Hospitals honored by Quest prize for quality
Hospitals honored by Quest prize for quality
Leadership involvement key to all winners
Maybe in today's jaded world, $75,000 doesn't seem like a lot of money to win. But along with that little financial windfall won by University Hospital Case Medical Center in Cleveland in July, came a prestigious title: Winner of the American Hospital Association McKesson Quest for Quality award.
It's kind of unsettling being held up above so many other great facilities, particularly when the finalists all have so much in common, says William Annable, MD, chief quality officer at the hospital. At a panel discussion with the three finalists, he said he was struck by how often they do the same things as each other, despite differences of geography or size or patient type.
Among the projects that the Cleveland facility was hailed for implementing was an innovative transparent reporting system for events that allows for facilitywide study, leadership review, and prioritizing of event attention. They also have one of the most unique resident training programs in the country, which requires new doctors to spend a rotation studying quality and then create a year-long quality improvement project to see from concept through implementation and review.
Other elements mentioned included a surgical safety checklist, which started off with a mandatory meeting for education that left the ORs vacant barring for emergent needs; implementation of checklists to reduce infections; focus on the time it takes to do several key tasks, such as admitting or discharging a patient, or getting a particular lab result; and accessible information for employees regarding how they are doing on key measurements.
"I think the most important thing about us is that our board is tremendously involved in quality and safety issues," Annable says. Patient representatives sit on the board committee for quality; they participate in "lessons learned" sessions related to adverse events.
The resident education in quality is something else in which Annable expresses deep pride. "Most doctors are supposed to learn about quality through osmosis or something," he says. "What we do is highly unusual, but I think it is vital to their future functioning as physicians."
Annual safety education for surgeons — that continues to shut the operating theaters for a morning — includes speakers and topics that engage people who might otherwise think they have nothing more to learn.
And what they learn isn't considered proprietary, Annable says. "People in medicine have often hidden things about their quality programs, but quality is for sharing." He is on line daily with other members of the University Health Consortium, either sharing ideas, asking questions of other members regarding what they are doing in a particular area, or brainstorming to help someone else solve a problem.
But most of what they do at the Cleveland hospital isn't much different from what other fine facilities are doing, says Annable. While they want to reach zero — or 100, depending on the metric — for everything they do, the last few points are often hard to achieve. One of the questions on the application for the award asks about something they have seen the least progress on. "For us it is timeliness on just about everything. Whether it's transfers, the surgical schedule, or discharges, we really struggle." They use the "Time Is" phrase a lot to engage staff — time is muscle, time is brain. And they have started working toward the finish line before the patient knows something has started. Discharge planning now starts on admission, or before if it is a planned visit.
The hospital and the other seven facilities in the University Hospital system are working to achieve new goals in new ways that continue to underline the ways in which it is different from its peers. For instance, they wanted to decrease healthcare-acquired infections by 5-10%. So far, it's down by half, in part because they are rewarding staff for achieving a decrease in those infection rates. That may not sound so unique, but in Cleveland it's not just doctors who share in rewards for good performance. "Incentive goals are kind of unique here because we reward down to the nursing level, and it is really helping."
North Carolina wins, too
To the southeast, University of North Carolina Hospital in Chapel Hill is also proud after being named runner up to the AHA-McKesson Quest for Quality award. The facility took home $12,500, according to Larry Mandelkehr, MBA, CPHQ, the director of performance improvement at the facility.
"I can't say I was surprised," he says. "I think we found we were where we thought we were, and that we deserved the level of award we received." He sees success in many of the facility's endeavors, and also room for improvement. "There is always something we can do to improve, and the nice thing about this is that after the site visit, they give you great feedback on areas where you can work harder. They give you ideas for things where you are challenged."
One area that needs work, he says, is spread — applying success in one area to a different clinical environment or a different patient population. "Our coordination needs work. We have multiple improvement groups, and we meet and work together well, but not as well as we could."
What does work in a stellar fashion, says Mandelkehr, is the model for interdisciplinary leadership they have at the facility. "We use triads that are co-led by a physician service leader based on a clinical area like orthopedics or pediatrics, a nurse manager, and a case manager. Those people drive the improvements within that particular group of patients, even down to documentation and coding issues, as well as patient experience and mortality and all the other things QI projects traditionally involve."
Patient experience data shows they are excellent on that front, too, in Chapel Hill. "We have seen real improvement in our HCAHPS scores, and are the highest in our area." That effort, called Carolina Cares, was spearheaded by the department of nursing and the dean of the school of nursing. It is a multi-pronged program that involves developing a caring connection; service recovering rounding; and words and ways to communicate. It was rolled out first among inpatient units, and has since been the basis of an education program for all employees in the healthcare system. It's currently being expanded to diagnostic and outpatient areas, as well.
The award specifically noted the leadership connection to quality in the hospital, and Mandelkehr says it has been spearheaded by the chief operating officer, the chief of staff, and the vice president for operational effectiveness. "We have strong physician leadership here, and that includes around quality improvement," he says. "But we make it a point to identify the right people to take a leadership role in specific projects. They are supported with coaches, the data is provided for them, and if we reach out to someone and it isn't a good fit, we are willing to find someone else to take over, rather than stick with what we have." They don't rely solely on division chiefs or chairs, but will engage physicians who are interested from a research perspective or on a personal level if that's the right person for the job.
Having a top-down quality emphasis has made it easier to engage physicians in quality improvement programs, he continues. It doesn't hurt, either, that the current chief operating officer was the chief of staff for a decade and had the reins of quality improvement among physicians that entire time.
Just having access to the other winners has proved an impetus to make some quality changes at the hospital, says Mandelkehr. "We have talked about the quality education program they have in Cleveland," he says. "We have a performance improvement project requirement in our pediatrics department, with a large educational session and expo after. But it isn't everywhere. So we're expanding it, and every resident in the preventive medicine program will have to do a quality improvement project."
Indeed, the best way to improve is to see what others are doing. The quality scorecards that University Hospital Case Medical Center uses in nearly every area of operation is another thing that Mandelkehr is looking closely at. Another finalist, Lincoln Medical and Mental Health Center in the Bronx — which also took home $12,500 — has a great community outreach and collaboration program. "I've talked to them about that, and also about the issues we have with spreading what we do in one area to another. This is a great chance for us to collaborate."
The AHA also gave out two awards in July to hospital associations for quality work. The Michigan Health and Hospital Association and the South Carolina Hospital Association were awarded the Dick Davidson Quality Milestone Award.
The AHA praised the Michigan association for several programs, including one that seeks to reduce left-without-being-seen rates in emergency rooms. The program saw a decline in such cases of 16.5%. Other quality programs related to reducing harm to perinatal patients and improving Apgar scores in newborns. Participating hospitals reduced elective inductions by 40% and elective Cesarean sections by nearly half.
South Carolina's hospital group has several noted programs, including a partnership with the American Heart Association to reduce treatment times for heart attack patients by more than a third over five years; a safe surgery program involving the World Health Organization Surgical Safety Checklist; and a project that helped reduce central line-associated bloodstream infections by two-thirds over two years.
For more information on this topic, contact:
- William Annable, MD, Chief Quality Officer, University Hospital Case Medical Center, Cleveland, OH. Email: [email protected]
- Larry Mandelkehr, MBA, CPHQ, Director of Performance Improvement, University of North Carolina Hospitals, Chapel Hill, NC. Email: [email protected]
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