Achieving Sustainable Quality: How Baylor Scott & White Health Leads Healthcare Improvement

Over the last decade, Dallas-based Baylor Health Care System, which merged on Oct. 1, 2013 with Temple, Texas-based Scott & White Healthcare to form Baylor Scott & White Health, the largest nonprofit healthcare system in Texas, has focused intensely on achieving one goal above all other competing priorities: becoming a high-value healthcare provider. The system's intense focus has paid off.

It has lowered healthcare costs, reduced readmissions, improved patient experience and, earlier this year, one of its hospitals, Baylor Regional Medical Center at Plano, received the highly coveted Malcolm Baldrige National Quality Award for performance excellence.

It's secret? STEEEP. The six-letter acronym represents an overarching guide to how care is provided at BHCS, and how quality improvement projects are selected, prioritized and executed. STEEEP has been a huge success at Baylor, and recently the health system published a book —"Achieving STEEEP Health Care" (2013, CRC Press) — profiling the development and rollout of the program.

David J. Ballard, MD, MSPH, PhD, the first chief quality officer for BHCS and now chief quality officer for BSWH, says the book is intended to help spread the STEEEP story, sharing best practices with other health systems in hopes that the information can be used to improve care globally. 

A little bit of history
STEEEP's early beginnings took root in 2000, when the board chair chartered Dr. Ballard to lead the development of a healthcare quality improvement strategic plan. Related to this plan, the board adopted a resolution that included the language "achieving quality and safety levels only equal to or slightly better than national, regional, or local norms is not compatible with the BHCS Vision and Mission." Through that resolution the board made a commitment that quality would receive the highest priority in planning and budgeting across the organization.

Around that time, the Institute of Medicine and the National Academy of Sciences was convening to explore the same issue for national healthcare delivery, the result of which were the seminal 1999 "To Err is Human" and the subsequent 2001 "Crossing the Quality Chasm" reports. The reports identified six aims for high-quality healthcare in the 21st century: healthcare should be safe, effective, patient-centered, timely, efficient and equitable. BHCS leaders believed in these six aims for healthcare and hoped to use them as principles in its quality strategy, but they pondered how to engrain them into the daily operations of the health system. "We considered the IOM framing, and we thought: 'How do you communicate what it is about to 20,000 employees?'" says Dr. Ballard.

The answer: Rearranging the six words in an easy-to-remember acronym that represents an ongoing march toward the delivery of high-quality healthcare. STEEEP — Safe, Timely Effective, Efficient, Equitable, Patient-Centered care — would be used to communicate to employees the areas of focus guiding the delivery of healthcare at Baylor.

"Achieving the transition from the current state of healthcare to ideal healthcare could be conceptualized as a steep climb," says Dr. Ballard, explaining how the acronym also represents the challenge of consistently delivering ideal healthcare.

More than an acronym
BHCS trademarked STEEEP and set out to instill its guiding principles into the hearts and minds of the individuals responsible for the system's day-to-day operations. Leadership knew, though, that simply rolling out an acronym wasn't enough to bring about the change needed to significantly improve care. Instead, cultural change was required, and BHCS decided to guide the development of this new culture through two major changes: First, putting a governance structure in place to oversee STEEEP initiatives, and, second, putting metrics in place that hold people accountable for a certain level of performance related to quality.  

"Over time we became increasingly deliberate about what we actually meant about care that is 'STEEEP,' what it really means in each of those domains, and what you need to have in place to successfully transform care to achieve those aims," says Dr. Ballard.

As the organization uncovered just what metrics would drive improvement across STEEEP aims, it adjusted its executive compensation plans to include elements of these six aims. "We had a 20-year history of performance-based compensation based on financial results," explains Dr. Ballard. Bill Aston [a long-time Baylor board member and former president, CEO and chairman of Dallas Power & Light Co., who passed away in 2010] proposed at one of the quality strategic planning meetings to consider modifying the BHCS incentive program so that there would be compensation at risk related to healthcare quality performance as well to "have skin in the game related to STEEEP care."

"When you have a board group that says, 'Our expectation is that you're going to have your performance incentive programs related to health care quality,' that really plays a major role in accelerating improvement in an organization with performance-based compensation," he adds.

STEEEP governance
To provide a structure to achieve these aims, Joel Allison, then the BHCS CEO and president and now the BHCS and BSWH CEO, chartered the STEEEP Governance Council, which now reports directly to the president of BHCS, Gary Brock. Donald Kennerly, MD, the BHCS chief quality officer, currently chairs the governance council, which consists of five subcommittees — Patient Safety, Clinical Excellence (which combines the principles of Timeliness and Effectiveness), Efficiency/Fiscal Impact, Equity/Population Health and Patient Centeredness/Patient Experience. Each subcommittee includes members from various clinical groups and roles as well as employees from business support services, including IT, compliance, finance, human resources and the supply chain. Patient advisors also serve on the various committees as relevant topics are brought for discussion.

Each subcommittee presents improvement project ideas, operational recommendations with systematic impact, and annual goal recommendations to the governance council, which prioritizes recommendations and assigns resources as necessary. If pilot interventions are successful, they are eventually rolled out to the entire health system. As one example, the patient safety subcommittee uses results of the system's patient safety culture survey  to guide patient safety project development, targeting areas with important improvement opportunities.

"It's about measuring, identifying where improvement opportunities are, and developing interventions and testing the effectiveness of the interventions in a continuous manner to improve care," says Dr. Ballard.

BHCS even created its own analytics group, called STEEEP Measurement, Analytics and Reporting, to provide comprehensive analytics for the quality improvement initiatives across the organization.

Improvement ideas don't just come from STEEEP committee members, though. Each employee at the director level and above is trained in rapid-cycle process improvement methods and applies these methods to a specific improvement opportunity in their day-to-day operations with coaching from the BHCS STEEEP Academy staff. Employees in front-line roles also participate in STEEEP care improvement training, including via "just in time" worksite training or in a classroom setting as part of a team, says Dr. Ballard.

Success stories
BHCS has had multiple success stories arise out of each of its five subcommittees, and each provides valuable insight for other health systems. Here, Dr. Ballard shares three of his favorite successes.

Effectiveness: The problem with encouraging cardiovascular screenings not supported by evidence
Recently the Clinical Effectiveness subcommittee evaluated an opportunity for Baylor to partner with a cardiovascular screening van that would travel throughout the community and screen community residents for potential cardiovascular problems. The committee reviewed the tests that would be administered by the program, and agreed with the U.S. Preventive Services Task Force's assessments that, for the majority of the tests, the potential benefits did not exceed the potential harms to patients — harm that considers not just clinical risk, but the waste in financial costs and patient time from unnecessary testing.

"So while from a financial perspective, it may have been a good idea to have [vans] out in the community [leading to referrals], from a clinical effectiveness perspective, we though that it was not the best thing to do because the evidence didn't support most of these screening tests," explains Dr. Ballard.

Efficiency: 60 order sets for one condition
"About five years ago, we were looking into heart failure care at our hospitals and determined we had more than 60 heart failure order sets," says Dr. Ballard. "So, a nurse might have to manage 10 different order sets for 10 different patients." Realizing the inefficiency that created, BHCS highlighted a standardized evidence-based approach to the heart failure patient as a key priority.

BHCS convened a working group of cardiologists, pharmacists, nurses and others, to generate a single order set based on medical evidence. The group did so, and within eight months of its launch, had achieved a 95 percent compliance rate. Use of the single order set reduced costs, as expected, but it also reduced mortality and readmissions. Specifically, the order set led to a $1,901 per patient decrease in total direct cost of care for heart failure, and a 51 percent decrease in in-hospital mortality risk.

BHCS extrapolated those improvements and found that, when they translated their numbers to all hospitals in the nation, the potential annual savings would be $2 billion, with approximately 15,000 lives saved annually.

Patient-centeredness: No 'visitors' leads to improved patient and family experience
As part of its work to improve patient-centeredness, in 2011 BHCS opened up all of its patients' hospital and exam room areas to their family members and/or loved ones 24 hours a day, seven days a week, 365 days a year. Shifting the paradigm from 'visitors' to 'primary supporting partners' required leaders from across the system to agree to loved ones spending the night, inviting loved ones into bedside rounds, allowing children to visit family in the intensive care units, and removing security access from many doors and areas. In less than 18 months, the entire system was able to remove 'visiting hours' signs, implement a single system policy and demonstrate improvement in patient and family experience. It announced the change with a tongue-in-cheek policy: 'No visitors! We welcome you in the care of your loved one!'

"We want to help our patients be close to their loved ones throughout their care, and having loved ones near has been associated with reducing anxiety in patients during their hospital stay, and it often helps caregivers to be better informed about the patient," says Dr. Ballard.

STEEEP's future
It's likely STEEEP will remain a guiding force for Baylor Scott & White Health. STEEEP has been immensely successful in driving quality outcomes at BHCS, and Dr. Ballard hopes it can continue to impact the new organization, as well as other healthcare organizations across the country.

"This is about aligning with the national framework for improving quality. Many other organizations are engaging in this challenge, and as people read the book, they'll see STEEEP aims as guiding forces for our efforts to cross the quality chasm," he says.

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