Consortiums, system win quality kudos
Awards show value in working together
The benefits of giving up data once considered secret in the name of patient safety and quality improvement were lauded at the annual John M. Eisenberg Patient Safety and Quality Awards when the National Quality Forum and the Joint Commission chose two consortia among its honorees.
The winners named in January include the following:
- The Institute for Clinical Systems Improvement (ICSI), Minnesota Hospital Association (MHA), and Stratis Health, which were recognized for their Reducing Avoidable Readmissions Effectively (RARE) Campaign;
- Anthem Blue Cross, the National Health Foundation, the Hospital Association of Southern California, the Hospital Association of San Diego & Imperial Counties, and the Hospital Council of Northern & Central California, which were recognized for their initiative "Patient Safety First a California Partnership for Health"
- Vidant Health of Greenville, NC, which was honored for its patient training program;
- Gail L. Warden, President Emeritus of Henry Ford Health System in Detroit, who received the individual achievement award for his continued work to improve and assure the well-being of hospitalized patients.
The ICSI, MHA and Stratis project was designed to work across the continuum of care and focuses on the impact of the data, rather than the esoteric numbers, says Jennifer Lundblad, PhD, MBA, President and CEO of Stratis Health, which is Minnesota's Medicare Quality Information Organization. So instead of noting the nearly 6,000 unplanned readmissions avoided, they talk about the 6,000 people they helped sleep in their own bed.
There are 82 participating hospitals, which combined account for 85% of Minnesota's annual unplanned readmissions every year. Over two years, Lundblad notes, there were 5,441 readmissions avoided by providing participating hospitals with tools, support, and help to redesign processes and policies to make the improvements happen.
All three participating organizations were interested in reducing readmissions when they got together in 2009, she says — who wasn't? And they had worked on projects together before. "We realized this was another case where we could get further faster if we worked together," says Lundblad.
"The other thing that spurred us on was that we were at the start of the Medicare penalties," says Mark Sonneborn, MS, FACHE, vice president of information services at the MHA. "Everyone was in the same boat with excess readmissions, and there was no disincentive for us to work together."
Indeed, there were health-plan-led efforts to get some group work on the topic going before this consortium got off the ground, says Sonneborn. "We moved from the health plans being the lead to these three groups, with other stakeholders being involved. We went from this being a project to it being a true campaign."
Kathy Cummings, RN, BSN, MA, project manager for RARE at ICSI, says that they grouped reasons for unplanned readmissions into five areas and assessed each organization on those areas to identify "pain points" that were ripe for improvement.
The five areas are comprehensive discharge planning; patient engagement and family inclusion; medication management; care transition support — of the patient from the hospital to the next point of care; and care transition communication — between care providers.
The goal was to reduce the state level of readmissions by 20%, and then for each facility to set its own goal based on where it was initially and what its particular problems were, Lundblad says. The framework for improvement was flexible but evidence-based, giving each hospital some leeway to choose elements for implementation that would work best for its particular situation, but also be sure that they would have a positive impact.
Translating rates into something meaningful and patient-centered was key to getting patients, families, providers, and the wider community invested in the RARE program, Lundblad says. They use a pillow as the campaign thermometer measure, with the stack getting higher for the increasing number of nights at home that patients sleep when they don't go back to the hospital unexpectedly. "It keeps the patient at the forefront of the mind," she says. "This is about real people being at home where they want to be. People can rally around that."
The goal was 24,000 more nights at home, and the goal was not just met but exceeded, says Cummings. There were 6,000 fewer readmissions, which met the numeric goal, and Sonneborn says the percent rate is at about 15% currently. For the third quarter 2013, the data was at about 7,030, and he thinks the final quarter data should hit about 7,500 when it comes in.
Meeting the goals the campaign put in place, Sonneborn says, requires not just the small and medium-sized hospitals to play ball, but the larger facilities, too. And if there are hospitals that are going to balk at sharing data and information, it is more likely to be the big ones, he says. Or they will sign up, but then not really participate or engage fully. "We did a lot of arm twisting to get them to do the work," he says. "It was challenging."
Sometimes, it meant personal calls to CEOs and hospital administrators. Sometimes, it meant getting participating CEOs to call their peers. Indeed, positive peer pressure played a key role, says Cummings. "When [Sonneborn] published the data, hospitals can see how they compare to others. That's a real impetus to really participate."
Lundblad notes that a lot of people will say that things are different in Minnesota, that sharing data has such a long history, it's no big deal. But she says the strong tradition of transparency doesn't always work. And "no one waved a wand and said you can be collaborative, making it happen all at once. It took work and leadership to make it happen. And it takes continued work to keep making it happen."
Even after getting everyone to play a real part, it can take continued hand-holding. Sometimes, a small change can take time to reap rewards, especially in a really large organization. "It can take months," Cummings says. "There can be pushback on participating when you don't see a result."
Think of something like the HCAHPS scores, which only come out annually, Cummings says. If moving that score is part of a goal, waiting to see a result can be achingly difficult. That's why interspersing long-range goals with other, nearer-term ones that can be trended more often is important.
The campaign has been largely aimed at hospitals, but will be expanded throughout the continuum of care in the future, says Lundblad. "Maybe we could have done it earlier, but we had our hands full with more than 80 hospitals. We hoped they would reach out to their associated enterprises, but they said they wanted to improve their own situation before they did that. Now we need to move far and fast through long-term care and other parts of the continuum."
The project has been a success largely because the environment was right for the organizations to work together, says Sonneborn. Medicare, commercial plans — no one wants to pay for unplanned readmissions. He notes, too, that in the Twin Cities in particular, there is an increasing percentage of total cost of care contracts, and readmissions are costs, not revenues.
Lundblad thinks that the exceptional assessment they used — which was based on the many publicly available assessments, like Project RED (http://www.bu.edu/fammed/projectred/toolkit.html), or Yale's CORE calculators (http://readmissionscore.org/) — helped hospitals come up with appropriate improvement programs designed to merge with the specific gaps identified.
And Cummings cites the advisory committee for RARE, which included patients, home care, health plans, and skilled nursing facility personnel. All were asked for each of the five areas mentioned above: What are the places you think need improving, and what are the basic needs in each area? They came up with a list of recommended actions, which is available on the RARE website (http://www.rarereadmissions.org/documents/RARE_Recommended_Actions_Care_Transitions.pdf).
In the end, it all comes down to the basics, Sonneborn says. It's eating your veggies. Look retrospectively at your patients who have come back and figure out why they were at risk. If you don't do this, you don't have a chance of getting a handle on the problem."
Reducing errors reduces costs
Anthem Blue Cross, the National Health Foundation, the Hospital Association of Southern California, the Hospital Association of San Diego & Imperial Counties, and the Hospital Council of Northern & Central California launched Patient Safety First: A California Partnership for Health in 2010. The idea was to bring people from the various California regions and multiple organizations together to try to reduce several healthcare-acquired infections to zero, sepsis mortality reduced by 30%, and preterm induction deliveries reduced to 5% or less. Doing so, they say, could save millions of dollars and thousands of lives.
So far, there are 182 hospitals participating, with an estimated 3,500 lives and $63 million saved. The first phase focused on hospital-acquired infections, perinatal care, and sepsis. The next phase was just rolled out.
The healthcare-acquired infections tracked included ventilator-associated pneumonia, catheter-associated urinary tract infections, and central line-associated blood stream infections. Those were the data points with a goal of zero incidents, says Tracy Wang, public health program director for Anthem Blue Cross.
Wang says that regional hospital associations did most of the heavy lifting, hosting learning exchanges through which best practices were disseminated. Among them were using a rapid response team for sepsis infections; using checklists and bundles with central lines or catheters; implementing hard stops when scheduling births so that early deliveries cannot go on the calendar without medical necessity; and providing resources for hemorrhage related to perinatal birth trauma. (More examples can be seen in the annual report at http://www.nhfca.org/psf/docs/760.NHF_EndOfYearReport_FINAL.pdf.)
The National Health Foundation collected data, and collated and benchmarked it for the region and the state as a whole. The data was blinded, with participating hospitals unable to see how their peers did.
Phase 1, which lasted three years, ended in 2012. Phase 2 began last year and includes three more metrics — Clostridium difficile reduction, surgical sponge/foreign object retention after surgery, and reduction of cesarean section rates for first-time mothers by 10%. While these data have been collected since last year, there are no interim figures available yet, Wang says.
The other goals weren't retired but were moved into a pay-for-performance program to sustain them, says Wang.
It wasn't easy to launch such a wide-ranging effort between so many different organizations, she notes. And they found that just because someone said they'd participate and signed on the dotted line doesn't mean they'll put any effort into it. Anthem helped solve that problem by creating a demarcation on its provider finder site for those who submitted data, indicating they participated in this important patient safety/quality improvement effort. "That helped us to increase data submission a lot," Wang says.
They also had a problem capturing data related to induction of delivery at less than 39 weeks. "The ICD-9 code doesn't tell you when it was, just whether it was 37 weeks or above. So we had to find additional data consultants to work with those hospitals that were having difficulty capturing that specific data."
All of those issues were eventually smoothed out, she says, and she thinks that collaboratives are an underutilized resource. People are often afraid of sharing information and best practices for fear of giving away some imagined competitive advantage. But, Wang says, "If something is working in your region, you should be able to build on that. Don't reinvent the wheel. It means you can find solutions faster."
Lemons from lemonade
When a blood event resulted in a patient death at the Greenville, NC-based Vidant Health in 2006, it was a wake-up call for the eight-hospital system, says Joan Wynn, PhD, RN, chief quality officer. "It caused us to examine our culture and oversight, and we started a systemwide patient safety training program. From the bedside to the boardroom, that tragic event galvanized us."
It was this program for which the system won the Eisenberg award. It involves four hours of didactic training for every single employee and medical staff member in the system — more than 8,000 people — from housekeeping to CEO. The system uses a train-the-trainer program, Wynn says, which allows physicians to hear a message from their peers, and likewise other staff members, making it more likely that they will accept the teaching and any new procedures and policies.
The program includes leader bundles that are designed to improve the situational awareness of department leadership, as well as daily check-ins where employees touch base with those department leaders at the start of each shift. They go over a three-point agenda, regardless of department: What happened during the previous shift (or the previous day in the case of executives and administrative departments who have just a single shift per day), what is anticipated during the upcoming shift, and any successes or concerns that any team member wants to address.
Longer-range quality planning also changed as a result of the 2006 event, Wynn says. That was based on four key points: board leadership, aggressive transparency, building patient/family partnerships, and leader/physician engagement.
Under the first element, board leadership, the goal was to teach board members to oversee quality issues just as they did other elements of health plan functioning, such as finances. Outside experts, like UC San Francisco's Bob Wachter, were brought in to teach board members the quality ropes. "As their literacy in the area grew, they started taking a more active interest in it," Wynn notes. They began doing quality rounds. By 2008, the board had progressed so far that the Institute for Healthcare Improvement named it a "Board on Board" and asked it to be a mentor to other boards that were interested in being more proactive in areas of quality and patient safety.
Regarding transparency, Wynn says that applies not just to data that the employees and medical staff can see, but that the public can see, as well. The information is exactly the same. The public Web page includes core measures and patient experience scores like many other health plans. But it also includes data on hand hygiene, pressure ulcers, and falls, and in easy-to-understand numbers rather than a rate.
"We found that using a raw number makes more sense," she says. "Point zero zero one doesn't have as much meaning as five patients with an infection." The data on benchmarks is also there, as is the information on the number of visits. The goal is to be in the top quartile or top 10% of any given measure. And any person can see any piece of data he or she wants. Nothing is off limits.
Patient and family partnerships continue to develop in the system. There is a cadre of patient advisors, Wynn says, who partner with them on safety and quality work. "People ask where we find people to do this with us, but it's really not hard." She notes that any patient or family member who has experienced a "miracle" in a hospital is a great bet to want to be part of such a group. And those people who have experienced a tragedy? They, too, are usually very keen to make sure such an event never happens again. The key is in the asking. "You have to recruit and collaborate with them, and then make use of what they have to share."
One way patients have been used is to put a face on data. In 2010, one patient talked to the board about her 90-day odyssey as a patient with ventilator-associated pneumonia (VAP). She had to be put in a drug-induced coma to heal. Her experience made VAP more than a number on a dashboard. "You could have heard a pin drop in that room when she told the story," Wynn says. "The data just came to life."
Another story involved the brother of an employee, who died alone in an ICU because visiting hours didn't allow someone from his family to be with him. That particular story led to a change in policy so that family members won't be haunted by the idea of a loved one being alone at the end of life. Now, Wynn says, there is a patient story told just about every month at the quality committee meeting.
Leader and physician engagement means ensuring that the people in those roles are sponsoring quality projects. Now, a physician or leader is listed on every single project, which helps to ensure buy-in from other people in the organization. It also ensures accountability: If something doesn't work and the data isn't moving, there is a person who is responsible for making sure another tactic is given a shot. "If no one has a name on the project, then that's exactly who will check in to see how it is going," she says.
Over the past few years, the training program has reaped rewards, but it wasn't without its bumps in the road, Wynn says. For instance, in the data reporting process, they looked at many ways to report information that was meaningful to all users. While a lot of scientifically minded people prefer information on rates, for the average person, it is more meaningful to use raw data. It also brings the issue back home to real people impacted. "It's hard to explain to someone in environmental services the concept of rates and benchmarks and averages," she says. "But when you say that this many people have a central-line infection, and it comes from bugs in the environment, which means they didn't clean well enough — that means something to them." By including contextual data on number of visits and national benchmarks, Vidant was able to appease the scientifically minded physicians while still having information that made sense to the wider public.
Wynn thinks it's pivotal to engage patients and families in the quality process, and while it can seem hard to do, there are methods to getting a group of patients and family members on board with your quality and safety efforts. The easiest way is to look at employees who have either been a patient or who have had family members or close friends in the hospital. They are well-placed to ask if the patient or family member would be interested in helping to serve on a quality committee or help with a quality project.
She also believes you should get over your fear of reporting data for all to see — or help your leadership and medical staff get over it if that's what's holding up wider sharing. "Putting up the raw numbers makes it simple and understandable to everyone. There are people attached to those decimal point numbers."
If there is an adverse event, raw numbers makes it easier to explain and builds the will to improve, Wynn says. And it's not as if you have to put it all on your website at once, either. It can happen over time, starting with some of the best practices you've already mastered.
Besides, Wynn concludes, knowing that data sharing is coming down the pike is, in itself, a great goad to improvement. "When they knew we were going to put hand hygiene data on the website, you can bet they started to make sure they were doing well on that element."
For more information on this topic, contact:
- Kathy Cummings, RN, BSN, MA, Project Manager, RARE Campaign, ICSI, Minneapolis, MN. Email: firstname.lastname@example.org
- Mark Sonneborn, MS, FACHE, Vice President, Information Services, Minnesota Hospital Association, St. Paul, MN. Telephone: (651) 641-1121.
- Jennifer Lundblad, MBA, Ph.D., President and CEO, Stratis Health, Bloomington, MN. Telephone: (952) 853-8523.
- Tracy Wang, Public Health Program Director, Anthem Blue Cross, Los Angeles, CA. Email: email@example.com.
- Joan Wynn, Chief Quality Officer, Vidant Health, Greenville, NC. Email: firstname.lastname@example.org.