Physician backing critical to QI turnaround

Dramatic improvement in cardiovascular surgery

In 2004, the mortality rates for several cardiac care areas (including bypass procedures, valve replacements, and treatment of heart attacks) at St. Dominic's-Jackson Memorial Hospital in Jackson, MS, were disappointing enough that the facility's leadership engaged the consulting arm of Golden, CO HealthGrades Inc. (recently renamed the HealthGrades Clinical Excellence Research & Consulting Group), to help it turn things around.

"There could possibly have been as many as six to eight surgery mortalities in a given year before," notes Jo Ann Alford, St. Dominic's director of quality review. "But we have had only two surgery mortalities in the last 11 months."

Both Alford and Samantha Collier, MD, chief medical officer for HealthGrades, agree that physician leadership and buy-in were among the keys to this successful turnaround.

"Physician leadership has really been instrumental in the whole process," says Alford. "We have some physician champions who have said, 'This is what we are going to do — we are going to improve our surgery care,' and they were quick to get others on board."

Initially, Alford recalls, there were challenges in getting the staff to adopt the Euroscore risk stratification tool, which has been a key in eliminating unnecessarily risky surgeries (A copy of the tool can be downloaded at the following site: "It helps you by providing a risk analysis of the patient as the final determination for what the mortality risk would be if you went to surgery," she explains.

Patient selection for surgery

"Ultimately, patient selection for surgery ended up being the area where we had the most opportunity to improve — and where we made the most improvement."

Through physician involvement in the cardiovascular surgery task force group (surgeons, anesthesiologists, cardiologists, and other caregivers), which has been meeting monthly for 18 months, the staff have adopted the tool.

Use PDA to calculate risk

Using the tool, it was easy for doctors to calculate risk using their PDAs. If the patient's score showed that his or her risk of death was above a certain threshold, it triggered an automatic consultation by the multidisciplinary team, which included another cardiologist, a cardiac surgeon, a pulmonary/critical care specialist, and any other specialists — for example, a nephrologist — indicated by the specific risks of each patient, Alford says. Each consultation resulted in a decision to proceed with surgery; to delay surgery until further investigation, intervention or appropriate cool-off; or to pursue other alternatives, such as medical management.

"It has basically given physicians and patients more information," says Alford.

"We had the cardiologists leverage their positions to get the surgeons on board," explains Collier. "By acknowledging that they [the cardiologists], too, owned the opportunity to improve outcomes for the patients they were referring to surgery, they made it easier for the surgeons to hop on board and together, along with other colleagues, the administration and the board, they were able to remove the final roadblocks."

Getting to 'yes'

It was a complex process to get to that point, however. First came the decision to bring HealthGrades in. "Actually, we had been working with them already — we had a quality assessment and improvement contract with them," Alford explains. "We knew that our ratings were going to go public; the data would be out there for people to see. Plus, if we were truly having poor performance, we wanted to know why we had low a rating and what could be done to improve. After all, the bottom line is patient care."

In the early HealthGrades ratings, the hospital received one star out of a possible five, confirming room for improvement. "As with all clients, step one was to look at Medicare data across 32 measures — a 5,000-foot view," notes Collier. "Then, for example, if in surgery we saw higher than expected mortality, we looked further into the charts, as well as other data such as those from the American College of Cardiology, or internal hospital data. Then, if the data appear real, we drill down to the root cause."

This was done side by side with the hospital staff. "Basically, they were our resource for analyzing the data, which is very time-consuming and labor-intensive," says Alford. "We basically provided support — we made sure we had all the data we needed, and served as a coordinator for the initiative."

"We produced persuasive data, presented them in a meaningful and actionable way, and then identified, cultivated, and inspired physician champions to take the lead," Collier summarizes.

Enlisting 'thought leaders'

The key to success in such an initiative is to have "thought leaders" on the medical staff work with their peers who may be reluctant to change, says Collier. "Someone, whether it's the CEO or the chief medical officer or a cardiologist, should pick up the phone and take the time to ask them for help with the hospital's initiatives," she says. "It's hard for physicians to turn away when you're asking for their help."

Collier and her team spent months identifying which physicians were likely to aid the effort and which ones would resist, and putting together data to make the case for the new process to the latter group. Cardiologists were the obvious starting point, because they referred patients for surgery to begin with. Convincing a few key cardiologists got the ball rolling.

"No doctor will go from 'zero to 60' right away," Collier notes. "The biggest challenge is acknowledging that there is something wrong and that it can be improved; that goes against the nature and the grain of physicians and nurses. Saying we can do better implies we have not been doing our best."

Getting them to admit that requires that several factors be simultaneously in play, Collier explains. "First and foremost, you often need a third-party, independent organization saying things that validate what others may have said on the inside; this can be a good start," she observes. "Then, there has to be data people believe, and opportunities to improve that matter to them — that they can possibly change outcomes, or make the patient's experience or quality better. Then, you have to have the doctors help you identify the opportunities."

The key to success, ultimately, was that some of the doctors got on board and started to implement the process improvements, says Collier. "We started seeing successes; this started to convince them they could do better, and they then moved forward with others," she notes. "It was a slow-moving train when we started, but once it gained momentum it was unstoppable."

[For more information, contact:

Jo Ann Alford, Director of Quality Review, St. Dominic's-Jackson Memorial Hospital, Jackson, MS. Phone: (601) 200-6592.

Samantha Collier, MD, Chief Medical Officer, HealthGrades Inc., 500 Golden Ridge Road, Suite 100, Golden, CO 80401. Phone: (303) 716-0041.]