12 Steps for Hospitals to Comply With Core Measures From Keith Granger, Former CEO of Flowers Hospital

The highest scorer in the nation in CMS' Core Measures process-of-care program in 2009 was 235-bed Flowers Hospital in Dothan, Ala., an affiliate of Community Health Systems, which operates 122 hospitals in 29 states.

The CMS program measures hospitals on how often they provide recommended treatments in 22 measures involving patients with acute myocardial infarction, heart failure, pneumonia and surgery.

Former Flowers CEO Keith Granger explains the 12 steps the hospital took to bring compliance up to the highest level. Mr. Granger has since become president and CEO of 560-bed Trinity Medical Center in Birmingham, Ala., which is also affiliated with CHS, but while at Flowers he planned and implemented the changes that led to the hospital's big coup.

1. Start off slowly. Flowers always had some type of quality improvement process, but the hospital started getting very serious about it in 2005 when CMS began laying the groundwork for Core Measures. It took 18 months of meetings before Mr. Granger felt he had the right environment. "The early meetings were emotional," he recalls. It was hard for staff to take critical scrutiny because "they did not like to think of themselves as contributing to a mistake."

2. Build the culture you need. Mr. Granger first aimed to create a culture of high performance, inclusiveness and teamwork before clinical applications would begin. "You need to build relationships with trust built into them and make sure people understand your expectations," he says.

3. The CEO must be facilitator. Mr. Granger saw himself as facilitator and mentor for some 1,100 employees at Flowers. He also tried to be inquiring, making sure everyone shared experiences and helping them look at their work in a new way. The CEO became a storyteller, presenting analogies from other walks of life. "I tried to keep the story simple and understandable," he says. "Employees want to do the right thing but you need to lay out for them what steps are expected."

4. Provide a clear vision. He tried to give employees a clear vision of what the hospital was trying to achieve. "I think it helped that I started early in my career as a radiology tech," he says. "Patient care was why I got into healthcare. For me, improving outcomes is a concept I can hold very deeply."

5. Remain focused. "The mindset we wanted was to stay focused 100 percent of the time," he says.

6. Assemble in small teams. Employees were assembled in teams of 10-15 people each, covering acute myocardial infarction, pneumonia, infection reduction and patient falls. Nurses made up about half of the team and the other half were employees from areas such as radiology, respiratory therapy and pharmacy.

7. Identify team leaders. Each team had someone who was process-oriented and could get a conversation going with questions like, "Have you thought of this?" and "What about that?"

8. Meet regularly. The teams met monthly and Mr. Granger also met separately with the team leaders.

9. Disseminate new ideas. Team members went back to examine their work areas from a fresh perspective. "They were sent out to be investigators," Mr. Granger says. Meeting in small groups with staff they worked with, they were charged with coming back to the team with three ideas that could improve a situation.

10. Embark on problem-solving. Teams used problem-solving activities with the people who deliver the care. "We got very specific," Mr. Granger says. "We talked about where we were successful and where we had failed to live up to expectations." For example, they would take a patient's chart and perform a simplified root cause analysis, asking: "Where did the process fail? What steps are needed to make it successful? And what impediments are in the way, both conscious and unconscious?" Teams came up with a list of problems, such as cumbersome documentation or a missing tool.

11. Don't bring excuses. Team members always told themselves, "Don't bring excuses; bring solutions."

12. You can always do better. As teams approached their goals, "we couldn't sit around and pat ourselves on the back, because it still wouldn't be good enough," Mr. Granger says. The shortcomings that remained were presented on a personal level that anyone could relate to. "If we had just one failure in a 1,000, we'd ask, 'What if that one failure involved a surgical site infection on my daughter?' It would be a 100 percent failure to me," he says.

Learn more about Flowers Hospital.

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