8 Steps to Building a Truly Transparent Hospital

Three hospital leaders discuss how their hospitals embraced transparency and data distribution to improve finances, satisfaction and clinical outcomes at their facilities.

1. Institute a "no blame" culture. "For transparency to be truly effective, hospitals must embrace a blame-free culture," says Judith Canfield, director of surgical services at Providence Regional Medical Center Everett (Wash).  In this type of environment, a hospital staff will respond to the publication of negative outcomes by thinking of ways to improve, rather than pointing the finger at an individual department or team member. "Once you take away the blame, people are more likely to immediately give you information on something [negative] that happened," Ms. Canfield says. "I know two or three years ago, people at our hospital weren't as forthcoming as they are today. If something happens in the course of a surgery, the patient will find out very rapidly."

A cultural shift of this nature is not easy, but it is possible as administration gets involved in encouraging providers and staff to disclose information. At Providence Regional Medical Center, if an unexpected surgical event occurs, the team notifies the patient as soon as possible and explains what happened. In order to implement this policy, the hospital initiated  a training course that taught physicians and leaders how to disclose adverse information. "All our leaders are trained in disclosure, so if we have a physician who doesn't feel comfortable, all they have to do is call one of the quality leaders [who] work with the physician to do it," she says. If physicians understand that disclosing adverse information doesn't equate to "getting in trouble" with hospital administration, they will be more likely to participate.  

2. Improve access to data across the organization. If you want your staff to engage with your benchmarks and outcomes, you have to make the data accessible. This means posting the data in a place where employees congregate or visit on a regular basis rather than hiding it on a little-visited section of your Web site. Ms. Canfield says her hospital posts data on bulletin boards and in employee newsletters. "We also have staff meetings once a month and review the information so that staff can see and understand it," she says. Dave Fox, CEO of Advocate Good Samaritan Hospital in Downers Grove, Ill., says hospital "report cards" are available on the hospital and health system's intranet. "We can all look at each other's performance and see how we're doing — and even more importantly, we can see where we're struggling and not getting it done," he says.

Jerry Royer, CMO of San Joaquin General Hospital in French Camp, Calif., says his organization shares information on quality improvement projects by asking every department to report to a standards committee on a regular basis. The committee collects information on which departments are participating in quality improvement projects. This reporting policy improves awareness across the hospital of how departments are working to improve their outcomes and meet benchmarks.

3. Set high goals. Even if your organization consistently meets industry benchmarks — and especially if it doesn't — your administration should set high goals for improvement. As data becomes more publicly available, hospitals will be held to a higher standard, and case volume may drop for facilities with unimpressive satisfaction scores or troubling infection rates. Improvement is also essential for raising employee and physician satisfaction. Good outcomes mean better job security for your staff and providers, and employees will likely be happier if they know the hospital is striving to improve and therefore secure their paychecks.

Advocate Good Samaritan boasts very impressive benchmarking rates now — but Mr. Fox says it hasn't always been that way. The hospital's success is based on a policy of transparency and constant improvement. "I can go back to July 2004, when our outpatient satisfaction was at the seventh percentile," he says. "Over a 24-month period, we moved it up to the 99th percentile. We decided to get serious about patient satisfaction." In July 2004, the hospital launched an initiative called "Good to Great," which sought to make Good Samaritan the best facility for patients, associates and physicians.

4. Give staff responsibility for improving hospital processes.
In order to build a transparent organization, Ms. Canfield says staff members need to understand organizational  goals and trust that you have faith in their ability to meet them. If you don't establish a foundation of trust, publicized data can feel punitive rather than instructive, and employees may feel discouraged when the organization does not meet its targets. She says Providence Regional Medical Center builds that level of trust by giving employees the accountability  for improving their individual areas of the hospital. When the hospital started planning its new 12-story patient tower, due to open in June 2011, she brought together teams of staff from the cardiac cath lab, interventional radiology and operating rooms to discuss how the divisions would work together in the new building. "These areas are separate right now and don't relate to each other, but are going to be physically located on the same procedural floor. A key element of these cultures coming together is  that all the IR, CVL and OR staff members  developed the processes of patient flow and how the patient's care would be delivered  in this unit," she says. "I have a book of  12 pages of decisions and agreements that they've made regarding  how they are  going to work."

She says the administration stood back from the collaboration to allow the departments to work together. When each division could explain their processes and challenges to the other divisions, staff members were able to work together and find a solution. By developing the booklet of agreements, staff members were able to standardize processes and increase transparency regarding what was expected of them.

5. Give physicians credible data. In order to involve your physicians in improvement efforts, give them data that clearly demonstrates how their efforts affect quality and cost. If physicians understand that their clinical waste negatively affects the hospital's bottom line, they will be motivated to change their practices — especially if you point out that other hospital physicians have seen better results. At San Joaquin General Hospital, physicians in certain departments gather to discuss metrics and compare results.

In some cases, Mr. Royer says, physicians point out that the data is unreliable because of a certain variable. "For gall bladder surgery, we'll have eight or 10 physicians who are doing surgery, and they all have different lengths of stay and different tests that they order," Mr. Royer says. "When you come together and share these, especially if you have 10 physicians in the room who are identified by letter, it's not very long until someone says, 'I'm letter E and my costs are greater because my patients typically come from the emergency room, and therefore the initial ultrasound shows up on my profile." In this case, sharing data with physicians can alert the hospital to compounding factors that may skew data. In other cases, physicians will come up with 'best practices' based on the shared results. Mr. Royer says when physicians at his hospital shared information on medication use for heart procedures, they were able to come to a consensus about which medication provided the best outcomes. He says the key is to gather a small, specialty-specific group in a room and ask them to speak openly about the data you provide.

6. Follow up quickly with underperforming departments. If you want your data to spur improvement in your facility, you have to follow up with struggling departments as soon as possible after results are released. If benchmarking data shows that a certain department is trailing the industry standard and hospital administration does not respond, staff members will probably think the data is not taken seriously. Advocate Good Samaritan promotes transparency by grading its facility on 25 organizational goals, some of which are published on a monthly or weekly basis to track progress. Every Tuesday the organization publishes and discusses patient satisfaction, Mr. Fox says. "If there's a particular department or service that isn't having good results that month, we drill down to understand why." He says the same holds true for net revenue (actual vs. budget), which is reported every Monday. If the hospital is not meeting its budget on net revenue, administration immediately responds to determine where revenue can be increased or spending can be cut.

Hospitals should also respond quickly in departments where data fluctuates over time and affects hospital costs. Ms. Canfield says her hospital benchmarks a productivity report against 400-500 other hospitals to make sure each department is appropriately using the resources of the organization. "A good example is Christmas week and New Year’s week, where cases are usually  low," she says. "We're always flexing up and down with our staffing, so we're not sitting there with a whole board of staff for half the cases." Looking at data on a regular basis can help you respond in time and save money that would otherwise be wasted.

7. Collaborate with outside providers to benchmark physicians. If your hospital uses an anesthesia provider with its own review process, make sure to collaborate with the provider to benchmark anesthesiologist performance. This collaboration will save your hospital time and money, and the provider may give you data on measures you would not have otherwise considered. Ms. Canfield says her hospital's collaboration with their anesthesia partner, Somnia Anesthesia, has improved the process of determining how adverse events occur in the operating room. "When a clinical patient issue is involved with a quality issue, anesthesia is always involved as they're part of the team," she says. "The team participates in root cause analysis to further examine elements that can be improved." If your anesthesia provider has its own peer review process, you can also depend on the provider for information about anesthesiologist performance, satisfaction and global issues in the anesthesia department.

8. Understand that as the industry improves, you will have to improve too.
Although Advocate Good Samaritan Medical Center sits comfortably in the top percentile on many of its benchmarks, Mr. Fox understands that the hospital cannot be complacent about its high scores. "Everybody is getting better, so you have to get better in order to maintain your percentile ranking in patient satisfaction or Medicare core measures," he says. "If you're standing still with your results, you're probably going to slip behind in terms of percentile." For example, Advocate Good Samaritan's outpatient satisfaction score two years ago put the hospital in the 90th percentile nationally; today, that same score would put the hospital in the 75th percentile, he says.

Thank you to Somnia Anesthesia for setting up these interviews. Read more about Somnia Anesthesia.

Read more on hospital transparency:

-New Continuing Disclosure Requirements

-New Jersey Hospital Association Opposes Proposed Bill Forcing Hospitals to Make Finances, Compensation Public

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