“How would you design a great hospital quality improvement program?”
A distinguished gentleman who looks to be in his 60s is asking the question. He and I are sitting across from each other at the end of a long, dark mahogany conference table.
I don’t remember how I came to be here. I probably look a bit confused.
“John. Tell me… How would you do that?”
I was sitting in a small conference room. Having worked full-time as hospital Chief Medical officer, I was now interviewing for a position in a larger institution. Midway through my interviews, I was talking with the hospital board chairman. He brought up the topic of hospital sentinel events. Apparently there had been a sentinel event at his organization and the chair and his board were quite concerned.
He explained that it was something they had not experienced before. They were upset that such an event could occur at their facility. He asked me to describe what I knew about hospital sentinel events and share some of my experiences.
For this post, I’m going to “nerd out.” I love using data. And I love monitoring, improving and discussing quality and safety. That was one of the fun things I did as hospital CMO. I also enjoy playing around with ways to display data, especially for lay people with a limited understanding of statistics. So today we will make our way to the “popular” Bubble Graph (well – it’s popular with me at least), as I demonstrate how to prepare quality reports.
The CEO and the Board of Trustees (or Directors) definitely want to see meaningful reports about hospital performance. They truly want to see that performance is improving. Along with positive financial results, nothing will make the CEO and board happier than seeing that quality can be measured, is at an acceptable level, and is improving.
Each hospital CEO must determine which departments should logically report to each senior executive. Historically, the vice president for medical affairs or chief medical officer was hired to address the medical staff and its governance, continuing medical education and quality improvement. But there is another department head that should report to the senior physician executive of a hospital: the hospital pharmacy director.
Medication administration is one of the most important functions of a hospital. Safe, effective and timely administration of medications requires coordination of multiple hospital staff departments, integration of electronic medical records, implementation of pharmacy automation, and monitoring and managing drug costs.
Every year, the health system pharmacy director and I would sit down and review the latest Institute for Safe Medication Practices (ISMP) list of best practices. These are practices based on reports of medication errors from hospitals across the country. When the ISMP identifies a trend, it seeks the root causes. It then compiles preventive strategies and publishes them as ISMP Best Practices for Hospitals.
I found these best practices to be a good source of goals for the pharmacy director. If there was a recommendation that we had not implemented, the director and I would add it to his goals for the upcoming year. The CMO should be a strong advocate for medication safety.
I was walking towards the cafeteria one morning when I recognized one of our hospital board members. I recalled seeing him at one the meetings where I had presented hospital board reports addressing quality. We stopped to chat for a minute.
He had been on the board for several years, and had an intimate knowledge of the performance of the hospital. He knew many of the local medical staff. His wife had once worked for the hospital.
At one point in our brief conversation he said, “ You know, John, I really look forward to your quality reports. We all do. The board members like to know that things are going well. We also want to know when there are potential problems, and the steps taken to address them.”
I thanked him and promised that I would continue to keep the board informed, and he went on his way. Over the years, other board members mentioned similar sentiments. They were very interested in how the organization was addressing quality and safety.
I started this series describing an approach to execution of management goals described in the book The 4 Disciplines of Execution (4DX) by Chris McChesney, Sean Covey and Jim Huling. The design of the WIG (wildly important goal) was described in detail. But what comes next?
Let’s imagine that your team has selected a WIG. And the goal is written in the format of “from X to Y by when.” According to the authors of 4DX, the next step is to develop lead measures. Lead measures, if implemented, will result in improvements in the lag measure.
I remember the first time our CEO announced to our board of directors that we had received the Top 100 Hospital designation. I believe the award was “owned” by Solucient at the time. It actually came as a shock because we were not expecting it. I was VPMA back then. We were just vaguely aware of the hospital performance measures it used.
The CEO and board were very proud of the designation. We all were. It was a welcome recognition of all of the hard work we had been doing.
Our executive team met on our usual Wednesday operations meeting shortly thereafter. We reviewed the data presented with the award, and determined that several factors had come together to help us achieve it.
We had started an aggressive length of stay initiative about 3 years prior. In addition, we had implemented a nurse documentation and coding program.
Finally, we had implemented a quality measurement tool from CareScience (now owned by Premier and called QualityAdvisor) several years earlier. And we were collaborating with our affiliate hospital, Rush University Medical Center, to work on quality projects together. We had seen some impressive improvements in mortality and complication rates, and reductions in length of stay as a result of some of the projects.
The metrics being considered have changed significantly since then. When this all started, present on admission (POA) coding had not been implemented, so it was very difficult to distinguish co-morbidities from complications when analyzing closed charts. And CMS core measures were not yet being tracked. A lot has changed.
In July of this year, I wrote a post that described the steps for achieving Truven’s Top 100 Hospital status. In it, I listed the metrics that Truven used to rank almost 3,000 U.S. hospitals using its balanced scorecard. The list of hospital performance measures had changed little over the previous decade.
When I reviewed the methodology for the 2016 report, I found several significant changes in the performance measures. The notes also mentioned that there are more changes to come.
Patient safety can sometimes be a nebulous concept. Like quality, it is difficult to define, but most of us recognize it when we see it.
I was standing in a conference room, trying to explain to a group of vocal physicians why we needed to approve a Code of Conduct for the medical staff. It was one of our quarterly medical staff meetings, so there were a good number of physicians present.
Some of the physicians were concerned that such a code would be used to punish passionate and otherwise well-meaning physicians who became angry in the heat of a stressful situation. Another group felt that any new set of rules would jeopardize their autonomy.
That word, autonomy, had been used countless times to argue against various bylaws changes over the years. The thinking was that physician autonomy was sufficient to ensure quality of care.
Of course, that had been proven untrue many times. The quality improvement and patient safety literature repeatedly demonstrates that system breakdowns cause harm even when the most brilliant and dedicated physician is caring for patients.
Many of the staff members begrudgingly came to agree with the need for approving the code. This was primarily due to a fear of being accused of creating a hostile work environment. Very few had come to recognize the main concern that I had: that this was a serious patient safety issue.
Patients don’t want to be treated at a hospital with a high mortality rate. Doctors and staff don’t want to work at a hospital with a high rate. It’s scary and embarrassing.
But there is more to achieving a low mortality rate than just hiring good staff and implementing evidence-based care. Hospital mortality rankings are heavily dependent on rating agency rules and documentation practices.
I was nine years old and obsessed with bowling. Maybe it was because Don Carter had become so popular. Perhaps it was the curiosity generated by the sound of bowling balls crashing into the pins at an alley only 2 blocks from my home. I had only bowled on a few occasions. But I knew that my dad had bowled in a league when he was a young man.
I begged him to sign me up for a league. On a lazy Saturday morning, after weeks of cajoling, he did just that and left me there to enjoy the games. I selected a ball and some bowling shoes.
I was assigned to a team and began bowling with the other kids in turn. I knock down a few pins and occasionally made a spare or a strike. But my score was hideous. When it was all over, I had three games with scores in the mid-double digits. Our team did poorly. I headed home disappointed and confused.
It turned out that there was something called a “foul line” and a rule against crossing it when throwing the ball. To this day, I don’t understand why nobody explained that to me. It wasn’t until much later that I figured it out.
But I learned a valuable lesson. Understand the rules or you will surely lose the game!