Tactical quality improvement teams have helped a Georgia hospital reduce complications and length of stay so much that the savings amounted to more than $12 million over one year.
Beginning in 2012, DeKalb Medical Center in Decatur, GA, developed a clinical leadership model that relies heavily on collaboration between physicians, hospital operations staff, and Six Sigma Black Belt project leaders serving on tactical teams that address particular key performance indicators (KPIs), says Ellen Hargett, RN, CPHQ, LSSBB, director of quality and process improvement. The tactical teams meet monthly and prioritize strategies for driving improvement.
DeKalb Medical simultaneously developed a dashboard that analyzes outcomes for KPIs, like length of stay or mortality, and compares the health system’s performance to national standards each month. They also created a clinical leadership model that uses data to identify opportunities and facilitate processes for improvement.
“Prior to this time we had reported our quality performance to the board of directors in the context of performance measures, core measures, CMS-required public reporting. There really weren’t the global outcome measures that reflect an organization’s overall performance,” Hargett says. “So while we were doing well on those process measures and publicly reported measures, we weren’t doing so well on the bigger issues like complications, mortality, and length of stay.”
More Physician Involvement
The clinical leadership model and tactical teams were designed particularly to get physicians more involved in quality improvement, Hargett says. Significant support came from DeKalb Medical’s physician hospital organization (PHO), which comprises the employed physicians and those who work primarily at the hospital. The PHO negotiates the doctors’ fee contracts with payers.
“The PHO really stepped up and said it would compensate physicians for their time on these tactical teams,” Hargett says. “It’s not a huge amount of money but it is enough to respect their time and maximize how we use them.”
From 2014-2015 these tactical teams have been able to reduce complications and length of stay, resulting in financial savings of $12,473,116. Mortality reductions netted 104 lives saved.
The Quality Department worked with outside analysts from Truven Health to develop a whole system measure dashboard called the Big Dot Dashboard. KPIs are displayed as Observed to Expected (O/E) Ratios, which enable the hospital to compare its performance to a national standard each month. Each KPI on the dashboard has a tactical team comprised of three or four physicians, an equal number of operations leaders, and one of the hospital’s two Lean Six Sigma black belts.
Drill Deep for Drivers
The challenges included hospitalist scheduling patterns and weekend inefficiencies. For example, DeKalb Medical determined that patients admitted through its ED on Wednesdays actually had a 1.7 average opportunity days per discharge. This type of analysis by the Lean Six Sigma black belt enabled the LOS tactical team to target improvement strategies resulting in an overall 61% reduction of opportunity days per discharge.
The complications tactical team began by drilling down to isolate possible drivers for the complication rates, says Sarah Kalaf, BSN, RN, CPHQ, performance improvement coordinator at DeKalb Medical and the facilitator for the tactical team. The team analyzed complications from various perspectives, first looking for potential factors that drive the complication rate up, such as particular physicians with a higher rate of accidental puncture during surgery.
“We found that we were not finding any particular trends that way, so we decided to go back to the ‘old school’ method of doing quality,” Kalaf says. “We isolated our top complications and did a deep dive into the medical record reviews. Having the physicians on that team was excellent because they could do the record review instead of someone like me doing a one-page summary that they reviewed.”
The complications team involved several departments in its investigation. The Quality Department coordinated medical record reviews, physicians contributed clinical expertise, and Health Information Management focused on documentation and coding opportunities.
“We found that what was driving a majority of our complications was documentation and coding,” Kalaf says. “For example, there was no difference documented between an inherent puncture that is an intentional part of the procedure and a true accidental puncture and laceration.”
Another example was postoperative respiratory failure. The tactical team found that patients with a history of chronic obstructive pulmonary disease or sleep apnea needed to be on the ventilator for a few hours longer than other patients, but that reason was not documented clearly, so it was coded as postoperative respiratory failure instead of continued postoperative vent management.
The hospital made improvements in documentation, coding, and clinical, resulting in a 55% improvement in the complications O/E.
“It was trying to find that low-hanging fruit that doesn’t necessarily involve clinical practice change — which Ellen and I like to call the ‘sexy part of quality’ — but rather the non-sexy, like looking at documentation and coding,” Kalaf says.
Watch the E and the O
Tactical team members have developed an ability to look for system issues and scrutinize the “expected” as much as the “observed,” Kalaf says. They learned that when using an O/E metric, you should give as much attention to the “expected” as the “observed.” This can be a motivator for improved documentation when physicians recognize that their words drive coding, which drives “expected,” Kalaf explains.
Hargett says DeKalb Medical’s experience yielded key lessons for other facilities. First, she says, it is crucial for physicians to feel they are part of the process and not just the targets to be “fixed.” Prior to this culture change, the hospital approached many metrics as a “doctor problem.”
“A lot of our assumptions were that we could find a doctor who was driving the problem or who was performing worse,” Hargett says. “Now we approach virtually every metric as an organizational system output, versus a doctor problem. We know that our system is supporting every standard of care, so we have look at the system first. The majority of the improvements we have put in place were system issues, so it is a fundamental difference in our approach.”
Another lesson was that hospital committees should be evaluated for their return on investment (ROI). Too many hospital committees, quality-focused or otherwise, are created with good intentions but then drain resources without accomplishing much, Hargett says.
“A lot of times, you see that you can get a better ROI by going to a team approach with very focused data analysis to target strategies,” Hargett says. “We’ve really worked on how well we maximize our resources, and I would encourage other institutions to do the same. Rather than being additional work, this is productive work that should take the place of inefficient work.”
For these quality improvements, DeKalb Medical received the 2016 Truven Health Advantage Award for Performance Improvement and Efficiency at the Truven Health Analytics Advantage Conference on April 27 in Dallas, TX.
- Ellen Hargett, RN, CPHQ, LSSBB, Director of Quality and Process Improvement, DeKalb Medical Center, Decatur, GA. Telephone: (404) 501-5435. Email: firstname.lastname@example.org.
- Sarah Kalaf, BSN, RN, CPHQ, Performance Improvement Coordinator, DeKalb Medical Center, Decatur, GA. Telephone: (404) 501-5372. Email: email@example.com.