Award winner involves entire staff in quality improvement initiatives

Hospital culture changes following leadership crisis

Quality managers know that it's hard enough to get nurses and physicians to buy in to their initiatives, but at Columbus (IN) Regional Hospital, even non-clinical staff members are expected to make quality improvement one of their primary goals.

This was one of the approaches quality leaders adopted following the exit of their CEO in 1997 and an attendant crisis in confidence. And the approach seems to be working — Columbus Regional has received the 2007 American Hospital Association–McKesson Quest for Quality Prize, which evaluates organizations for their commitment to improving areas of safety, patient-centeredness, effectiveness, efficiency, timeliness, and equity.

The award committee shared with the facility's quality leaders some of the reasons why it was chosen, says Thomas A. Sonderman, MD, FACEP, chief medical officer. "They were very impressed with the fact that all across the organization, not just quality people but multiple levels of clinical and non-clinical staff are empowered to drive quality," he says. "They also cited our ability to drive down the incidence of VAP [ventilator-associated pneumonia] and surgical-site infections."

This move to involve the entire staff started several years ago, says Sonderman, when the hospital's new CEO "really started to realize that the way to get people dedicated and engaged at work was to try to connect everyone to the bedside.

"Obviously, the bedside caregiver has a pretty clear, direct line and those clinicians can easily see how they directly affect patient outcomes; but he recognized that the non-clinical staff had a lot to bring to the table, too, and connecting them to outcomes would be a way to charge them up and keep the 'flywheel' turning."

How did management draw these non-clinical staff members into quality improvement initiatives? "One example would be the 100,000 Lives and Five Million Lives campaigns from [the Institute for Healthcare Improvement]," says Kathy Wallace, RHIA, CPHQ, director of medical quality management. "When we launched those efforts, I gave presentations to the facility staff, the materials management staff, and the environmental services staff."

The managers and directors of those departments were all present, she says. "I explained that they were there because we wanted to try to connect how they did their jobs with patient outcomes," she recalls. While she basically used the standard IHI presentation, she says, "in my own mind, I thought of examples to prime the pump — how biomedical engineering or facilities might see a connection."

But it wasn't until the departments themselves held follow-up sessions that they "really connected the dots," says Wallace. "For example, the facilities department was talking about how good, compliant hand washing was so important in stopping the spread of nosocomial infections.

"They decided that any report that came in about a non-functioning sink would be put way up in terms of prioritization; they said they would make a commitment to get to it within 24 hours. They made the same commitment with alcohol gel dispensers because they realized that every extra step would make it less likely that people would wash their hands." This type of action, says Wallace, demonstrated to the staff some concrete efforts they could make every day to help reduce infections.

Growing from crisis

The Columbus Regional success story was born of crisis, says Wallace. "Our improvement work goes back a decade to 1997, when the medical staff took a vote of no confidence with the CEO," she recalls. "There was a loss of confidence in the medical staff and in the community."

"You hate to have a crisis, but it does serve as one heck of a motivator," adds Sonderman. "We were always good clinically, but 'good' can be the enemy of 'great.'"

Patient and physician satisfaction were huge parts of the challenge, he says, "but we learned very deliberate skills of finding out which were the best as far as techniques in driving patient satisfaction." Determining which are, in fact, the best is possible for any area of hospital service, says Sonderman. "Even tasty, warm food, getting trays to patients on time, or the best way to polish and clean a floor or turn a bed or a room around — when you take that approach and can really take it down through the whole organization, that's when I think quality really picks up."

"We knew we had to get back from the bottom," adds Wallace. "The new CEO, who had been the COO, took steps to reconnect with the medical staff. The staff wanted to provide great care, and they wanted happy patients, so we engaged everyone about how we could build things up. That was really our focus."

Benchmarking played a big role, she says. "We did a lot of benchmarking; we began benchmarking in nursing and became the first accredited magnet hospital in the state; we started benchmarking best places to work in Indiana and nationally — not necessarily to go after the award, but to learn what to do to get there." When you apply for such awards, she explains, "they tell you where you're at and what you need to do to improve."

The hospital also worked with the Baldrige Award people for the same reason. "We started a balanced scorecard to understand where we stood vis-à-vis our five pillars: people, satisfaction, quality and safety, growth and innovation, and financial," says Wallace. "Then a couple of years ago we adopted the vision that it was not enough to be a good community hospital anymore; we wanted to be the best in the country at what we do."

Transparency is key

As the recovery continued, Wallace recalls, the new CEO stressed transparency as a key to success. "In terms of sharing data and information, we consider ourselves very transparent. Measurements are used everywhere and everyone knows how we do them," she says.

For example, she notes, they use a cascading scorecard system, which is used by all areas of the hospital. Based on selected key measures, "each of us knows how we are performing compared to how we would need to perform to be the best in the country," Wallace says.

So, for example, leadership has a scorecard that tells them what they need to do to improve on corporate measures. Then, "on a given unit, you'll see what you need to do for CMS, what your patient safety index is, your mortality rates, and so on," says Sonderman. "As you go down through the organization, there is a very deliberate alignment of the behaviors of people during the day that should drive hospital-wide goals."

In addition, every employee has a "passport" that shows one key measure for each pillar, and then the department or leader's goals. "They work with leadership, and see how their own goals are going to help their leader attain their leadership goals, so they can feed into achieving corporate goals," says Sonderman. "This way, every employee understands how they impact the total picture."

Making practical improvements

Of course, it takes concrete commitments "on the ground" to engender improvement, and here, too, a sense of common responsibility is created. The VAP initiative, for example, was led by the ICU team — an intensivist and a clinical nurse specialist. However, adds Sonderman, best practices were benchmarked and everyone on the care team — including the dietary staff, the pharmacy, and the family — would huddle at the patient's bedside and discuss the clinical aspects of care.

"This way, the care for that day is optimized," says Sonderman. "It also helps with discharge planning, because everyone knows where everyone else is at; it's a wonderful forum to get everyone on the same page."

"We also have interdisciplinary teams that work across all areas of the hospital to provide evidence-based practices," adds Wallace. The teams are co-led by a clinical nurse specialist (CNS) and physician champions. "They find out what is in the literature, and what we need to do at this hospital in order for the best care to be provided," says Wallace, noting that these teams remain permanently in place and are continually focusing on ensuring that improvement is "hard-wired," and as new evidence comes out it is immediately implemented. "They work on designing processes in order for us to deliver the new best practice as soon as possible," says Wallace.

"They also monitor medical societies and scan their sites for changes in parameters," adds Sonderman. "They tell us if anything needs to change in protocols and pathways."

Part of the culture

The interdisciplinary team approach, says Sonderman, is one of several indications that "the way we do things" has really become part of the culture. "I know it gets to be a cliche, but when you involve the physician clinical leader and a CNS, who has in-depth training, with a great quality team and run a rigorous program, and involve frontline staff in a team that has truly been pushing improvement, you will make that improvement stick."

"We see every employee concerned about being the best," adds Wallace. "They are so engaged every day; they all want to come to work to deliver great care."

While the award is "great cause for celebration — an external validation that we think we are working on the right things," says Sonderman, "we never really consider ourselves to be awards junkies; we do not chase awards. These evidence-based best practices are the way to go about it, and along the way there has been a lot of learning and getting feedback reports to tell us what we need to work on next."

Columbus Regional, says Wallace, is always looking for that next quality challenge. "We never stop; you never think you're there there's always room for improvement," she asserts. "Our goal is for every patient to receive every treatment every time, so the work continues."

[For more information, contact:

Thomas A. Sonderman, MD, FACEP, Chief Medical Officer; Kathy Wallace, RHIA, CPHQ, Director of Medical Quality Management; Columbus Regional Hospital, 2400 East 17th Street, Columbus, IN 47201. Phone: (812) 379-4441.]