Getting leaders out on the floor, mixing it up with patients and staff, is one of the keys to success at South Nassau Communities Hospital in Oceanside, NY, which has established itself as a tertiary referral center and a standout in the region for women’s healthcare.
The hospital recently was named by Healthgrades as a 2018 5-Star Recipient for all four women’s care cohorts. It also received Healthgrades’ Gynecologic Surgery Excellence Award. Also, South Nassau stands alone in New York State in 2018 for receiving from Healthgrades all five awards in women’s health services lines: Gynecologic Surgery Excellence Award (six years in a row), Five-Star for Gynecologic Procedures (six years in a row), Five-Star for Hysterectomy (four years in a row), Five-Star for C-Section Delivery, and Five-Star for Vaginal Delivery.
These awards mean South Nassau is in the top 5% of hospitals evaluated for gynecologic procedures and top 10% of hospitals evaluated for providing quality outcomes in gynecologic surgery, says Alan Garely, MD, chair of obstetrics and gynecology at South Nassau and clinical professor of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York City.
At South Nassau, breast health, obstetrics and gynecology, maternal fetal medicine, genetic counseling, women’s imaging, and gynecologic oncology all are part of its women’s services.
“The number-one thing that has pushed us to where we are with women’s care is that our leadership is in the trenches every day,” Garely says. “We don’t manage from an ivory tower; we manage from down there. This comes from our CEO who has mandated the challenge to clinical leadership that we need to be involved with the people who are cleaning the rooms, serving the meals, answering the phones.”
Department Chair Visits Patients
Garely makes a habit of visiting each patient on the OB/GYN service at least once a week, talking to them about their experience at the hospital — everything from clinical concerns about their care to logistical issues.
“Immediately, I can find out what’s going on with that patient and find out if the issue is at a nursing or physician level, anything they’re not comfortable with. Patients can’t believe that the chair of the department is putting in their breakfast order because somehow they got skipped over by food service,” Garely says. “That sends a message to all the people in the hospital that leadership is willing to get their hands dirty, that they’re not just telling people what to do. It speaks to the philosophy of the hospital.”
Garely recently visited a morbidly obese patient who was experiencing shortness of breath after a cesarean section. The nurse had given her more oxygen, but when Garely visited, the patient said it was not helping.
Garely called for a rapid response team and had the woman transferred to intensive care immediately. The patient ultimately ended up with a pulmonary embolism. A half-hour delay could have been fatal, Garely says.
“That probably would have happened without me, but the fact that I’m on the ground means things happen faster,” he says. “It also elevates the expectations for people who work here because they know that ultimately everything is going to be checked and double-checked. They know that that patient is going to be visited by the department chair, and so they want to make sure everything is right.”
The motivation is not fear of being caught but rather taking pride in their work, Garely explains. Morale is extremely high among employees at South Nassau overall and particularly in its women’s care areas, he says. The hospital also enjoys a strong reputation in the community.
PI Committees Empowered
South Nassau also places a lot of power in the performance improvement committees at the hospital. Each specialty has its own performance improvement committee. Obstetrics and gynecology each have their own committee.
“I let them set the protocols and look at all the safety and quality measures. I oversee the committees, but we leave it to the professionals in each of those areas to make the decisions,” Garely says. “We’re very protocol-based. When doctors apply for privileges here, they have to understand it’s not the Wild West and we have very strict protocols. That’s why we have amazing outcomes in terms of safety and quality.”
Such an emphasis on protocols only works if you have buy-in from physicians, Garely says. They must understand the reasoning behind the protocol, or they will not adhere to it, he says.
“We don’t just launch it on the department. We have a protocol committee that meets once a month to come up with standardization protocols, and then those are sent by email to all the attendings in the department and nursing leadership,” he explains. “We’ll say, ‘This is the protocol we’d like to implement for a specific scenario, and here are the recommendations from the professional organizations, but we think we can do better. Is this practical?’”
The protocol committee considers the feedback and may alter the protocol as necessary. No suggested protocol ever gets 100% support from physicians and nursing leaders, but those supported by a majority are implemented.
Once implemented, the protocol is monitored for compliance and effectiveness, and it may be altered as a result.
“We’re a very fluid organization, and the leadership of the department are good listeners. We don’t rule by fiat,” Garely says. “We hear doctors talking about other hospitals where it’s ‘my way or the highway,’ one size fits all, with not a lot of listening.”
South Nassau’s chief medical officer also has chairman rounds once a month where all department chairs discuss patient care across specialties.
Metrics, Not Opinions
Healthgrades analyzed patient outcomes from 15 states and the District of Columbia, showing differences between hospitals that received its Gynecologic Surgery Excellence Award and hospitals that did not (it looked at years 2014 through 2016).
Patients in hospitals that won the award had a 46% lower risk of experiencing a complication while hospitalized compared with patients in other hospitals.
As a pelvic reconstructive surgeon, Garely puts great emphasis on operating room metrics.
“We try to run the department not based on opinion, feelings, and gestalt but on deep analytics. We look at individual physician metrics like transfusion rates, operative times, and admitted days in the hospital before discharge,” he says. “Those are things we can immediately intervene with because we follow them on a monthly basis and I always know from a scorecard where people are.”
South Nassau adheres to a just culture and works with physicians in a positive way without making it punitive. Physicians used to be afraid of receiving a level letter from the performance improvement committee, Garely says, but now they see it as the hospital reaching out in a proactive way to offer help.
“It’s a collegial atmosphere. I know it sounds quaint, but a lot of the complaints you hear at the major academic centers are that the big specialists are telling the generalists what to do,” Garely says. “We don’t manage like that. We manage more from the bottom up than from the top down.”
The hospital also makes liberal use of root cause analysis.
“We’re very interested in process but also in having everyone involved in analyzing and improving processes. Regular floor nurses are not afraid to bring up in a meeting what they think is a problem and offer a solution,” he says. “We try to maintain consistency in how we address problems, with committees that are structured to follow the same methodology each time.”
South Nassau uses the TeamSTEPPS approach, a set of evidence-based strategies and tools from the Agency for Healthcare Research and Quality (AHRQ) that includes checklists and mnemonic devices. It is intended to improve teamwork and communication in healthcare settings. (More information on TeamSTEPPS is available at: http://bit.ly/2p0Ysd2.)
Nursing usually takes the lead in coordinating any investigation into a poor clinical outcome, Garely notes.
Garely attributes South Nassau’s excellent scores in women’s health to other factors as well. The hospital has a robust imaging program for breast cancer screening and diagnosis, and the radiology staff are active clinicians rather than primarily reading images, he says.
The hospital also has one of the largest pelvic floor centers in the country, with four board-certified urogynecologists performing the most advanced pelvic floor reconstructive surgery in the country, Garely says. They work closely with the hospital’s colorectal surgeons and urologists.
South Nassau also is a leader in what it calls “gentle C-sections,” in which the drapes are clear and the parents can see the baby being delivered and even participate. The hospital also is expanding its relationship with midwives in response to community interests.
- Alan Garely, MD, Chair of Obstetrics and Gynecology, South Nassau Communities Hospital in Oceanside, NY. Phone: (516) 763-7820.