Boosting quality, safety scores hiked staff morale, too, Newark's University Hospital CEO says

When former New Jersey Health Commissioner Shereef Elnahal, MD, became president and CEO of Newark, N.J.-based University Hospital in 2019, improving quality and safety became part of his central goals. 

The 519-bed hospital has seen significant improvement in quality measures, and is on track to meet goals in decreasing catheter-associated urinary tract infections, hospital-acquired pressure injuries, lengths of stay and decreasing deaths, according to figures provided by Dr. Elnahal.

Dr. Elnahal outlined his journey to improve quality and safety at the hospital during the pandemic in a recent conversation with Becker's and shared tips for other healthcare leaders seeking to do the same.

Editor's note: Responses were lightly edited for length and clarity. 

Q: I know University Hospital has seen significant improvements in different quality measures for various hospital-acquired conditions in recent years. What do you attribute that success to?

SE: We've had a very diligent lean, A3 transformation at University Hospital, and we branded the initiative, UHCares. A lot of that has been focused on a culture of safety. I noticed substantial changes in that culture of safety [since 2018]. Part of it was resetting the tone with staff around psychological safety, in raising safety concerns, which I think has been very helpful, but then you also have to institute real structures and governance around quality improvements. The way that looks is huddles in every unit of the organization, especially our clinical units, that cascade up to the hospitalwide safety huddle that we have every morning to raise concerns and issues that the broader group of leaders can address, up to and including our executive leadership team. We've also had targeted committees and improvement efforts on areas where we knew we had deficiencies, so central line-associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, and clostridioides difficile. 

All of those had tremendous improvements over the last couple of years, because they were clearly areas of organizational focus and were buttressed by a multidisciplinary team that used A3 thinking to find out the top contributors and chip away at those contributors every week. And so I'm really proud of that work, mostly because I think the foundational issue which was around willingness and psychological safety to raise issues has been the major ticket and allowing us to improve.

Q: And when you say "A3 thinking" can you clarify exactly what that entails? 

SE: The A3 framework is a tool within lean management that allows you to break down an end state problem into its top contributors using data and critical thinking. So all it is is a methodology for critical thinking and an improvement that doesn't allow you, by its very nature, to simply assume why you have a problem, but rather force you through coaching and through catch ball discussions, to defend your assumptions. And in the process of folks defending their assumptions, they use data, and they use evidence to do so. So it's really just a way to implement the scientific method when it comes to quality improvement in hospitals.

Q: When did the hospital begin implementing this framework of thinking? 

SE: We started, actually, during the pandemic. So we started it in the summer of 2020. We had a little bit of bandwidth, and because we had a lull in cases. Our intention actually was to do this much earlier in the year, but of course we had to contend with the acute surge in the New York metro area. But we knew that despite the pandemic, we had to get ahead of this because we saw our hospital-acquired infections go up significantly, you know, during that time, during those very difficult months, March through May of 2020. And so we had a baseline when I got there this summer before, that wasn't where we wanted to be, and it got even worse. So we knew we had to take quick action. And we did, and I think we're seeing the results now.

Q: How would you say the pandemic has affected quality improvement work? 

SE: The pandemic highlighted the importance of solving these problems, because so many of them got worse. But it also made us a stronger team. The fact that we had to band together — it was a life or death situation for so many patients, and unfortunately, for so many staff because we did have employees die as well, from the disease. That, you know, we've essentially set aside our differences internally and became a very, very strong team during the pandemic — one of the few silver linings, I would argue. That really enabled and motivated us to make progress here because I knew that if we didn't initiate this, we would have people with significant morbidity or even mortality from these hospital acquired conditions. And so you know, people understood that this hospital was responsible for so many lives saved. But we're reminded that if hospitals don't focus on these issues, we can actually be the cause of problems, and so I think that motivated so many of us to engage.

Q: Looking into 2022 and what has gone on in the pandemic thus far, what are your top priorities for patient safety and quality improvement at the hospital?

SE: Our top priority this year is around two things. The first is continuing our progress with CLABSI. We have room for improvement there even though we've made substantial reductions. But then also looking at patient experience. Patient experience suffered during the pandemic period for obvious reasons. We couldn't do the normal scope of things that we do because the system was so stressed to make sure the patient experience was optimal. So we've launched something called our AIDET initiative, which is an acronym that essentially makes sure that whenever people communicate with patients, they do so in a scripted way that allows for everything from an introduction to acknowledgement of the patient and their condition to explaining the duration of what they're going to expect in terms of next steps in their care. It makes sure you don't miss anything when you're talking to patients and that communication is enhanced. We did an A3 analysis on why our HCAHP scores were not where we wanted them to be, and found that communication across the board, from clinicians to patients was the major issue. 

We are also focused on health equity as a major piece of our quality improvement efforts. It's not just understanding how many preventable infections you have. There's also the task of stratifying that by race, ethnicity and gender to understand how much implicit bias is factoring in and how much structural issues around equity can impact quality as well. And so we're in the beginning of that journey, but very informative and important to do that as well.

Q: What advice do you have for other healthcare leaders looking to reinvigorate quality improvement efforts after the pandemic?

SE: I've heard a lot of leaders say that, you know, because of issues around staffing and morale, that it's hard to focus as much on quality improvement and lean transformations like the ones we've instituted. And I think we've, we have a counterexample here in our hospital where, by virtue of engaging people through our quality improvement efforts, we are actually improving morale, because people feel like they have agency, they feel like they're a more central part of the mission. And so it's not just the imperative to improve quality and safety, which is the most important reason to do it for our patients. But it can be a tool to better engage your employees and improve morale in and of itself.


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