Believing in Quality Care and Delivering it: How UPMC Has Mastered Both

Tami Minnier, RN, MSN, chief quality officer at University of Pittsburgh Medical Center, will tell you the simplest things often generate the most excitement and change. Since assuming her position in 2008, Ms. Minnier has been a key leader in UPMC's safety and quality innovations and also successfully led the system's hospitals in Italy and Ireland through the Joint Commission International accreditation process.

"It's an amazing time to be involved in the quality and safety of healthcare today. It's always mattered, but today it matters even more," says Ms. Minnier, who took time to discuss fearlessness and risk-taking, the secret to success when working with physicians, the importance of clinical evidence when working with CMOs and healthcare quality on an international scale.

Q: What skills, communication strategies or leadership tactics have you found to be most critical or effective in quality improvement initiatives?

Ms. Minnier: When you step back and think about skills and tactics, I think one thing that has made UPMC successful is our willingness to speak what’s right. It's the ability to be transparent, to state expectations, put the patient first and fully believe in arguments around why that patient needs to be first. It sounds so simple. Skills matter, but what really matters is courage — the courage to say, "No, I hear what you're saying, but I really think we need to go in this direction."

Courage and risk-taking make the most difference between an organization that is willing to talk about safety and quality and an organization willing to do [something about] it. You can learn these things, but [leaders] have to put money where [their] mouths are and jump in. These leaders are willing to speak out, to have courage, take risks and even be disruptive at times.

Q: Can you recall a risk that UPMC has taken?

Ms. Minnier: UPMC was the first in the nation to launch a Condition H (Help) program. Essentially, Condition H is when patients and families call for a rapid response team. We decided, that patients and families know more about their situation than any of us, so in 2005, we implemented Condition H. [Editor's note: Condition codes traditionally have been activated by health care providers. This program asks patients and visitors to act as a care team by alerting caregivers to clinical changes.]

I had the privilege of hearing Mrs. Sorrel King speak. She lost her 18-month-old daughter, Josie, to narcotic misuse, severe dehydration and breakdowns in communication. She said, "Gosh, if I had been able to call one of those rapid response teams, maybe my daughter would still be alive." And I thought to myself, she's right. So I came back to UPMC as chief nursing officer and we began discussions about rapid response teams.

The president of our Hospital and Community Services Division, Elizabeth Concordia,  jumped right on board and really believed in the program. We became one of the first hospitals to allow patients and families to do this. We know now that there are about 200 hospitals from across the country that adopted this program. When we first talked about it, some people said, "You're crazy! Are you nuts?" And we said no, let's step back and think about this: it's the right thing to do. When you're sitting at home on your couch, you know when to call 911.

We've had it in place for a little over five years and it's not abused. It's used by people with real issues who need something in healthcare they're not receiving. I'm proud of that and think it's a good example of risk-taking. I give all the credit to our leadership, which had the courage to say, "We're going to do this." It's a national innovation that we're still called to speak on from time to time.

Q: How do you boost or maintain physician involvement in quality/safety improvements?

Ms. Minnier: We begin with a very strong core value. Fundamentally, every physician cares about quality and safety. Through busy careers, patient volume and activities, they might not have the time to stay actively engaged in quality. Our quality model helps them stay engaged. We have improvement specialists, staff with clinical backgrounds but also  skills in quality improvement and safety. We partner them with busy physicians, and they give physicians some pieces of infrastructure to engage them. The physicians need that partner to help make [quality initiatives] come to life.

Part of our success is recognizing that everyone believes in it, but how do you deliver it? Our quality symposium, which is coming up on Oct. 3, will feature the more than 100 physicians who are working with improvement specialists to deliver quality or safety goals. A few years ago, that number might have been 20 or 30. We've given them the platform to succeed.

Q: How can the CMO take on a more active role in quality/safety improvements? Are there any aspects of quality the CMO can accomplish through their role that other chiefs might not be able to influence as strongly?

Ms. Minnier: The CMO is an extremely critical role in most organizations today. Every CMO role is a little different in each culture, but all CMOs care about quality and safety and drive home those improvements. To get them to be more actively involved, one of the things we've found successful is to provide them with the information to have the conversation. We're data rich and information poor. [This industry] is still building the infrastructures that are necessary that other industries have had for years.

It makes a difference when I can give a CMO good information on a clinical practice, and they can talk to practicing physicians. We're giving them the infrastructure to succeed (just as we've done with our physicians), which is solid, factual information that helps them.

This is the greatest secret about success: physicians are scientists. They are used to analyzing information to make decisions about patients. You don't want to go up to them and say, "Oh, I have an issue, can you help me fix it?" You want to say, "I've looked at this analysis, and I've looked at this information, and now I need your help finding out what it means."

Q: A recent survey by Thomson Reuters found quality improvements to be the top priority of hospital CEOs. Do you think quality improvements have a more prominent role in healthcare administration today compared to years past?

Ms. Minnier: I do think quality is much more of a priority. I mention my boss, Elizabeth Concordia, president of our Hospital and Community Services Division, often because she is the driver of this work in our hospitals. Nationally, I think value-based purchasing, whether you like it or not, [has made a difference].

For less enlightened organizations that haven't put quality as a cornerstone of their functioning, VBP pushes them to do it. So whether you've been pushed or ran towards it, all hospital CEOs are paying more attention to this topic than ever before. They're seeking more guidance from quality staff, national experts and others.

Q: What are your thoughts on quality now being tied into payments?

Ms. Minnier: I firmly believe that certain metrics should be tied to payments. I think the most important points I have caution around are this: Let's not make so many metrics that the metrics matter more than the patient. In two years, I'll have more than 100 things to measure.

We've got to be cautious about how quickly we grow and how many measures we add. We're moving an enormous system in the United States. It's a big job, and an important job that takes time. I just don't want to lose the good by trying to push so fast that it becomes about checking off a box. There are unintended consequences of measuring something, and there's a difference between checking a box versus doing the right thing.

It's a fine line between how quickly and how many metrics you tie to performance versus how many will stimulate change. I think it's an issue of the number [of metrics]. Now, realize, I can see the other side of it — there is so much evidence in literature that the healthcare industry has yet to adopt into practice.

I appreciate our regulators’ sense of urgency about quality of care. But that has to be balanced against how much a system can still tolerate in change while maintaining success. I don't mean to be critical of it, I just think we need to be thoughtful of what we add to this matrix in the future. We should add [metrics] that can save people's lives and reduce mortality rates.

Q: You've been involved in the Joint Commission International accreditation process, as well. Can you share some insight on quality in American hospitals compared to quality care elsewhere?

Ms. Minnier: The amazing thing about international quality is the breadth of difference you see in these countries. There are countries where care is delivered in a shack or a rice field, and a healthcare professional might not even be present. Then there is the other extreme, where care is delivered that meets or exceeds U.S. standards. How do you take these countries that have very diverse performance in quality and delivery and move them towards a standard?

I think Joint Commission International has been very thoughtful of that. All of our [non-U.S.] UPMC hospitals are Joint Commission International accredited. We're very proud of that, and we look at that as a step in establishing basic care standards in our organization. The quality of care delivered in our sites is spectacular. I'm very proud of what our international sites have done, but I also recognize they're a small portion of international sites that have achieved [accreditation].

It's a huge hurdle for most international organizations to come up to speed. In many parts of the world, there's this wonderful desire and drive, but sometimes it's an issue of resources.  I'm never critical of them, because they're doing the best they can.

Q: How does UPMC approach quality measurements or benchmarks? How are these figures communicated with staff, and how do you break goals into manageable processes?

Ms. Minnier: We measure everything you can imagine. We use benchmarks a lot, and we firmly believe in benchmarking our performance. Certain benchmarks are easy to get our hands on, like CMS measures, patient satisfaction scores, and Joint Commission measures. The more clinical you become, the harder it is to get data. So you start benchmarking yourself against yourself.

We use benchmarks to stimulate improvement. We'll look at other scores and say, "Well, we're here. They're there. Wonder how we're different? How could we get better?" So we call people, we engage and we learn from many people across the country. We try to bring processes back and engage our clinical leadership to improve at UPMC.

Every benchmark has a process behind it. If your emergency department throughput is the best in the country, then why are you so successful? Is it your triage to treatment time? We want to break this down, make it very granular. Then we use fancy tools, like Lean or Six Sigma. There's a science to improvement that we firmly believe in and use, but we don't run around and talk about it. We teach others as we go, and we use different tools.

Q: Can you share any exciting developments or news that is happening at UPMC in terms of quality?

Ms. Minnier: We have so many things going on. One new innovation is our reliable and variable rounding system for nursing care delivery. Nursing assistants are intended to do basic things, like bathe the patient and help them to the bathroom. From a patient perspective, those are very important jobs. Many times, when it comes down to a patient's perception of care, they judge the nursing assistants' jobs quite a bit.

Healthcare has traditionally never approached nursing assistants in a structured, organized way. By bringing in the principles of the science of reliability, we recognized that there is work that needs to happen on a nursing unit that is very reliable and very predictable. People need their water pitchers filled. People need to be turned and repositioned in their beds. People need meals fed to them. Then there is variable work — a patient needs an X-ray, or a patient has suddenly been discharged and needs to go home. We’ve been trying to mix that work, but you just can't.

It's been two years since we started a completely new care delivery mode. We're an early adopter of this model, which separates the work of nursing assistants into reliable rounders and variable rounders. We have a ton of early data to show how much we've improved how frequently patients see nursing assistants, how much they're turned, how much they walk and how much happier they are.

Q: It seems like an innovation that is so simple it makes you wonder why no one has thought of it before.

Ms. Minner:
Yes, exactly. We're super excited about this innovation, and this new way of thinking about nursing care delivery in healthcare. It really shows how you can change healthcare by using principles from other industries. The stuff that is most innovative and creative is not sexy, advanced technology — it is simple sense. The things that excite me most tend to be the most basic.

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