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In one year, the seven hospitals of CHI Franciscan, based in Tacoma, WA, achieved extraordinary improvements in quality and safety. They did it by adopting more of a team-based approach to patient care, improving communication and reducing silos that prohibit information-sharing.
In 2017, the hospitals scored C’s, D’s, and one F from The Leapfrog Group, but the fall 2018 Hospital Safety Scores indicated across-the-board improvement in quality and safety ratings — all A’s and B’s.
CHI Franciscan altered processes to become more reliable around patient safety, explains John Krueger, MD, MPH, vice president of quality. He joined CHI Franciscan in 2016 and says he has never seen a health system improve its safety scores so quickly.
Across the seven hospitals, the Leapfrog raw safety score has increased 26% over 18 months, he says. The top hospital’s raw score increased by 84%.
That happened because the health system focused on restructuring itself rather than simply seeking better grades, he says. Part of that restructuring included adopting more of Leapfrog’s approach to patient safety.
“When I came here, we saw that there were some opportunities to really improve our scores, and … we thought the Leapfrog methodology had a lot of the structural and procedural components that would benefit our organization and our patients,” Krueger says. “We saw that we could be most effective by overlaying the Leapfrog structure on our own.”
CHI Franciscan uses its own measurement system, called Safety First. Leaders there realized that much of it corresponded well with the Leapfrog indicators. Safety First uses a mix of root cause analysis and failure mode and effects analysis. That allowed them to use the Safety First system to track their internal rating on a daily basis, identifying gaps and socializing best practices across the system, Krueger says.
“Safety First is about becoming a high-reliability organization, using methods that have been proven in the airline and nuclear industries,” he says.
“Healthcare is starting down that path toward high reliability, but we’re not there yet as an institution or as an industry. This effort takes us a step closer.”
CHI Franciscan used the eight-step model for change developed by leadership and change management guru John Kotter, a Harvard Business School professor. The first step involves creating a sense of urgency within the organization.
Within the health system, that was achieved using data from Safety First, the Leapfrog scores, and metrics from the CHI parent organization.
“We used that data to say to our hospitals, ‘If our patients were going to get perfect care, where would we want all of these things to be?’” he says. “I spent a lot of time being a cheerleader, talking to people and trying to connect with them about why this was important. Everyone knew it, but this was about making it part of their conscious, daily activity.”
The second step was to create a guiding team, or a “coalition of the willing,” Krueger says. That team included Krueger and his colleagues in quality improvement, but they also had to recruit people from all seven facilities spread over a large geographic area.
“We made the decision right off the bat that we were not going to focus on one facility alone. We were going to try to move our entire organization together,” Krueger says. “We knew that we could probably move one hospital to an A faster if we focused on that one facility, but we didn’t focus on the grade. We focused on the methodology, on doing the simple things really well.”
The team set a goal of having three hospitals with A grades and three with B grades by the end of 2018, which Krueger says was a simple way to explain the goal across the entire organization, including the board of directors.
The interim steps and improvements required to get there were more complicated, but it was important to have a message that could be communicated simply and effectively to a broad audience, Kruger says.
The board and CEO supported the effort fully, and Krueger says that was key to its success. That brought support from the rest of CHI Franciscan all the way down the line, he says. Such broad support was needed as the health system tackled the problems that led to poor Leapfrog scores.
“Improvement work is not pretty. It’s not a linear line; you sometimes have to go down to go back up,” Kruger says. “That’s exactly what we experienced, but we were persistent, trying to push forward through the barriers and just solve the problem that was in front of us.”
The health system consulted Leapfrog for advice as well as other health systems and hospitals that had scored well. One strategy that emerged early on was for CHI Franciscan to focus on performing well on the scores from one external agency, such as Leapfrog, rather than trying to address performance on a number of outside measures.
Krueger worked closely with the health system’s CEO and chief medical officer to confirm that the CHI Franciscan priorities aligned closely with Leapfrog methodology.
Focusing on the Leapfrog formula helped CHI Franciscan target improvements more effectively rather than scattering resources across multiple quality improvement philosophies, Krueger says.
Krueger notes that CHI Franciscan leaders suspected the earlier poor Leapfrog scores were not entirely accurate in reflecting the quality of care, but the health system took responsibility for not adequately collecting and reporting data that might have improved the scores.
“The Leapfrog methodology does force you to be conscious and thoughtful about how you do things in your organization,” Krueger says. “It causes you to focus more intently on assessing and improving what you already thought was high-quality care, and maybe it was, but with room to do better.”
The CHI Franciscan team also learned the importance of “overcommunicating” about the quality improvement efforts, Krueger says.
“Across an organization as large as ours, with 1,200 clinicians, a large accountable care organization with more than 4,000 physicians, we did a lot of late-night meetings, early-morning meetings, to get in front of as many physicians as we could to communicate what we were doing with Leapfrog and why it was important,” he says. “We made some real allies immediately by focusing on our intensive care units because we knew that was where our sickest and most vulnerable patients were.”
Krueger’s team relied on research from patient safety expert Peter Pronovost, MD, PhD, then John Hopkins Medicine’s senior vice president, showing the value of intensivists in ICUs. The research was adopted by The Leapfrog Group to support its assessment of ICU physician staffing. (The Pronovost research is available at: https://bit.ly/2Bobozy. Information on the related Leapfrog measure is available at: https://bit.ly/2Q7uvGv.)
CHI Franciscan is now known in the region for its virtual ICU, which provides telemetry monitoring and remote oversight for high-risk patients from board-certified intensivists. Six of the system’s hospitals now employ board-certified intensivists available at all times, either in person or virtually, Krueger says.
“Dr. Pronovost found that when you have board-certified intensivists working in your ICUs, the mortality rate drops 30%. That’s pretty impressive, and when you’re dropping mortality rates, you also lower other complication rates,” Krueger says. “Communication was essential because we found out that our intensivists needed some support that would allow them to work more effectively. Getting those stakeholders on board was very important in driving that forward.”
CHI Franciscan also emphasized involving every staff member on the front line, particularly by giving them the ability to do what they knew was right for the patient. They heard the organization leaders say that quality, safety, and the patient experience are the most important goals, but they sometimes felt they were constrained in achieving those aims, Krueger says.
“We empowered people to do the right thing. We granted them the power to always do what was in the best interest of the patient, and we have to be explicit about that in healthcare, exactly what that means,” Kruger says. “We explained to them that if they ever have any concerns about a patient’s safety or quality of care, they should notify someone either by contacting a supervisor, filing a report through our internal system, or simply asking for help. The challenge is convincing them that you really mean that.”
Getting the entire organization, including frontline staff, involved in the campaign was one of the hardest parts, but it was key to success, Krueger says. Quality improvement professionals can impede their efforts by thinking they are the ones who will produce change within the organization, he says.
One of the greatest transformations in the culture at CHI Franciscan was getting staff members to feel like they are part of the quality improvement team rather than being told what they are doing wrong and how to improve, Krueger says.
“Our quality department here can be a consultant, doing data analysis and showing opportunities. We can have some influence over people, explain the methodology, and educate people, but we are not the ones doing the work on the front lines,” Krueger says. “It is very important for those people on the front lines to know that we expect them to do the right thing for the patient, and if they don’t understand parts of Leapfrog or why it’s important, they can reach out to us.”
Eliminating the silo in which quality improvement often is relegated made a difference, he says.
Krueger sees the different outlook up and down the line, with frontline staff and administrators embracing the quality improvement effort. The system’s chief financial officer and human resources director will stop him in the hallway to ask about ongoing efforts and how they might contribute more, he says.
“Sometimes, because the Leapfrog score is such a large methodology, people don’t understand how their role has an impact. Our success was tied to our ability to get all these people who might have been siloed to unite around the common goal of improving safety and quality,” Krueger says.
Quick wins were important. Any time a unit had a positive experience like improving a patient safety metric, that was celebrated, Krueger says. The aim was to create momentum and not wait for grand achievements before rewarding those involved, he says.
CHI Franciscan also made a point of quickly and prominently acknowledging staff who brought concerns about safety and quality or who suggested a way to improve.
“Sometimes, it wasn’t something we were proud of — an infection or problem that a staff member brought forward. But we championed the fact that they stepped forward and reported it, giving us the opportunity to address it,” Krueger says. “We emphasized that this was the behavior we expected from our staff, recognized them for doing so, and thanked them.”
The health system also emphasized that the focus was not on the score of any one hospital but rather improving the system structures and culture to improve care overall.
Krueger says the CHI Franciscan experience shows that rapid improvement is possible, but he cautions other quality improvement leaders that the task can be formidable.
“It’s going to be much harder work than most people anticipate. A lot of the work is very chaotic,” Krueger says. “Quality improvement does not come in a pretty package with a bow. A chief nursing officer was telling me that quality improvement is usually about pretty explanations and posters, but the truth of the matter is it’s a lot of gritty conversations with people, just trying to solve problems together.”
The challenge going forward is to ensure that the changes are permanent and durable, Krueger says.
“You can see that something has transformed when you go out in the hospitals and visit people,” Krueger says. “There is a new level of energy, and people are invigorated.”
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Amy M. Johnson, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.