconess was a finalist for the Quest for Quality Prize in 2009, when, unsurprisingly, executives for the medical center at the time pointed to transparency and employee engagement as two areas of emphasis.

Kathleen Murray, director of performance assessment and regulatory compliance at Beth Israel Deaconess' Silverman Institute for Health Care Quality and Safety, says the hospital's work to improve quality has become second nature. When starting a project or task, hospital workers begin by addressing how it aligns with the dimensions of quality, how the work supports the hospital's priorities and whether input from advisers can be obtained.

"They work quality improvement into everything," Murray says. "It is all the way across, it is all the way up and down."


Letting employees do what they do best

Employee commitment to patients and their care drive the quality improvement efforts at Franklin Woods Community Hospital in Johnson City, Tenn.

Officials at the hospital, part of Mountain States Health Alliance, say its employees have a genuine desire to provide the best care possible, which makes implementation of quality improvement programs a smoother process and more successful than might otherwise be the case.

"If we're going to point out our key success factor, it would be culture," says Tony Benton, CEO of 80-bed Franklin Woods.

The quality-centered work environment is the legacy of two hospitals that came together in 2010 in the new Franklin Woods Community Hospital. Johnson City Specialty Hospital, which was combined with North Side Hospital, had scored in the 95th percentile in patient satisfaction nationally among clients of Press Ganey Associates Inc. in 2009.

That dedication to enhance the patient experience continues, supported by a quality improvement effort that has several moving parts.

Mountain States began emphasizing patient-centered care about 10 years ago, largely as a result of its adoption of a Baldrige Performance Excellence Program. To start, the key customer — the patient — needed to be identified, says Tamera Parsons, MSHA vice president of quality and patient safety. "We just followed that framework," she says. In the last 18 months, Franklin Woods and Mountain States created patient advisory councils to further bring the voice of the patient into the care processes.

Franklin Woods' attention to the patient is reflected in the design of its facility. "We recognized that we had an opportunity to do something special," Benton says. "It's a very soothing environment."

Examples of that can be found in the building's use of natural light and natural terrain. "The design literally was based on patient input and patient-guiding principles," Parsons says.

Franklin Woods, as a part of MSHA, maintains a 10-year strategic plan that drives the implementation of its quality efforts. "There's a lot of visioning for that 10 years ahead," Parsons says.

Mountain States encapsulates its efforts in what it calls a "House of Quality," which is supported by the "Four Pillars of Excellence": clinical care, operations, service and safety.

Progress in those four areas is measured using 26 metrics — five to nine for each pillar — that together are the basis for the system's "Blueprint." The Blueprint is a scorecard used to guide performance evaluation at the employee, department and facility levels. Information in the Blueprint report is shared within the different layers of the organization and also is available to employees on a website.

A set of 10 patient-centered care guiding principles helps to connect hospital workers to the goal-setting and performance measurement information found in the Blueprint. Employees are required to commit formally to supporting the principles by exhibiting 10 behaviors that are tied directly to the principles.

Examples of the behaviors include: "I do the right thing because it is the right thing to do," and "I always keep the customer informed."

"Everyone signed a contract to uphold those guiding principles in their daily work," Benton says. "We feel as though it's everyone's job and role. Everybody's participating toward improvement."

Looking ahead, Mountain States Health Alliance continues as a member of the Partnership for Patients, which focuses on quality, safety and affordability. It also expects to make greater use of Lean management approaches, which had been used informally until they were formally added to the mix at MSHA about two-and-a-half years ago.

"Our goal is to be a world-class provider," Parsons says.


Working together to improve quality

Front-line employees and their supervisors at St. Mary's Hospital, Centralia, Ill., have learned to share something important: management of the hospital. And the St. Mary's shared-governance model, which gives front-line employees a voice in running the 104-bed facility, is one of the key drivers behind the hospital's culture of safety and quality.

We've got a very good culture for safety," says Bruce Merrell, hospital president. "Our culture at St. Mary's Hospital is very tight. We've got a lot of accountability."

The hospital, part of St. Mary's Good Samaritan Inc. and co-sponsored by SSM Health Care and Felician Services Inc., has made good use of a systemwide framework for executing strategy and managing operations that is tied to the broader mission. The mission focuses on improving and providing regional, cost-effective, high-quality health services for all, with special concern for the poor and the vulnerable and as an extension of the Catholic Church's healing ministry.

To translate its mission into identifiable and measurable goals, SSM created a strategic and operational plan for its hospitals with three major parts. The three areas, called the "Exceptionals," are exceptional patient care, exceptional commitment from employees and physicians, and exceptional financial performance and growth. They are divided further for the sake of categorizing the organization's performance measures. The exceptional care portion is broken down into patient safety, clinical and service quality, and patient satisfaction, while the exceptional commitment category is divided into employees and physicians.

St. Mary's uses several sources for measuring performance, including federal and state quality metrics and data from third-party vendors. It's adding business intelligence tools that will increase its ability to perform population management, create better benchmarks and provide more accountable caregiver standards.

The hospital instituted a formal, facilitated departmental goal-setting process several years ago, which has had a positive effect on quality improvement efforts, says Michelle Darnell, vice president of systems improvement for St. Mary's Good Samaritan Inc. Each department has a council that monitors performance and celebrates success when appropriate, Darnell says. For large departments, the council includes staff representatives; and for smaller departments, the entire staff comprises a council of the whole.

Staff, meanwhile, are never far from their own personal goals, which the hospital documents for each employee in personalized "Passports to Success." The Passport identifies the hospital's mission and its Exceptionals, along with specific goals and measures for the employee's department and the employee. "It's a small document; we keep it with our badge," Darnell says.

When first introduced, the Passports were checked regularly to ensure that employees had their goals with them and were consciously working to achieve them, but that became unnecessary, she says. Now only spot checks are conducted periodically.

Merrell says employees are integral to figuring out ways to improve quality in the hospital, which means giving them the tools they need to make decisions. "We're very transparent," he says. "We try to make sure that everyone has any information he or she needs to make decisions."

For example, an employee who participates in shared governance may identify undesired noise as contributing to lower-than-desired patient satisfaction scores. A staffer on the floor is in the best position to identify the source of that dissatisfaction.

"The employees figure this out," Merrell says. "We don't make decisions at the top of the organization unless they need to be made there," he says.


Spreading the word on quality and patient safety

Executives for Vidant Medical Center in Greenville, N.C., every year create a quality plan after a review of its operations and the industry, looking at such matters as community needs, national best practices, and feedback from patients and patient families.

The plan helps to identify Vidant's priorities, goals and initiatives for improving quality. The work goes along with a number of reporting andincentive requirements designed to improve quality and the patient experience.

That's a big change from less than eight years ago. Following a patient death in 2006 related to a blood transfusion incompatibility, the hospital's quality improvement and patient safety programs have undergone a major transformation.

"That really was a wake-up call," says Steven Lawler, president of 909-bed Vidant Medical Center, the flagship hospital for Vidant Health system. The changes have made quality and patient safety major priorities in broad strategic moves and in day-to-day activity. Every executive staff meeting starts with a discussion about quality.

The hospital's board deserves most of the credit for the changes that have resulted, Lawler says. "Our board really challenged us to look at every event and patient," he says. "I think we've changed our culture."

Walter Pofahl II, M.D., currently the chairman of Vidant Medical Center's board, was chief of staff in 2006 when the event occurred and says the hospital totally revamped its approach to quality, taking a measured approach in doing so. "It has been an evolutionary process," he says.

Changes have taken place in how the organization views quality and patient safety and in how it discloses its progress. "The big thing that has changed from then is the level of transparency," Pofahl says.

If it concerns quality and patient safety, the hospital wants to get the word out on it. Sixty-eight hundred employees and roughly 1,100 doctors, residents and fellows "see the same thing that I see," he says.

The hospital board and management have become aggressive about tracking quality and errors and figuring out ways to improve. "We're pretty compulsive about counting every single event," Pofahl says.

Rebecca Ross, R.N., assistant vice president for patient safety and quality, says Vidant's public reporting on quality issues exceeds the regulatory requirements, largely as a result of a transparency policy adopted in 2008.

A look at the patient safety section of parent Vidant Health reveals the hospital's number of incidents for each of the four quarters in 2012 for device-related infections for three different devices, medication errors, MRSA, patient falls and pressure sores. "We put our information out for the public," Ross says.

The hospital also produces an internal weekly snapshot for management and staff that highlights quality issues, such as an incident of a patient experiencing a central line infection, Ross says. The weekly snapshot is reviewed at executive meetings to identify opportunities to improve patient safety, quality and the patient experience, Ross says.

But Vidant's managers and board are not planning to pare back their work to improve. Lawler says, "We still haven't reached our full potential."


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