Voluntary participation in quality scores like those from The Leapfrog Group require a leap of faith, hoping that your organization will not regret the decision to participate. But even when that does not turn out so well at first, the experience can lead to improvements that make the decision worthwhile.
That was the experience at Arrowhead Regional Medical Center in Colton, CA, which first participated in the Leapfrog group’s patient safety grade scoring in fall 2016. The hospital’s first score? An “F.” But in spring 2017, that score improved to a “C,” then to a “B” in fall 2017, and an “A” in spring 2018.
That first “F” was a bit of a reality check, says Katrina S. Shelby, JD, MBA, associate hospital administrator for quality and accreditation at Arrowhead.
“It’s very telling when you have a score that doesn’t reflect what you think you’re providing in your organization,” Shelby says. “We were confident we were providing good care and keeping our patients safe, but that score opened our eyes to some issues we needed to address.”
Journey from ‘F’ to ‘A’
Leapfrog uses 27 different measures that focus on patient safety. Because Leapfrog scores are released only twice a year, there is a sense of delayed gratification when making improvements, Shelby notes. It takes a while to know whether the work you’re doing is leading to the results that will yield an improved Leapfrog score.
Shelby joined Arrowhead in July 2017, and the hospital president tasked her with getting an “A” with Leapfrog, from its “C” at that time. She started first by asking, “What are the key Leapfrog measures? Where are we? Where do we want to be? Who can get us there?”
The first priority was making sure hospital leaders understood the Leapfrog measures.
“A lot of people assume they understand the measures, but they really don’t,” Shelby says. “We met at least on a weekly basis and identified in each department a Leapfrog champion who kind of ate, slept, and breathed all things Leapfrog. We had someone in each area who could really drive this training.”
She sought input from physicians, information technology, performance improvement, nursing, and pharmacy. Arrowhead also created a strategic dashboard and examined progress daily.
“It’s important to make sure you have the right stakeholders. So many people look at Leapfrog as the responsibility of patient safety, or quality, but in reality it is the hospital’s responsibility,” Shelby says. “It crosses all departments in the hospital, and that is by design. You have to have everyone understanding the measures, their impact, and participating directly. It can’t come from the top down.”
In practice, that means having the active participation of people from both the front lines and administration, Shelby says. They must both be at the table so nurses and doctors can discuss how communication happens in the ICU, for instance, and then administration leaders can remove the barriers that impede that communication.
EHR Needed Work
Arrowhead learned there was room for improvement with its electronic health record, particularly with medication reconciliation and the computerized physician order entry (CPOE) process. The hospital needed to allow physicians to more directly order medications without unnecessary layers and steps.
“There were a lot of layers and steps between the physician writing the order and getting that medication to the patient — places where things got lost in cyberspace or within departments, overridden, or removed,” she says. “It really forces you to open up your electronic health record workflow and understand the complexity of what happens when you assess the patient, determine what drug is needed, and give that to the patient. We wanted to streamline that process and eliminate any unnecessary hands in the system that could interfere with patient care.”
The hospital also identified opportunities for reducing hospital-acquired infections. Physician partnership turned out to be a key element in improving patient safety, as well. The hospital typically reported information to physician leaders on the back end, showing them the results, rather than involving them in the process up front.
Arrowhead changed that approach so that physician leaders were involved in key conversations on the front end.
Involve IT Up Front
The same strategy was applied to the hospital’s IT leadership.
“Oftentimes, we look at our IT department as the technical folks who make tweaks on the back end after others have made decisions about what needs to be done, but they are now helping to design our workflow,” Shelby says. “In the same way, we involved departments like pharmacy and nursing from the beginning. Involving all of these players in designing workflows, from the inception, really made a difference.”
Patient safety committee members meet at least weekly, and there also are multiple subcommittees. Patient safety is on the agenda of every key meeting within the hospital, all the way up to the San Bernardino County Board of Supervisors.
Shelby encouraged the leaders at ARMC, through its book club, to read Straight A Leadership: Alignment, Action, Accountability by Quint Studer.
“We parlayed the book’s guiding principles of ‘Alignment, Action, Accountability’ at all levels of the organization to earn our Leapfrog A,” Shelby says. “ARMC’s receipt of an A on its Leapfrog score is a true testament to the organization’s journey to high reliability. The change has been transformational and is attributable to the organization, making this a key area of focus within the quality pillar of ARMC’s strategic plan.”
The journey from F to A has been a positive experience for Arrowhead, Shelby says. A major improvement involved the notion of accountability — the idea that everyone in the organization is responsible for patient safety, she says.
“We have learned things along the way that led us to ask questions, questions I’m not sure we would have asked if we were not participating in this program,” Shelby says. “We were surprised that we were not as far along as we thought we were. The good thing is that Leapfrog provides you with the algorithms, so you can almost predict where you will end up if you’re asking tough questions about your practices and systems and whether they are effective — whether they are improving patient safety.”
Shelby’s advice for other hospital quality leaders saddled with a poor score from Leapfrog or an accrediting body is to start with top hospital leadership. Make sure they understand the impact of the low score, and be prepared to find out that they don’t.
“If your leaders don’t understand the importance of that grade in your community, and how improving it could benefit your organization, you will not get to where you want to be,” Shelby says. “We’re in a new world where third parties are very knowledgeable about hospital-acquired conditions, so there is a direct financial penalty for poor patient safety. You have to start with your CEO and your board of directors because they have to understand Leapfrog just as much as your patient safety committee.”
- Katrina S. Shelby, JD, MBA, Associate Hospital Administrator for Quality and Accreditation, Arrowhead Regional Medical Center, Colton, CA. Phone: (909) 580-1000.