How health systems infuse quality into daily operations

Gone are the days when quality is owned by a single department or measured on a distant dashboard. 

Today, clinical quality is woven into the fabric of nearly every aspect of health system operations, with leaders treating it as a core strategy to improve outcomes, reduce costs and address inequities. But this was not always the case. 

Just 20 years ago, chief quality officers were not a common part of hospital C-suites. At the time, quality improvement was still largely seen as the work of a single department, rather than a shared responsibility across the organization. 

Efforts to integrate quality and safety into healthcare operations gained momentum in the 1990s, with initiatives such as the founding of the Institute for Healthcare Improvement and the Leapfrog Group in 2000. The passage of the Affordable Care Act in 2010 also amplified this focus, creating additional accountability measures for hospitals and health systems.

Over time, this emphasis has grown significantly, with today's health system leaders routinely highlighting the importance of ingraining quality and safety into their organizational culture.

Becker’s recently spoke to leaders at Jefferson Health, Ascension and Johns Hopkins Medicine to explore how they have evolved their strategies. 

Culture as a differentiator 

Monitoring data, setting goals and implementing improvement initiatives are critical to advancing patient outcomes. But the ability to sustain an ever-present focus on quality and continuous improvement boils down to an organization's culture, leaders told Becker's

"This is critical," said Richard Fogel, executive vice president and chief health outcomes officer at St. Louis-based Ascension. "It's not just me speaking about culture and it's not just clinical leaders speaking about culture. It's Mr. [Joseph] Impicciche, who is the CEO, talking about the importance of putting the patient in the center of everything we do."

The ability for teams to align around a goal is table stakes when it comes to quality improvement. But historically, this is also where patient safety advancements fall short. Targeted efforts to reduce the rate of a specific compilation, for example, are important, and many hospitals excel in this space. The differentiator, leaders say, is having a culture in which teams' focus on quality and safety is constant — where momentum and progress are not lost when a goal is met.

"The real movement in healthcare quality is around the culture that you build," said Thomas Aloia, MD, executive vice president and chief clinical officer at Ascension. "You need the culture to be gap fillers on any initiative."

At Ascension, building a high-reliability culture where employees are comfortable stopping the line if they identify a potential safety risk and reporting events has taken years of intentional efforts from leaders and is an ongoing priority. Over the next several years, leaders plan to elevate this focus to ensure the 136-hospital system is able to continue driving measurable improvements in patient outcomes and eliminating disparities long into the future. 

"We're really going to double down on that culture side of the equation as much as we do the initiative side over the next few years to really take us to an even higher level," Dr. Aloia said. 

Harnessing data to align priorities

Data is a critical part of building trust with team members and sustaining a strong quality and safety culture at Philadelphia-based Jefferson Health, which recently merged with Leigh Valley Health Network to form a 32-hospital system. Several years ago, Jefferson developed a quality and safety management platform called OnPoint to disseminate information about clinical priorities and care pathways. The platform is also used to show clinicians how their efforts are directly improving patient outcomes. 

When Jefferson introduced new sepsis care pathways through the platform in 2021, for example, data was routinely shared with clinicians to demonstrate how the changes they were being asked to make were achieving the desired results. Since then, the health system has achieved a 25% reduction in average annual sepsis mortality. 

"Change can always be challenging," said Patricia Henwood, MD, executive vice president and chief quality officer at Jefferson. "Focusing on the why and transparent communication is really important in bringing people along [when asking them to do something differently]."

At Ascension, Dr. Fogel said data is key to achieving the system's larger care goals. The health system has spent years building a robust data structure that allows it to identify and address disparities. 

"We are gathering data, big data at scale, on the 6 million patients that Ascension sees each year," he said. "That's about 2% of American healthcare [that] flows through Ascension, and we collect clinical data and demographic data, which really allows us to look at mega trends and to really focus on improving things at scale, especially at reducing disparities at scale."

One of the system's clinical priority goals for this year is connecting more patients to primary care, particularly in regions where there is high emergency department utilization for nonemergent needs. 

"We've expanded our clinic offerings, our community health outreach to try to provide more access points for those patients in primary care, so that we catch things earlier and it doesn't escalate to an emergency visit," Dr. Aloia said, underscoring the role data played in determining which areas to prioritize. 

Balancing system goals with local needs 

Competing priorities are inevitable at large health systems, given teams may be caring for different patient populations across care settings. At the local level, clinicians are often focused on the unique resources they need for certain service lines, while system leaders have an eye out for major trends across the enterprise. 

"Sometimes the challenge is, how do we marry our big-picture and top-down priorities with those that are at the local level, which may be related to very specific patient populations," said April Taylor, vice president of operations and COO at The Johns Hopkins Hospital in Baltimore. 

One of Johns Hopkins Medicine's strategic pillars is clinical excellence, which encompasses quality and safety. Within that, there is a shared set of systemwide goals and priorities, much of which are foundational measures of quality and safety that are tracked annually and do not change — elements such as hospital-acquired infections, readmissions and length of stay.

Reviewing safety dashboards during daily unit huddles and multidisciplinary rounds are a core part of centering care team members' focus on these areas at all of the health system's hospitals. Each hospital also has a structure in which clinicians in different specialties partner with leadership to ensure there is enough flexibility for them to address challenges that may be highly specific to the patients for whom they are caring, Ms. Taylor said. 

"There needs to be a level of flexibility and fluidity in terms of how we work with folks to really be able to address challenges at the local level because the challenges for neuroscience, for example, are going to be very different than those of heart and vascular or pediatrics," she said. 

Similarly, Jefferson Health leverages its OnPoint platform to elevate focus on systemwide quality and safety goals. Each day, units review leading indicator real-time dashboards during their huddles, which flag opportunities for things such as removing a foley catheter or performing a CHG bath to prevent a central line infection.

"That is something that's very deeply embedded for us," Dr. Henwood said. "Those dashboards get run multiple times during unit huddles that happen at shift change across the entire organization and have helped us with improvement efforts in the domains that we have focused on in those radar dashboards," such as sepsis. 

She described the OnPoint team's role as serving as an enabler to embed quality deeper into the organization. Rather than being a separate department that owns responsibility for quality improvement, the team designs systems to best support clinicians in delivering safe care and centering their focus on core quality and safety metrics. 

"How can we ensure the best outcomes, recognizing that our teams are very busy — sometimes there's an interruption and they might miss something or forget," Dr. Henwood said. "So how can we support them in delivering those outcomes?"

These structures help maintain attention on evidence-based care and reduce unnecessary variation, while still enabling local teams to tailor care as needed.

"We try to have things as similar as possible, but as different as necessary," Dr. Henwood said. "We recognize that we have a lot of different care settings, from designated rural hospitals to quaternary urban referral settings, and that we need to think about the things that can and should be similar across those domains in terms of evidence-based care pathways, but also recognizing that there's different resources that different locations have and/or different challenges that our patients are facing."

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