When it comes to healthcare quality, should titles matter?

A push to make quality everyone’s business

A few years back, staff suggestion boxes were a big thing. It was as if there was a burgeoning realization that people who didn’t have big titles might sometimes have a good idea on how to make things better. Some organizations even gave prizes away to the little people who came up with the best big ideas for saving money or time.

The idea has evolved. It seems that the powers that be understand that the people who do the actual work usually have the best ideas of what is wrong with processes and often how to fix them, and they are increasingly seeking their advice and input in quality improvement.

At Cleveland Clinic, J. Michael Henderson, MD, FASC, the chief quality officer, says he came to his job seven years ago wanting to turn things "upside down" by making sure every department or institute had the tools and infrastructure it needs to implement ideas that come from the front line, and an overarching quality and patient safety institute to handle all the reporting, infection prevention issues, and environmental health and safety. Staff are free to change things to serve patients quickly and innovatively, he says.

Guido Bergomi, BS, the senior director of the quality and patient safety institute, says that the new structure has enabled people to work together across functions and disciplines in a way they didn’t before. For example, they are developing several new care pathways, and anyone who is involved in the process of care, whether a nurse or orderly or dietician, can comment and participate in the writing and review of that care path. During the pilot phase of any pathway, Bergomi continues, those same people are encouraged to speak up about what works and what doesn’t.

There are no egos among the highly educated or shrinking violets among those who make hourly wages, he says.

Unforeseen benefits

Henderson says there are some unforeseen benefits that come from this cross-discipline work. Practices change quickly. In an orthopedic pathway that was created, they saw transfusion rates plummet as physicians and nurses saw what others were doing. "The culture of working together around the patient, rather than just doing things as we always had took over," Henderson says.

By putting the focus on who is involved in a process and figuring out how it should run in an ideal situation, Bergomi says the focus becomes the patient. Hierarchical issues such as titles or nurses versus doctors disappear, or at least recede. "The focus is on the outcomes we want to achieve, like reducing readmissions or infections or falls. If you talk to a team about surgical-site infection rates, and to a surgeon about fixing it, the docs know that nurses, technicians, the equipment entering and exiting the room matters. Smart people know that. And since most people want to do a good job, it becomes about the work, and the goal you want to achieve," he says.

Henderson says that one way you get titles to make less difference and create cross-functional trust is to get the right stakeholders involved from the start. "You get a nurse or physician or other key project manager to facilitate, and people who are involved in the process to complement that," he says.

Simple, measurable, attainable

Bergomi adds that you need to make the goals simple, measurable, attainable. They need to be shared by all participants, fit the mission of the organization, and be about more than just Medicare reimbursement rates. Money alone won’t resonate, he says.

Limit their number, too. "You can’t have 400 goals in an organization," Bergomi says. "We have a lot of hospitals around the country and the world, but have a small number of enterprisewide goals, maybe a dozen of them."

Don’t let participants sit quietly, Bergomi says. "Ask questions to encourage participation."

If you are worried that departments that you haven’t involved before might not be willing or capable of participating, think again. Bergomi says a recent insulin project needed input from food service, and they were thrilled at being involved. As more organizations create a culture where the well-being of the patient is paramount, giving every department a chance to participate in ways to improve patient care is something they will welcome. "If the activities have meaning, like improving patient care, they are engaged," Bergomi says. "We have done a lot of work here so that everyone in the organization from surgeon to housekeeper has participated in half-day meetings to discuss our culture. How we treat patients, and each other, whether we work in finance or as engineers, matters. It helped us create an even field."

Down in Phoenix, the Banner Good Samaritan Medical Center Emergency Department found a way to translate removing hierarchies into better patient satisfaction scores. In that case, the department was struggling with low scores, says Moneesh Bhow, MD, FACEP, the medical director for the department. "We wanted to look at the patient comments and see where we were falling down."

New voices

But it wasn’t as simple as finding a single thing wrong, or even a few things to put on a to-do list, Bhow says. Many of the items boiled down to poor communication. "Even if we attributed every negative score to one of five categories, half of them were in communication," he says. In many cases, if a nurse had spoken up to a doctor, a problem could have been averted. "Why weren’t the nurses speaking up to the doctors? Was it a culture thing? Do we blow the nurses off or make them somehow uncomfortable?"

They knew that nurses spend more time than physicians with patients, and the more that the nurse tells the physicians, the better care the patient gets, and the more cohesive the group looks. Bhow wondered whether there was too much hierarchy and blinkered work going on. "With computers and instant messages, we don’t have to talk to each other," he says. "The electronic world means we gain stuff, but we lose stuff, too."

The goal became to have doctors and nurses talk more and to break down the idea that one of them was more important than the other, Bhow says. "The old school idea that you stand up if the doctor walks into the room? No way. We wanted to empower the nurses to speak up, to say what they think, to say why. In my own practice, I know that the nurse knows more about the patient and what he or she wants, his or her goals, than I do."

The lesson would be that everyone can give anyone a suggestion, regardless of their place on the pay scale, he says. "And if the suggestion isn’t useful, you don’t have to be rude or shut them down."

Not everyone is comfortable speaking up, though, and not everyone feels he or she has a voice, Bhow says. Similarly, not everyone is ready to hear all those new voices. So Bhow and his team identified the people they thought had challenges.

For them, they talked not about patient experience numbers, but about how better communication with patients reduces the risk profile of the patient, or improves outcomes, or increases repeat business. "We look for the intrinsic motivation of the person. We ask them what their goal is." Chances are, improved communication between physician and nurse can positively affect that goal.

Happiness

While the initial goal was to improve patient satisfaction, Bhow says that is just one component. "Don’t focus on that. Focus on your happiness instead. Our motto is that a happy provider means a happy patient. One of the unintended consequences of this is that people are much happier coming to work. Our retention rate for nurses has improved, and they are more involved. When you have engagement like that, the patient benefits, too. There is a greater chance that the nurse will pick up something she might otherwise have missed."

Having an environment where you feel like a member of a team, rather than like someone being given orders from above did far more at Good Samaritan than Bhow anticipated. He still hasn’t seen patient satisfaction scores hit 100%, although there has been ample positive progress.

"When we take our eye off the ball, it slips or we plateau," he says. "We have to keep our focus on all the time. But the culture is changing. The really cool thing is that people are feeling a lot freer to speak up about other ideas, too."

For more information on this topic contact:

• Michael J. Henderson, MD, FASC, Chief Quality Officer, Cleveland Clinic, Cleveland, OH. Email: henderm@ccf.org. Telephone: (216) 444-8462.

• Guido Bergomi, BS, Senior Director of Quality, Quality and Patient Safety Institute, Cleveland Clinic, Cleveland, OH. Telephone: (800) 223 -2273.

• Moneesh Bhow, MD, FACEP, Medical Director, Department of Emergency Medicine, Banner Good Samaritan Medical Center, Phoenix, AZ. Telephone: (917) 596-6588.