Integrated system helps hospital improve quality
Integrated system helps hospital improve quality
Communicates priorities across organization
At Fairview Hospital, a small critical access facility in Great Barrington, MA, a decision was made in spring 2005 to switch to an integrated system for performance measurement and improvement. "The external environment is changing dramatically, and hospitals are facing new pressures of comparative quality reporting, performance transparency, and pay-for-performance," explains Pavani Rangachari, administrative director of quality and patient safety.
In light of this, the hospital's leadership saw the need for an integrated approach — not only to set up systems for measuring performance, but also to communicate priorities across the organization. "You need to institute a system for continuous improvement based on your organizational priorities," she says. "Without that, you have fragmentation of information and varying priorities at different levels of the organization."
The new system completely changed the way data are collected, analyzed, and disseminated. Performance data are now integrated across all six of the organization's strategic goals into a central location, including clinical excellence, service excellence, workforce development, and medical staff development.
These strategic goals are now aligned with departmental and individual performance measures.
Here is how the process works: A comprehensive set of measures is organized by strategic goal, and the list is distributed to department managers. These measures are divided into two groups — one for which departments don't have to collect data because they are available electronically, and another group for which staff must collect data regularly.
For example, the emergency department doesn't need to collect data for core measures or patients leaving against medical advice, but they do need to track how long patients wait to be assessed by nurses and the number of nursing direct care hours.
The quality office now functions as a library for performance information. All employees are involved in data collection, and all have access to how the data are analyzed and used to make changes.
In addition, a new structure was created to prioritize quality issues, using an administrative team with representation from nursing and operations, quality and patient safety, and medical staff. The team meets weekly to discuss performance outcomes and other pressing internal issues, and to identify priorities for discussion at monthly committee meetings.
The hospital's quality and patient safety council now serves as the primary vehicle for determining and implementing performance improvement priorities each month. Previously, a piece of information might have been exchanged between two people but is now part of the organization's body of knowledge and becomes a topic of discussion in a larger group.
The new system has resulted in dramatic improvements in core measure performance, Rangachari reports.
For example, when guidelines for giving antibiotics within one hour before surgical incision were not being met, staff came together to identify solutions, followed by education on the new processes. After new protocols went into effect, compliance rose from 0% to more than 80%.
Quicker action is taken
Core measures required by JCAHO and CMS are only one aspect of quality, notes Rangachari. "The external environment only provides support and guidelines to measure only a very small segment of the care we provide," she says. "It's not going to help create the legitimacy within the organization for improvement."
Each organization needs to supplement the measures provided by the external environment with its own priorities. "Otherwise, it leads to lack of understanding and involvement and engagement across the entire organization," Rangachari says. "You miss that if you just focus on a few areas and just a few people are doing it and leadership is not involved."
As a result of the new system, the quality professional's role has changed significantly. "There is no question that the role has changed and is more integrated with hospital leadership," Rangachari says. "Essentially, that is where it is heading toward. If quality is relegated to a small corner in the organization, quality professionals cannot undertake activities leading to change and improvement."
The goal is to have quality priorities "seep in through the entire organization," she says, giving a better picture of quality with quicker results. "Because of the systems we have set up, aligning it with departmental goals and staff feedback, we are able to have action for improvement take place as soon as the information gets disseminated," says Rangachari.
For example, data are collected on how often the rapid response team was actually called, and this number is compared with how many times that the criteria were met. "If we see a gap, then the department directors take this information back to staff and institute improvements," Rangachari says.
At the same time that performance is being improved for rapid response teams, other areas such as medication reconciliation and adverse drug events also are being improved. "All these areas are clearly spelled out in organizational priorities and communicated across the organization," says Rangachari.
[For more information, contact:
Pavani Rangachari, Administrative Director of Quality & Patient Safety, Fairview Hospital, Berkshire Health Systems, 29 Lewis Avenue, Great Barrington, MA 01230. Telephone: (413) 854-9626. Fax: (413) 644-9968. E-mail: [email protected].]
At Fairview Hospital, a small critical access facility in Great Barrington, MA, a decision was made in spring 2005 to switch to an integrated system for performance measurement and improvement.Subscribe Now for Access
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