A poor accreditation survey is bad news for any hospital, but with the right approach it can be the beginning of systematic improvements that improve quality throughout the organization. That was the experience of one hospital that received an extensive list of deficiencies in a Healthcare Facilities Accreditation Program (HFAP) survey but bounced back and now receives outstanding scores.
For three years after receiving the survey report, Wilson Memorial Hospital in Sydney, OH, invested time and energy into quality improvement based on HFAP’s guidance and recommendations. By the next survey, the hospital had completely corrected all the deficiencies and implemented a sustainable system for ongoing quality improvement.
Wilson switched from Joint Commission accreditation to HFAP in 2007, partly because hospital leaders had grown weary of what they saw as TJC’s view that there was only one way to meet quality standards, says chief nursing officer Linda Maurer, RN, MSN. Having been through several HFAP surveys now, Maurer says HFAP surveyors are more educational and supportive.
“They are very communicative and allow you to share your story about how you are meeting the quality standards. There are standards that must be met, but they truly believe there is more than one way to meet the standard,” Maurer says. “I also appreciate the fact that their surveyors are living day to day in hospitals, working in hospitals full-time, and only doing surveys in addition to their regular job. They’re very supportive and will sit down to talk with you about what you’re doing to meet a standard, helping you understand if you’re meeting the intent of the standard.”
Bad Results on QAPI
In a 2013 HFAP survey, Wilson Memorial did not fare well on many quality measures, particularly quality assessment and performance indicators (QAPIs).
“Just about anywhere you saw QAPI in the survey, we were deficient. We really didn’t have effective QAPI,” Maurer recalls. “We were very good at collecting data and that’s what we were calling QAPI. But just collecting data is not quality. Quality is collecting data and using that data to direct the outcomes that your patients deserve.”
At the exit interview with the HFAP surveyors, before receiving the final report, Wilson Memorial leaders heard “QAPI” over and over again in the summary of findings. As soon as the surveyors left, the hospital leaders discussed the implications of the deficiencies.
“The executive team was still sitting there and we looked at each other, saying this is a big deal. We decided that we as an organization need to understand that quality is more important than finances,” she says.
“We had to decide if we were willing to put forth the time, energy, and resources necessary to make this change. There wasn’t anyone in the room we had to convince.”
Deficiency Report as Road Map
Maurer and other hospital leaders responded to the poor survey results by systematically reviewing all HFAP quality measures, particularly those involving QAPIs. They also used the HFAP deficiency report to focus on where change was needed in the organization.
An HFAP-accredited organization must have QAPI indicators that are reviewed regularly and communicated effectively to the hospital board, but Wilson’s leaders realized they did not have effective systems in place for QAPI even though they were collecting data.
“We have a spreadsheet now that shows everything that has to be reported up to the board and which HFAP standard requires it to be reported,” Maurer says.
“We also have a monthly QAPI committee meeting in which departments report their data, along with what they are doing to affect that data and improve the quality of care within their department. We have hospital goals and each department has goals for their own data.”
A key strategy was to better educate staff and clinicians about the difference between merely collecting data and actually using it to implement changes, she says. Every department has a key process indicator (KPI) board displaying its quality indicators, some of them updated daily.
The executive team also visits a department every weekday morning to review the indicators.
“We’re there to support them and ensure there are no roadblocks in the way to improving their data. We want to know if there is anything we, as the executive team, can do to help them succeed and improve,” Maurer says.
“Each department’s data also is compiled on a monthly basis and reviewed by the QAPI committee, which then passes it on to the board,” she adds.
Board Is Now on Board
The board now is far more involved in quality issues than at the time of the 2013 survey, Maurer says. At that time, board meetings usually focused every month on finances and quality was on the agenda four times a year. Now, the board reviews a quality report every month just as it reviews a financial report, Maurer says.
“Getting the board in that mindset was not as big a challenge as I thought it might be. One of the board members had a background in quality, and we had that person chair our quality committee,” she says. “When we went to them with the HFAP deficiency report, they became invested in that. It wasn’t a matter of telling us that’s our job and we should go fix it.”
The hospital also adopted Lean process improvement methods to address specific issues. One problem involved the delays in getting patients from the ED to an inpatient bed. Once admitted by a physician, it sometimes took hours to get a patient to his or her room.
A Lean process improvement committee was formed with emergency and med-surg staff, the frontline people actually involved in the issue, along with senior leaders.
The committee mapped out the current process for moving patients from the ED to inpatient beds, then applied Lean process improvement. The committee looked for patterns and behavioral issues that were affecting patients moving from the ED to inpatient care.
“By the end of the week, we had a completely new process in place designed by the bedside staff. That’s how you gain buy-in, because they’re the ones who do the work,” Maurer says. “Now, we can get patients from the ED into a bed within 60 minutes the majority of the time, instead of hours. That is a key process indicator that the ED tracks.”
Journey With No End
That experience became the model for how Wilson Memorial handles all quality process issues now, Maurer says. Part of the approach involves using a Kaizen event, which typically is a short-duration improvement project with a specific goal, involving those people directly involved in the process and, perhaps, representatives from support areas or hospital leadership.
“We find a problem, we create a team, we have a Kaizen event, add an indicator to our key process indicator board, and we improve it,” Maurer says. “This organization has always been fabulous at collecting data for the past 20 years, but we never did anything with it. Now, we use that data to improve process.”
Hospital leaders also have adopted the outlook that accreditation is a journey with no end, Maurer says. There may be points at which you realize you’re not meeting a standard and need to put a team in place to address it, she says, but you don’t put that off until time for a survey.
“You don’t want a culture in which you scramble to comply with standards every three years,” Maurer says. “This is a journey in which you’re constantly measuring and assessing, and looking for opportunities to improve. Getting everyone into that way of thinking is a big step toward improving the care your patients receive, and then a survey is just a formality.”
Much Improved Survey Results
The five years since the disappointing survey have brought significant improvements to the hospital, says Sue Neumann, RNC, MS, CPHRM, CPPS, director of quality, risk management, and corporate compliance. Wilson Memorial now has four stars on Hospital Compare, an “A” rating from Leapfrog, and excellent HFAP survey results.
HFAP surveys facilities every three years, and the 2016 surveyors told Neumann and Maurer that they were bracing for a number of deficiencies after reading the previous report. But in the end, the surveyors did not cite Wilson Memorial for any QAPI deficiencies in 2016, and there were few other deficiencies.
The HFAP surveyors were surprised that the hospital could make such significant changes in only three years.
“This should be encouraging for hospitals out there that are struggling. It is possible. You can get there,” Neumann says. “You just have to be very intentional about how you do it.”
Getting the hospital board to prioritize quality improvement is crucial, Neumann says.
“It’s important to get the board to recognize that this is just as important as finances and patient satisfaction, the things that the board usually can grasp more easily,” she says. “We’re all pulled in different directions, and the board is no different. They have to be shown that this is something to prioritize.”
Neumann also points out the value of hiring high-quality assistive personnel.
“It’s hard to keep all the plates spinning, and having the right support personnel can make a difference. It’s important for senior leaders to understand the value of those ancillary personnel who help keep things going,” she says. “That is an important part of what makes our quality program work here: the fact that we have excellent support staff who keep things from falling through the cracks.”
That’s not possible in some hospitals because everyone is trying to operate on such small margins, but good support staff are worth far more than whatever you have to pay for them, she says.
“We are a team of three in my office. You don’t have to have 20 people doing this, but you need people who can help you organize and utilize technology to get the information out in a way that can be understood,” she says. “People who live in small communities deserve high-quality care, and I believe we can do it in small community hospitals. We just have to look at how to do it creatively. We’re an example of that.”