How to set priorities for your QI year
So much to do, so little time
To call quality improvement a "resource-intensive enterprise" like Patricia Reid Ponte, RN, DNSc., the senior vice president for patient care services and chief nurse at Dana Farber Cancer Institute in Boston, is really just a fancy way of saying it costs money, and that means making very careful choices about where to focus those resources.
But given the reality of competing initiatives, increasing data collection requirements, and being able to show you’re doing better every year, how can you do anything as structured as choosing a project to champion?
There may be a lot of requirements for reporting that leave little choice in picking programs, but Ponte says there is always some room for choosing areas of focus, and to do that effectively, you need to create a prioritized list. "You do have to monitor and improve what CMS and the Joint Commission ask, and what payers put into your contracts," she says. "Beyond that, you have to see where you have an intersection of high volume and high risk. It might be an issue in medication administration in oncology because you had sentinel events there last year. Perhaps you have a lot of volume in your OR, so that might mean looking at ways to improve care for surgical patients is a better idea."
Where to start
Start by looking at the areas of practice where you have the most patients — either based on procedure, disease process, bed days, or costs, says Ponte. Those high-volume cases are also the places where you will see the most risk, simply because you do hip replacements more often than you face a situation with a new mom bleeding out during delivery.
Next, figure out if you have any small patient groups that are the focus of a lot of dollars or undergo extremely high-risk procedures. Also figure out if there are any areas — large or small volume — where you have had a higher than expected number of adverse events or near misses.
All of this information should be readily available through data, or by asking members of your patient care assessment committee. The latter can be particularly helpful in pointing out areas that aren’t evident by looking at data.
For example, Ponte says that a year ago her facility determined it had to improve its patient access process. Patients and families were complaining they couldn’t get an appointment when they wanted. "We knew we could lose market share, so for us, that was an important process to improve."
When Massachusetts General Hospital set up the Lawrence Center for Quality and Safety in 2007, it got a suggestion from the malpractice provider to become a data hub for the entire institution, says Elizabeth Mort, MD, MPH, the senior vice president for quality and safety and the chief quality officer at the hospital. "They said we should reach out to all corners of the institution, to anyone and everyone that has any data of any kind, which could impact what we do. That’s really just about everyone."
Having access to those vast amounts of data helps Mort and her team prioritize projects for the year. They make sure that each project involves at least one of the six pillars from the Institute of Medicine — that care is: Safe, Timely, Effective, Efficient, Patient Centered, and Equitable. She says that most institutions aren’t great at including equity, so she always makes sure there is some quality improvement goal related to that.
"I know innovation has to be a piece of it, too," she says. "It’s an obligation because the healthcare world looks to us for innovation."
By making sure that her projects stem from data and address one of those six pillars, Mort says she can find an island of calm in her busy quality department. "It makes me feel comfortable knowing that I haven’t forgotten any important area," she says.
A process and a spreadsheet
The mechanism for creating an annual to-do list is pretty basic, she says. "You just need a process and a spreadsheet." The Mass Gen process was described in a recent article published in the journal Academic Medicine1. It involves gathering data, internally and externally, and then classifying it. Those managing the priority designation process determine what the most pressing quality issues are and bring their conclusions to an internal review team, which then chooses the top quality goals for the year. Each goal is given an "owner." They choose appropriate metrics and send regular updates to senior hospital leadership.
The spreadsheet? Well, it helps keep your desk neat and keep track of goals that are of interest, but not imperative right now. "This pays off because there are always urgent things that have to take precedence," Mort says. They often have a longer-term trajectory, but require regular work on them. There are other things that are more aspirational — like reducing healthcare disparity. "We have a commitment to doing this, and we create an annual report on the subject that usually relates to the latest literature on disparity — right now, pain management in the ED is a big issue.
"It’s not as urgent as looking at medication errors, but if every year you identify a couple of these kinds of issues to investigate, they won’t get lost among the other urgent priorities."
One way she can get the resources she needs for the things that are not required, but still of interest and important, is to make sure that on all the quality requirements, results are not just good enough, but exceptional. "I think that for smaller hospitals, it might be harder to get the basic quality and safety work done and do what we manage here," Mort says. "But you should still figure out what you would like to do beyond that. If you get more money, or through philanthropy or a grant, then you will be clear about what to do with it. But I get that other facilities may be just thrilled at getting the ever-increasing requirements done."
You might have more opportunity, too, as value-based purchasing expands: It will help you quantify the value of the quality department and argue more effectively for increased resources, Mort says. "And often community hospitals have an edge over us in that they don’t have to have buy-in from 500 people."
Mort says she’s working on tracking tools and dashboards to try out that could help organizations better plan their annual quality calendars. She expects those to be published sometime in 2015.
1. Mort EA, Demehin AA, Marple KB et al. Setting Quality and Safety Priorities in a Target-Rich Environment: An Academic Medical Center’s Challenge. Acad Med. 2013 Aug;88(8):1099-1104.
For more information on this topic, contact:
- Patricia Reid Ponte, RN, DNSc., FAAN. Email: Pat_Reid_Ponte@dfci.harvard.edu Senior Vice President for Patient Care Services and Chief Nurse, Dana-Farber Cancer Institute, Executive Director, Oncology Nursing and Clinical Services, Brigham and Women’s Hospital.
- Elizabeth Mort MD, MPH, Senior Vice President, Quality & Safety, Chief Quality Officer, Massachusetts General Hospital, Boston, MA. Telephone: (617) 724-4638.