Strong collaboration sets QI program apart

Top performer bases compensation on quality

What sets one quality improvement program apart from all the others? To hear the staff at El Camino Hospital in Mountain View, CA, tell it, it's the unique relationship between the physicians and nurses.

"What makes us unique is an extremely strong collaborative quality program," says Diana Russell, RN, vice president of patient care services.

"We do not look at quality initiatives in silos but as an overarching program where physicians, nurses, and other caregivers regularly come together in monthly meetings to review the quality outcomes of their particular division or service," she adds.

El Camino, which is one of only four hospitals nationwide recently named as a "top performer" in a report from the Commonwealth Fund - Hospital Quality: Ingredients for Success - has a very strong physician/RN relationship, she continues.

"Nurses are highly respected by the physician staff and seen as co-caregivers," Russell notes. This, in turn, has led to a long-tenured nursing staff, and low vacancy and turnover rates.

When new physicians come on board, she says, there are two major expectations: "They must learn the computer system, and they must treat nurses with respect - and that comes from the other physicians. It is a very unique culture and environment."

Support from the top

Support from the highest levels of leadership also is evident. "When I came here four years ago, we already had a culture built around putting the patient first and delivering high quality," recalls Lee Domanico, El Camino's CEO.

"We proceeded to set up five areas in which we needed to be excellent - people, service, quality, growth, financial performance. Organizationwide goals were set, and we rated ourselves on how well we did; the employees rated from within," he explains.

Quality actually is part of the annual performance review for the entire executive team, says Domanico.

"It is one of five key indicators on which their compensation and performance review - and mine - are based," he adds, "And it is even more heavily weighted for Diana and the other people who work in quality."

El Camino participates in as many statewide, regional, and nationwide benchmarking studies as it can, Domanico continues.

"That's why the Commonwealth award was so significant; they compared us to 3,000 hospitals, and we came out as one of the four they chose to benchmark," he says.

Finally, Domanico notes, the hospital invests aggressively in technology. "We try to eliminate the chance someone will make a mistake, because technology won't allow a mistake to be made," he explains.

Another one of the hospital's strengths, adds Chris Hunter, RN, manager of clinical decision support (supporting quality efforts with data), is its 35 active clinical pathways, which have been in place 10-12 years.

"They really are part of the infrastructure, built into the process of care," he says. "We track and trend LOS [length of stay] and costs, as well as outcomes, and capture our gains. We have also reduced variation in care."

"Computerized care plans, critical paths, and protocols allow us to better standardize our care, and it gives us some advantages in terms of limiting variation," Domanico explains.

Putting it all to work

Over the years, El Camino has translated the aforementioned approaches into a number of quality successes.

One of the more recent examples is an effort to create a new alcohol withdrawal protocol. The multidisciplinary team includes nursing, respiratory therapy, physicians from critical care and behavioral health, chemical dependency professionals, care coordination, and general medical internists.

"We rolled it out a few months ago and have been able to demonstrate not only shorter LOS [from 4.4 to 3.4 days], but also less use of critical care, sitters, restraints, and decreased patient falls," Russell notes.

"When the team first got together, they felt if they did not decrease overall LOS, then at least they would seek to cut utilization of the CCU [critical care unit]," she recalls. "The driver behind it was to improve patient care."

"The team felt these patients that were treated with IV benzodiazepine tended be agitated and needed to be restrained or required sitters," Hunter adds, noting that the team ultimately decided to use oral benzodiazepine whenever possible, based on symptoms.

"I sat in on the initial meetings," Russell explains. "They had a very cooperative dialogue on how to achieve the best results. It was very evidence-based; they did the research, brought it back, and discussed it together. It was not just a case of physicians saying, `Do this.'"

In addition to shorter LOS, use of restraints was reduced from 21% to 6%, and there also was a pretty clear-cut drop in falls as well, she points out.

Average cost per patient dropped from $4,170 to $1,755 from the 2002 baseline.

The medication administration team, which focused on reducing errors, has benefited from the introduction of new technology, Russell adds.

"It has really helped facilitate and achieved a reduction in medication errors," she points out. "We have CPOE [computerized physician order entry], first of all, which helps eliminate handwriting and abbreviation issues. Then, we have a Pyxis [from Cardinal Health] automated drug-dispensing system, which, combined with CPOE, has been able to reduce our time for pharmacist order verification significantly. And we're just getting started with bar coding."

In addition, Russell notes, last year El Camino converted to a new "smart" IV pump. "It can react with a higher alert level if the medication dosage is set out of range," she explains.

Need More Information?

For more information, contact:

Lee Domanico, CEO, El Camino Hospital, 2500 Grant Road, Mountain View, CA 94039-7025. Phone: (650) 940-7300.

Diana Russell, RN, Vice President of Patient Care Services, El Camino Hospital, 2500 Grant Road, Mountain View, CA 94039-7025. Phone: (650) 940-7300.

Chris Hunter, RN, Manager of Clinical Decision Support, El Camino Hospital, 2500 Grant Road, Mountain View, CA 94039-7025. Phone: (650) 940-7300.