The Quest for Quality continues. Hospitals across the country are striving to provide highly reliable, exceptional quality care and improve the health of the community. Health Forum convened a group of health care executives and industry experts Dec. 7 in Orlando to examine progress in achieving the six Institute of Medicine quality aims: safety, patient-centeredness, effectiveness, efficiency, timeliness and equity. The closed-door discussion focused on the best practices of organizations that have won or were finalists of the American Hospital Association–McKesson Quest for Quality Prize. The discussion also explored how best practices can be disseminated at a faster pace to dramatically improve health care outcomes across the United States.
Health Forum would like to thank all of the participants for their open and candid discussion, as well as McKesson Corp. for sponsoring this event.
MODERATOR (Haydn Bush, Hospitals & Health Networks): In light of forthcoming payment changes, hospitals are focusing on quality improvement while also undertaking cost-reduction efforts. What is the business case for quality in your hospitals?
DONNA ISGETT, R.N. (McLeod Regional Medical Center): At McLeod, we very much see the business case for quality. Poor quality care stretches resources, such as treating health care-acquired conditions. We have been working on Lean initiatives for about four years now. We have found opportunities to improve efficiency in care coordination and wait times. That's part of quality, too. Remember, the six aims of the IOM include efficiency and timeliness. It's all connected.
JOHN KELLY, M.D. (Abington Memorial Hospital): Clearly, speaking as an infectious disease physician, we always had this notion that infections are inevitable and a part of the process of care. Our major goal is the elimination of preventable harm. We cannot afford to waste resources and we all have a moral obligation to eliminate infections. Ventilator-associated pneumonia may cost between $20,000 and $30,000 per episode. So, there is a fiscal obligation as well.
UMA KOTAGAL, M.D. (Cincinnati Children's Hospital Medical Center): We have a goal to eliminate preventable harm by 2015. In addition to that, we are really focusing on better resource utilization, particularly our fixed resources that include our buildings and our staff. Our goal is to get to 90 percent occupancy seven days a week. Under our current model, the variation from day-to-day is significant; we might have 75 percent occupancy on Monday, 85 percent on Tuesday and 90 percent on Friday. We are doing a lot of work to try to manage that. Among other things, this work has allowed us to avoid building any new buildings.
We're also working at managing flow to avoid delays at the system level. We are using a prediction model that enables us to predict who is going to go home and when, and then we adjust our flow accordingly. It's a very dynamic model. By getting the right patient in the right bed, we're not only impacting safety, but also capacity within the organization.
MAULIK JOSHI (Health Research & Educational Trust): I think the business case — from a national perspective — gets to the why. We are beyond the why in many areas and are now focusing on the how. Between meaningful use and readmission penalties and purchasing, it is already linked together. Today, it is about how we replicate and make these efforts stick in the system.
MODERATOR: How has reform impacted your organizations' journeys and how does that fit into your business case?
KOTAGAL: Obviously, as a pediatric hospital, we are very impacted by Medicaid. We expect more of our patients to be on a fixed pay source, which requires us to think very differently about how we manage care. Bundled payments already existed under capitation in a certain way, so bundled payments are a large part of our design. We are living this. The question is: Are we living it as aggressively as we could?
KELLY: I think we're going to have to adopt a variety of care delivery models to meet the changing delivery system. I would expect that the staff at Uma's facility is primarily salaried, which makes it a little bit easier in terms of getting things done. At Abington, 80 percent of our staff is in private practice and they are all in practice separately. We have to form new kinds of partnerships if we're going to meet the challenges of payment reform, such as bundling. There are probably going to be a lot of speed bumps along the way.
We haven't quite figured out what accountable care organizations are yet. The rules are out; if anybody here has read the complete set of rules, let me know. But we are uncertain. There's actually a lot of uncertainty as to how the Affordable Care Act will, in fact, go forward and whether the mandatory purchase of health insurance will be upheld by the courts. Our approach has been to look for all of the necessary partnerships within our community of providers to come to a better rationalization of care to meet the needs of the northern suburbs of Philadelphia.
ISGETT: We are very similar in our position, but I think none of us will argue that better coordination of care is mandatory for us going forward. Whether or not we take on the model, whether or not an ACO actually survives as a thought, whether or not we move to bundled payments, the lack of coordination in care delivery is clear to all of us and we must do better going forward.
KOTAGAL: Whichever way the wind moves from the quality of care point of view, the lack of coordination is a significant factor affecting patient safety, wellness and cost. One of the things we are working on in our patient care coordination effort is to make sure that we are using less expensive resources to do the same work. It's about having the right person for the right job. Not everything has to be done by a physician or a registered nurse. That approach is an important piece, getting our processes in order.
JEFF SELBERG (Institute for Healthcare Improvement): An important question for us is how various mechanisms are created that can generate a greater spread scale than what we've experienced before. My experience on the American Hospital Association–McKesson Quest for Quality Prize Committee has been eye-opening. Every year, I see wonderful things happening in hospitals. It's just that there aren't enough hospitals in which wonderful things are happening. So how do we make that jump?
I believe by changing the business model to one that is in alignment with what needs to happen, such as paying for high-quality care, that will generate the spread. That's a long-winded approach to say that the Affordable Care Act can have a desirable effect in terms of reducing harm, creating higher levels of quality for patients and greater value. But it is going to be a very focused effort in terms of those key payment elements. How do we develop more of a passion, more of a fervor for improvement than what has been generated to date by both public and private efforts?
MODERATOR: That brings up an interesting point. Your organizations are early leaders in the quality journey. What advice do you have for organizations that are at different stages in their quality initiatives?
MARY VOUTT-GOOS, R.N. (Henry Ford Health System): I can talk about something we've done recently. One of my former colleagues just worked out a model to do a cost analysis of our harm events. We've adapted that in our organization; we've presented the data and it is stunning what the different aspects of harm cost. Not only can we figure out what it costs, we can prioritize our efforts based on what costs the most, and then look at what it costs to prevent that harm so we can do a cost-benefit analysis. It really engages people when you talk about dollars.
KOTAGAL: For an organization that starts down this journey, it's important to start before you are ready. I find that most organizations often are waiting for something to happen before they start. It's okay to have a few failures early on in the process. The organization will learn from those mistakes and will get better as it goes forward. That's a very important characteristic — to start before you are ready.
The second aspect that we think is important is transparency. Transparency allows the organization to provide the data that show everyone how well the organization is doing. It provides a realistic view of how many people we harm. And since most of us really went into this field to be healers, once the facts are there in front of us, it helps move things along.
MARY BETH NAVARRA-SIRIO, R.N. (McKesson): One of the things I've seen during the Quest for Quality site visits is that leadership and culture play a very important role. Quality can't be a addressed through an initiative-of-the-month type of approach. In successful organizations, leaders must really believe that it is their responsibility to deliver high-quality, safe patient care and they address that at the board level, at the senior management level and they have that culture from top to bottom.
We've all heard stories of clinicians being able to stop the line. If clinicians can't approach their senior leaders to help them with problems, then you just can't be successful. It's really about leadership and culture and having the courage of your convictions to be able to move forward with some of these tough initiatives.
SELBERG: Transparency in leadership is important, too. If leaders aren't transparent, it's pretty hard to stand up and drive transparency in the organization. It just doesn't compute to the people who are trying to follow you. I absolutely agree that leadership is a key.
JOSHI: I would like to build on that. We used to say, Pick a few vital things to work on and then move on to the next few.' But, today, the vital few are different from what they were. It used to be a couple of heart failures, a couple of things we know. Today, it is more complicated. The vital things we need to address are such issues as readmissions and mortality, and these things can't easily be moved, so it takes a real strategic leadership culture to get there.
VOUTT-GOOS: From a cultural change perspective, we often work on processes and then wonder why we can't sustain them. We don't concentrate on building a structure that can sustain those processes. It is time-consuming, but if you take the time to do that, you can support and sustain the process of the changes you've initiated.
ISGETT: There is true magic in methodology of improvement. An organization has to become an expert in improvement methodology of some sort. Organizations need to learn the science of improvement and the science of change theory. Those are the critical underpinnings for actual success and then comes the management theory for sustainment, which is very important.
MODERATOR: What are some other ways you can keep the momentum going after you've got everybody on board?
KOTAGAL: It's important to remember that bodacious goals take awhile. If the goal is to have zero preventable harm, that's a portfolio of robust work that takes some time, and keeping that in front of everybody is important. We've moved from really thinking about projects to thinking about scale and what it will take to reach that. It's also important to emphasize, as Donna mentioned earlier, capability and capacity for improvement.
VOUTT-GOOS: For us it is employee empowerment, getting employees engaged and empowering them to actually fix the problems that bother them. Employees identify their own issues and we empower them to make the necessary changes. We are using video with humor to help keep people engaged, and to share stories. It is working.
MODERATOR: How do you integrate patients and their families into your improvement methodologies?
KOTAGAL: In 2002, we invited patients to help us redesign care. In our early journey, we focused on cystic fibrosis. We invited 25 families out of 250 patients; 18 signed on and seven provided us with a list of instructions about what we should be doing. It helped us get over some initial anxiety about whether patients would view us with concern if our data were not good. We have really continued that process. All of our teams have patient and family participants. We also have a 45-member Family Advisory Council. We can approach the council as needed with questions, so we don't have to convene a new group of parents all the time. We have several parents who serve on our board. We also have a teen advisory council that gives us a lot of advice, as you might imagine. Patients are an important part of what we do; they reaffirm our activities, but they also provide energy for change within the organization.
ISGETT: At McLeod, we start our day with a patient. Every day at 8:30 a.m., the senior leadership team gathers in the board room and then visits patients. That keeps us patient-centered. The group includes our chief financial officer and our vice president of business services. It reminds all of us why we are here.
SELBERG: It is very effective. I recently visited the Dana-Farber Cancer Institute in Boston. Prior to my visit, I was told that patients would lead the tour of the new Yawkey Center for Cancer Care. I figured the patients would come along, but they actually led the tour. They were the ones who answered our questions, and the staff stood behind them, ready to provide support. It was quite impressive. I do think patients and patient committees are the true disruptors and we need to be disrupted.
MODERATOR: The Quest for Quality Prize recognizes organizations that have made progress around the Institute of Medicine's six quality aims. In what areas have you achieved the most success, and in what areas do you feel you need to do additional work?
VOUTT-GOOS: We use the IOM aims as scoring criteria for our annual quality expo. Our teams submit their posters to be evaluated and we use the six aims as our scoring criteria. Equity continues to be a challenge, getting people to think about equity when designing their quality initiatives.
ISGETT: Equity is probably the one that we struggle with the most, not necessarily equity across races or sexes but equity in terms of whether a patient shows up at the emergency department on a Saturday morning versus a Friday night. Will the care be the same?
KOTAGAL: We have incorporated the IOM aims into our 17 system-level measures that serve as our quality framework. As mentioned earlier, it is all interrelated. You can't work on flow without working on safety. Patient concerns really turn out to be safety concerns. Effectiveness is probably one of the few aims that resides more with the provider; but self-management also plays a role. A provider may prescribe the correct medication; it's up to the patient to follow instructions.
KELLY: All of the aims are difficult to achieve. Equity in our community is important, but there really should be equity across the system. I can guarantee that when somebody comes to the emergency room, he or she is going to get the best care and the same level of care. But when patients go back to the community and it is the private gastroenterologists who don't accept medical assistance or self-pay, then I have a problem. We are working with some gastroenterologists who want a new endoscopy center and a partnership with the hospital. We are happy to do this, but we will address the need for access irrespective of the ability to pay, because that's what we're here for in our community.
What has moved our organization more than anything is transparency. We talk about transparency and share stories with our staff and the community. We invited a reporter from The Philadelphia Inquirer to stay with us for a year. He worked out of the hospital. We had some painful stories appear in the Inquirer, but they made us better. There is no question they made us better. And they helped build trust within the community. We shared the story of the death of the mother of one of our internists from methicillin-resistant Staphylococcus aureus, from a knee infection. It took her 2 1/2 years to die from all the complications that took place. But it moved us to push our hygiene compliance rates to around 95 to 98 percent. That rate has stayed at those levels for four years now. We had some resistance from the board, but our president thought it was worth the risk. And there is a lot of risk-taking involved in all of these things.
KOTAGAL: Courage is an important step. Where we are currently is, in some ways, not very good, especially as you look at the data and realize what needs to be done. And it takes courage to take the next steps.
MODERATOR: Is there a way to take something like courage and institutionalize it to engage your entire clinical and nonclinical staff?
KOTAGAL: Well, we did something similar to what John described. We agreed to do a movie about American health care. Three of our parents of children with cystic fibrosis participated and they publicly said how awful the care was that we provided. One of them said, "I work in this hospital and I bring my child here and every time she is hospitalized, there is an error. And because I work here, I have people to help me, but what about the parents who don't?" Every time that video is shown, we cry. It was overwhelming. So, making the video, just like having the reporter, is courageous.
I agree that sharing stories leads to change. We tell stories at the start of every board meeting. We discuss the harm that we caused. We also share stories on our intranet site. And when times get tough, we don't retreat. When we have an undesirable outcome, we don't turn away from transparency. That is the price we pay to build the movement, to move forward.
SELBERG: That's the most important piece. If you, as the leader, are not willing to model the behavior that you ask of your team, the organization will not move in the desired direction. So, modeling behavior becomes really critical, especially when challenges occur. There are also important economic decisions to consider, too. If one of your high-volume surgeons is not playing ball, you have to confront that behavior regardless of the potential fallout.
VOUTT-GOOS: We had a prominent member of our community die in our care. We worked with his wife and we turned that story into a team communication exercise. We created a video that we share with our staff to work on team communication, and we talk about it. We are working on similar videos for use in training and to generate discussion. It really gets emotional engagement. It is a great strategy.
JOSHI: I think what you are hearing from the leaders here is courage, and courage comes from doing something uncomfortable. There are a lot of master's of hospital administration students out there looking for summer jobs. Imagine if they all did something that made them uncomfortable, such as going to work in public health departments, for example. That would allow them to get a different perspective and would provide courage going forward.
MODERATOR: What is the role of the board in this process?
KELLY: The board is vital and we've had a really positive experience with the board at Abington. I meet regularly with our board chair in my role as chief of staff. About seven years ago, he asked me about his annual gift to the organization. He asked what I would like. I had just attended my first Institute for Healthcare Improvement National Forum a few months before and I asked him to sponsor attendance for 30 to 40 of us at the next meeting, from front-line staff to board members. And he did that. He came along, in addition to three other board members, and we've attended every year since then. One of the things we brought back from the meeting is mandatory patient safety walk arounds for every board member. We also reorganized what is now the safety and quality committee. We open every board meeting with safety and quality. It really has changed the entire perspective of the board to where they see safety and quality as equal to finance, and even to the point of saying, "Well, this is going to cost us some money, but we need to do this because safety and quality matter." A board that's behind you is indispensable to getting this done.
ISGETT: I completely agree. We also begin each board meeting with quality and safety. We lead with incidents of harm or successes that we have achieved. The board is responsible for holding our feet to the fire and they are the representatives of the community. They are really good at making sure that we remember why we're in this business. We are in this business to take care of patients, and money is the second piece.
VOUTT-GOOS: The husband of one of our board members suffered an airway event, and she has contributed a large amount of money to airway improvement teams in our organization, as well as mannequins for training. At our recent quality expo, I showed her some of the mock code work that we are doing. She asked very tough questions and she told us, "It's not good enough yet." It was great to get that feedback from her.
JOSHI: Boards also set the linkage of quality and financial incentives for leadership. I serve on a hospital board and 45 percent of our CEO's incentive payment is based on quality measures. That's big and they are not easy measures. Another board quality committee that I sit on sets a patient satisfaction baseline, a trigger to even be eligible for part of the bonus program. Individuals have to hit patient satisfaction, community benefit and financial measures. It sets a high standard of care.
KOTAGAL: I think boards can be a positive source of energy. Their interest in quality and safety is so clear and obvious that it really inspires the front line. At our board meetings, I never present anything. The people that present are the people who do the work. Our board members often approach them afterward and follow up with them to learn more about their work. That makes people believe that this organization is serious about quality and safety. So, boards are inspirational. They represent the community and really speak for the community. Their support is critical.
MODERATOR: So, is it really about linking with the community and spreading the message of what you are doing?
SELBERG: Yes. The board has to be in alignment for sure. It is really important. Many hospitals have organized medical staffs that have direct accountability to the board. If the board isn't willing to assure accountability for the practice of care across all elements of the hospital, including the medical staff and operations, it will be a difficult journey for the organization.
MODERATOR: Let's discuss medical staff engagement. One of the biggest issues for the hospital field right now is the ongoing alignment and integration with physicians. How do you engage physicians?
KELLY: It is not easy. I think physicians, like the rest of us, are worried about their income. Their immediate recourse is to look to the hospital as a vehicle of rescue, either through partnerships or employment. Hospitals now employ 220,000 physicians. That's an amazing number. Clearly, we can't run hospitals without our doctors. Many of our doctors can't practice unless they have a strong hospital partnership. We must enable them to envision a future in which we are one entity. There probably is going to be some decline in physician income. Don Berwick, M.D., put physician salaries on his list of places where we need to cut dollars. And there was an article in Health Affairs not too long ago stating that one of the big reasons health care is so much more expensive in the United States than Europe is because we pay our doctors far more. Those kinds of realities will take a few years to sink in, but we need to make certain that we have a quality physician workforce. There is no question about it.
I worry about today's medical students coming out with so much debt. That's not new. But, there is talk about expanding the medical school class size by 30 percent; yet, this year there were about 170 U.S. medical graduates who could not get a residency position. That's the first time it ever happened. The government needs to remedy something there or we are going to have a true crisis in a few years, and a lot of people aren't going to take that chance. As a society, we have to make sure that we value our physicians adequately. We recently had to employ our infectious disease division because they weren't making it; you can't run a 600-bed hospital without an infectious disease specialist. I think other organizations are experiencing the same thing.
ISGETT: We really focus on physician engagement. We want to show physicians that we provide opportunities to improve. We try to demonstrate that the improvement work, with the support of improvement methodology, will make it easier for them to do their jobs and do their jobs well.
We've never compensated our physicians for their work in quality, but the very core of why they went into medicine, in most cases, was to make a difference; that really seems to be the motivator for our medical staff team.
KELLY: But do you reach a point where you can't ask them to do anymore?
ISGETT: That's a good point. We've probably been very conservative in the amount of time that we ask of physicians and we are careful in saying we only need your intellect for a specified period of time. We'll do all of the legwork, but we need your guidance. What's interesting is that we have local competition, and our physicians, because of their belief in our health system to be driven toward patient safety, are making concrete decisions to align with us overwhelmingly because of the reputation that we've developed. They know we want to provide excellent health care.
KOTAGAL: We are seeing the same thing. Our physicians want to deliver quality care and if they perceive that the hospital also has the same aim, then they sign on. Early on, they were skeptical about it. But once they saw how committed we were, they became engaged. Most of the time, our physicians represent the voice of the patient. They share feedback from their patients as to how we can improve. Responding to their concerns is very important.
SELBERG: Quality improvement should be taught in medical school. We are working hard to figure out ways to do that, and the Accreditation Council for Graduate Medical Education is certainly one important lever. It's important for all professions —- physicians, nurses and pharmacists — to understand these concepts. They need to understand the power of evaluating variation, the concept of testing for change and determining whether or not improvement is needed. I think it would serve the field well.
VOUTT-GOOS: I would take that a step further and say that we need to engage all clinicians in multidisciplinary learning in their graduate programs so that when they get to the hospital, we don't have to start teaching them how to work together.
SELBERG: That's a great point, a really great point.
MODERATOR: Beyond physicians, how do you engage other clinicians?
KOTAGAL: All of our training sessions are composed of multidisciplinary groups. We include administration as well. We really think that the folks with the business degrees have an important role to play.
VOUTT-GOOS: We've done a lot of team training, but weren't able to sustain the behavior. We ended up putting together an interactive human factors program that is multidisciplinary. It focuses on human limitations. We do a lot of video and group activities to make it fun. We also started a safety champion program that trains staff to be safety experts. That is also a multidisciplinary program that includes physicians, nurses, pharmacists, technicians, engineers, housekeepers and secretaries. We talk about their roles and discuss the value of the different team members before we start the team training. It has been really valuable.
JOSHI: The next frontier is teamwork across organizations, not just from within. That's the next challenge — partnership with the community and with other health care organizations. And I'm not just talking about long-term care or home health, but departments of health, adult day care centers — all types of organizations will contribute to achieving the Triple Aim.
VOUTT-GOOS: We just launched an innovation institute in partnership with the Center for Creative Studies. The group is shadowing staff and working with physicians, and they are coming up with some great ideas.
KOTAGAL: One area in which we are really learning to work across boundaries is in population health. We are working in a single community, bringing all community agencies together. We are