Healthcare Leaders Discuss Key Concepts to Police, Improve and Measure Quality

At the Becker's Hospital Review Annual Meeting in Chicago on May 18, Kathleen Crawford, COO of Ashtabula County Medical Center and HFAP nurse surveyor, and Marion Martin, COO of the Center for Quality Innovation and Patient Safety at Roper St. Francis Healthcare, discussed key concepts to police, improve and measure quality.

Q: Can you give us a sense of the state of healthcare quality and what we need to work toward?

Ms. Martin: We need to focus on the patients' experience. It's been a lot of focus on data and compliance [so far], so we all need to step back and look at the patient experience either through the perioperative experience, transitions of care or the emergency department. That focus will take us where we need to be. [The healthcare industry] is at a C- level, so harm needs to be on our radars because there are still pressure ulcers, infections and other adverse events happening in hospitals across the country. We still have harm but we have to change our view and become more patient-centric to get to where we need to be.

Ms. Crawford: From a surveyor standpoint, [the focus on quality] has changed. We used to focus so much on the books, but now we look at actual patient care. We look at whether staff members are doing the right thing at the right time at the right place. We actually follow the staff as they carry out their duties. It's important for us to see you practice what you preach. We make sure, from the housekeeper level to the executive level, that everyone is on the same page.

Q: Marian, it's interesting you bring up the patient experience. Could you both elaborate on that more?

MM: [We at Roper St. Francis] have really changed our tactic around patient experience. It's no longer about how small groups of people take care of patients, but how large groups — from the physicians' office all the way to home — impact patients' experience. It goes back to what Kathy said about the patient experience no longer being about policies and checklists or procedures.

KC: At the Cleveland Clinic, we now have a physician and nurse that work together to enhance the patient experience. Apart from the clinical leadership, we're focusing on teaching the physicians to sit at the patients' level, not stand at the door, etc. It's also been my experience that if a surgeon can openly to patients about medical errors, patients are less likely to sue.

Q: In terms of healthcare quality improvement, what top issues do you think are worth focusing on first?

KC: When there is not any leadership involvement, there's going to be issues. Physician champions are also critical to the success of quality improvement efforts.

MM: Physicians should be leading quality improvement efforts and projects. The other thing, as Kathleen was saying, is it's about culture. It's no longer about being afraid to point out mistakes. Healthcare organizations also must have board accountability. [At Roper St. Francis], there was no patient safety/quality committee on the board. Now we can take quality issues to the board, such as root cause analyses. It creates a culture where it's okay to be transparent.

Q: What steps can leadership take to engage physicians?

KC: Make sure you have meetings with good food. [Laughter] We had a fun year. CMS came in for a complaint and then we had a full survey. When CMS comes back for a full survey, you cannot have any errors. [The hospital leadership] quickly became buddies with the physicians and nurses, and they became more engaged and we passed that survey with flying colors. If they understand what's going on, they will help. Help them help you. The other thing you'll see at organizations like the Cleveland Clinic, many CEOs are also physicians now. And the competitive nature of physicians is they want to do better.

MM: Our leadership is actively walking with physicians on their journey. We have infection prevention rounds with epidemiologists at least once a week. I'm working with a colorectal surgeon to get ready for his disease-specific survey. I asked him to lead a quality committee, and he agreed. When hospital leadership does this, they have to meet them halfway and partner with them. Let them see you'll come in early and stay and help them get to where they need to be in order to be successful.

Q: What have you seen hospitals do to bring down readmissions?

KC: Education of the patients, education of the case management staff who works with patients. Some hospitals have robust case management program that extends to outpatient areas. Some hospitals have programs for high risk "frequent flier" patients to prevent a rehospitalization. We do concurrent utilization review programs, and use benchmarks to monitor our readmission rate. We also have pharmacists help with patient education. All that education can help reduce readmissions.

MM: We have a transitions of care team. Again, the patient journey doesn't end at discharge. We are aware of the top five readmission areas, so we have physicians leading projects that focus on those top five areas. That'll help us bring us where we need to be by October. Physician leadership is going to be the key to success.

Q: What other programs have been successful to combat other patient safety issues, such as medication errors and falls?

MM: We do a root cause analysis on every single infection. We send out our findings as "points to ponder" and share our learning experience with the rest of the hospital. A root cause analysis on every infection takes it to the next level, and our rates have dropped drastically.

KC: The multidisciplinary aspect of patient safety is critical. It goes back to getting the staff to own the issues. It is important everyone is on board. Also, if we have an error, we are always transparent with the patient and the family about medical errors and how we are going to prevent it next time.

MM: In regards to medication errors, we have a pharmacist dedicated to medication safety. A nurse liaison to the pharmacy also boosts patient education. We have another project that encourages and rewards staff members for reporting near misses and medical error.

Q: How do you make the case to the governing board to create these extra positions, such as a nurse liaison to the pharmacy?

MM: We took the idea of pharmacist-led education from another organization. We showed our leadership the return on investment of having that dedicated role. We had 13 adverse occurrences involving insulin pen issues, and we now have zero. So every few months, we will show to the governing body new improvements. We also send the vice presidents to the floor so they can see what it takes to improve quality.

KC: Two things: I'm not afraid to steal from any hospital. If they do something better, I bring it back. Secondly, one thing we implemented across system is leadership rounds. Toby Cosgrove and his crew at the clinic will go out and do facility rounds and unit rounds. That helps the administrative team see that maybe there should be a person who just looks at this or another pharmD that helps identify risks. It helps them get out of the mahogany role.

Q: Measurement is critically important for quality improvement, but it's easier said than done. I'm interested in knowing how you work with data and ensure accuracy.

KC: Scorecards with core measures are great. Every month, we present those scorecards to the entire healthcare organization so everyone understands where we are. We do it in a stoplight fashion — green yellow and red — so they don't have to analyze numbers. Also, the electronic medical record system has helped a lot, even though the go-live process is painful. It helps us gather data easier.

MM: Besides dashboards and scorecards, we also have a cost quality matrix. We are tracking those high-cost complications and adverse outcomes so we can show how their quality improvement efforts also save money.

Q: Policing can be daunting word. How can leadership help employees feel comfortable with policing?

KC: I think the patient safety culture has changed a lot. Ongoing professional practice evaluation and focused professional practice evaluation were put into play this last year with our physicians. It's better for credentialing. We've also created a disruptive physician policy.

We also make sure to always promote safety even though it takes more time to be safe. You cannot make the culture punitive. It's been successful. People are not afraid to report things anymore.

MM: We are doing tracers and mock surveys all the time. If I do a mock survey in the labor and delivery department, my findings are sent to CEO of that hospital. The CEO can check in and see how he can make it better and easier to improve quality. The other invaluable thing, in terms of monitoring, is sharing results, whether they are good or bad. It's more of a dialogue that's much more positive, and you get more people to talk more openly.

Q: If you had to share the single most impactful change or program that improved quality, what was it?

KC: At our hospital, we did not have a vice president of medical operations. Having that leader in place has really helped. Our quality and physician involvement has improved 10 fold.

MM: For us, the biggest thing that has happened is leadership is now on board with what quality can be. It's more about how are we doing and what can we be doing. Educate the leadership.

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