Success Factors for High Clinical Performance

1
Success Factors for High Clinical Performance
Dale W. Bratzler, DO, MPH Medical
Director Oklahoma Foundation for Medical Quality
2
Whats driving healthcare policy discussions?
3
1 - Cost

• 1.9 trillion
• 16 of the gross domestic product
• 6,280 for each man, woman, and child
• In 2006, the Federal government will spend 600
  billion for Medicare and Medicaid
• By 2030, expenditures for these two programs are
  projected to consume 50 of the federal budget
• Crowds out spending for other domestic programs

4
2 Variation
Dartmouth Atlas of Healthcare
5
(No Transcript)
6
Relationship Between Healthcare Costs and
Hospital Quality of Care
In the majority of studies, costs for healthcare
are INVERSELY related to quality of care!
7
3 Quality of Care
Patients care often deficient, study says.
Proper treatment given half the time. On
average, doctors provide appropriate health care
only half the time, a landmark study of adults in
12 U.S. metropolitan areas suggests.
Medical errors corrode quality of healthcare
system
Medical Care Often Not Optimal Failure to Treat
Patients Fully Spans Range of What Is Expected of
Physicians and Nurses
Study U.S. Doctors are not following the
guidelines for ordinary illnesses
The American healthcare system, often touted as a
cutting-edge leader in the world, suddenly finds
itself mired in serious questions about the
ability of its hospitals and doctors to
deliver quality care to millions.
.
8
Quality from the Patients PerspectiveHospital
Quality Measures, Qtr. 4, 2005
The Appropriate Care Measure reflects the
percentage of hospital patients that receive all
indicated care (all-or-none).
Bratzler DW. Unpublished data.
9
Whats the big picture??

• Serious and widespread problems of quality
  exist in the United States, with evidence of
  underuse of beneficial services, overuse of other
  procedures that are not medically necessary, and
  mistakes leading to patient injury. The Institute
  of Medicine of the National Academy of Sciences
  has stated, that the quality of health care
  received by the people of the United States falls
  short of what it should be. Commonwealth Fund

10
Even the best are not the cream of the crop
but are better described as the cream of the
crap
11
We still have a long ways to go.

• The pace of improvement is too slow

12
So what characterizes high performing hospitals?
Role of Leadership and Governance
13
(No Transcript)
14
Common Themes from the Leadership and Governance
Summit

• Research findings are consistent
• Intent versus Reality a perception gap
• Playing to the test
• Need for physician involvement
• Boards need training too
• Need to target poor performers
• We need to apply what we know

15
Why Focus on Hospital Leadership?Research
Findings are Consistent

• Research suggests that more engagement of of
  hospital leadership (C-suite, boards, and
  physicians), in cooperation with other health
  care professionals in QI, is associated with
  higher performance in clinical care.
• The active involvement and collaborative
  participation of top level leaders is essential
• Hospital leaders must be given the knowledge and
  tools to address the issue

16
The Developing Evidence Base

• Studies that have looked at high performing
  hospitals in relation to governance and
  leadership
• Solucients /Governance100 Top Hospitals
• Yale/AHRQ
• Commonwealth Fund
• Vanderbilt
• Mathematica/Delmarva
• HSAG- Health Services Advisory Group
• Iowa Field Study
• CMS/Iowa/CareScience
• Estes Park/National Patient Safety Foundation

17
Twelve common findings
A. Leadership

• CEO dedication to quality as job 1
• Direct board involvement
• Leadership both understands and articulates the
  business case for quality
• Support for a culture of quality
• Support for EBM beyond mere lip service

18
Twelve common findings (contd)
B. Structure Process

• Medical and nursing leadership engagement at all
  levels
• Attraction and retention of the right people
• Development of effective in-house processes
• Monitoring and use of benchmarks
• Exploitation of the power of IT

19
Twelve common findings (contd)
C. External Resources

• Engagement with consumers
• Access to external support and assistance from
  peers

20
Intent Versus Reality

• Optimizing quality and patient safety has
  garnered high priority and focus, but
• Boards and C-suites often perceive a very active,
  visible level of engagement in a culture of
  quality and patient safety, while..
• Middle management and front line healthcare
  workers often have a very different perception of
  organizational commitment to quality and safety

21
I am encouraged by my colleagues to report any
patient safety concerns I may have.
Probability of VAP
 
Safety Climate Percent Positive Score
22
Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
23
 
of respondents reporting positive safety climate
EWRExecutive Walk Rounds
24
SAQ Results for 22 RI ICUs Paired Samples t-tests
 
of respondents reporting positive climate
t1.14, p.261
t 0.58, p.567
t2.35, p.028
t .74, p.470
t2.43, p.024
t1.41, p.172
25
Playing to the Test

• We all do it
• Healthcare workers will focus their energy on
  those areas of their work upon which they are
  held accountable
• If all measures for a performance evaluation
  focus on productivity, volume, or amount of work
  done, quality will not be a priority for the
  front line

26
Need for Physician Involvement

• Research has consistently demonstrated the value
  of physician champions in quality initiatives
• Take ownership and help overcome barriers
• Incorporate evidence-based practices into care
• Assist in the redesign of processes

27
Boards Need Training Too

• High performing institutions have modified the
  way they recruit members for the Board of
  Directors
• Several studies have shown that while members of
  hospital Boards have working knowledge of
  concepts of healthcare quality or patient safety,
  they often do not understand fundamentals of
  quality improvement

28
Barriers to Transformation

• Must be able to focus on more than the short-term
  including financial instability
• Need for Board members to understand their
  responsibility for hospital quality just as well
  as they understand their fiduciary responsibility
• Overcome the lack of personnel, skills, and
  experience
• Challenges
• Lack of training in performance improvement
• Need to better describe the business case for
  quality

29
Leadership Survey

• 18-question survey distributed via internet in
  early 2005 to 1,380 hospitals in 9 states AZ,
  CO, IL, IA, MD, NJ, NY, PA, and WI.
• 438 usable hospital responses (rate 32)
• CEOs (55), QI execs (25), CMO/CNO (13)
• Examines hospital QI drivers and impediments,
  reporting methods, board and physician
  participation in QI, and senior executive
  incentives.

The Governance Institute and the Solucient Center
for Healthcare Improvement
30
Whats already happening Board Engagement and
Incentives

• 24 of boards interact with the medical staff a
  great amount in setting hospital quality
  strategy
• 27 of boards spend more than one fourth of their
  time on quality issues
• 66 of hospitals base some type of executive
  compensation on measurable Quality Improvement
• BUT only 13 of hospitals tie quality improvement
  to executive base compensation packages

31
Survey link better outcomes are associated with
hospitals where...

• the board spends gt25 of time on quality issues
• the board receives a formal quality performance
  measurement report
• there is a high level of interaction between the
  board and the medical staff on quality strategy
• the senior executives compensation is based in
  part on QI performance

32
NB numbers above bars are case counts
33
Survey link better outcomes are associated with
hospitals where...

• AND..
• the CEO is identified as the person with the
  greatest impact on QI (p0.01), especially when
  so identified by the QI executive (plt0.001).

Quality CANNOT be delegated to a department or a
person
34
N 438
Hospitals where the CMO/QI exec identifies the
CEO/Pres as the most influential person are about
three times more likely to be in high performance
group (p-value lt 0.001).
35
Need to Target Poor Performers

• Many approaches to quality improvement have been
  based only on identifying poor performers
• In some proposed efforts to improve quality
  (i.e., value-based purchasing), poor performers
  could be penalized
• How do you engage the leadership (and Board) at a
  poor-performing hospital?

36
We Need to Apply What we Know

• We have a spread problem, not a discovery problem
• There is a great deal of common knowledge about
  the characteristics of high-performing hospitals
• We really know little about transferring this
  knowledge

How can you motivate to alter culture?
37
Quality Improvement Landscape

• Recognition of the need to fundamentally change
  health care processes and systems to deliver
  consistent high-quality care
• The need to incorporate the IOMs six aims for
  health care

38
Need for New Metrics for Quality

• Leadership and culture
• Patient outcomes
• Care coordination and transitions
• Costs and efficiency
• Adverse events
• Patient experience and satisfaction

39
Summary

• While hospital quality has improved a lot, much
  remains to be done
• There remains considerable variation in quality
  and efficiency across hospitals with quality
  often variable around a mediocre mean
• Some hospitals demonstrate deteriorating quality
  over time

40
Summary (continued)

• We need to continue to refine the metrics we use
  to measure hospital quality
• Focus on more than processes
• Evaluate care across the continuum
• Account for unintended consequences

41
Summary (continued)

• Studies continue to highlight the pivotal role
  for hospital leadership to achieve improvements
  in quality of care
• Hospital executives and board members must take
  as much responsibility for the quality of care in
  their institution as they take for the fiscal
  health of the organization

42
Summary (continued)

• While the important role of leadership and
  governance has been consistently demonstrated in
  studies of high performing hospitals and in
  rapidly improving hospitals, this commitment to
  quality has not been widely embraced by all
  hospital executives and boards

43
Summary (continued)

• Institute of Medicine on the Medicare QIO
  Program
• priority should be given to those providers
  who demonstrate the most need for improvement or
  who face significant challenges in their efforts
  to improve quality.