Hospital Peer Review
March 17, 2014
Healthcare can be a competitive industry, with individual hospitals and organizations unwilling to share information for fear of giving something away that might provide a competitive advantage to a facility or health plan across town. But in Wisconsin, a collaborative leveraged off the national Partnership for Patients program has led hospitals big and small, even in the most competitive markets, to share data, information, and best practices in an effort to improve care. The results have been nothing short of remarkable, says Kelly Court, MBA, chief quality officer of the Wisconsin Hospital Association, and no one's business has suffered from the sharing.
Among the results: more than 3,500 unplanned readmissions prevented; associated reduced hospital costs of more than $34 million; 291 early elective deliveries avoided, a 78% reduction; 37% reduction in surgical-site infections, saving an estimated $4.5 million; total estimated reduced healthcare costs from all aspects of the program of more than $45 million; third best state in the nation for Centers for Medicare & Medicaid Services (CMS) Value-Based Purchasing Program incentive payments.
The state Partnership for Patients project started in 2012, she says, and aligned with the high-volume conditions and patient safety concerns CMS had already identified. To date, more than 100 hospitals in the state are active, participating in webinars and engaging some 1,800 quality improvement teams in activities. They have reduced readmissions, hospital-acquired infections, adverse insulin reactions, and the average length of stay. Costs per stay have gone down.
Court says that Wisconsin has a long history of transparency. The Wisconsin Collaborative for Healthcare Quality (wchq.org) has been around since 2003, sharing information on a variety of all-patient, all-payer data, with comparisons to state and national benchmarking data included. (You can see an example at http://www.wchq.org/hospitals/)
"We did this before Hospital Compare," she says. "We provide a lot of support for sharing best practices. Very occasionally, we get—in a competitive market—someone who doesn't want to do that. But it's rare." What is really unique, she continues, is the level of engagement among small and medium-sized hospitals. "All of the rural hospitals are participating, sometimes even more aggressively than the bigger ones. They seem more likely to share. They really just want to help each other, and help their patients."
The national goals were to reduce readmissions by 20% in each state, and other areas of harm by 40% within three years. Court says Wisconsin hospitals are on their way, and quarterly data reported since the annual report (http://www.wha.org/Data/Sites/1/quality/WHA2013QualityReport.pdf) was released at the beginning of 2014 show the trend is continuing.
While there is an element of truth in the notion that all healthcare practice is local, and that what works in one setting may not work in another, Court says that Wisconsin hospitals only tackle problems where there is a "best known practice," which means that just about anything suggested can work in any of the facilities with the minimum of tweaks for local conditions.
Making it work
"But what we do find is that cultures can be different," she says. "There is a different tipping point for the number of staff that have to buy in before something becomes widespread. In a large unit, it might take six or eight nurses being on board with something to get a new practice embedded in the culture. Some hospitals will need everyone on board to make a new practice work."
The oft-stated truth that the will to change has to start at the top holds true, too. "Senior leadership has to want to drive the hospital to better outcomes," Court notes. She adds, "The middle managers, though, can be as or more important. They control the staff time. They hold the front-line staff accountable. If we say we will make follow-up calls to discharged patients, the middle managers are the ones who get that done. They get the team together. They make sure there is time available for them to be involved in learning webinars."
The senior staff may sign off on an idea, but if the middle managers do not believe in it, they can be a huge road block. Court continues: "The nursing managers are some of the most important people to engage and help to understand why changes in practice are important. They are the nurse owners and the process owners of the things we are trying to change."
They can also be the cheerleaders when changes you make don't have the intended or dramatic impact you'd like. For example, Court mentions ongoing struggles with pressure ulcers and falls that Wisconsin hospitals continue to have. "The issue with them is that you have to do all the things, every time to prevent them. It's not like giving an antibiotic before surgery, which is something you get done once. It's an around-the-clock process change. And there just isn't a lot of breakthrough science on how to prevent either issue."
People get burned out, Court says. Hourly rounds are hard to get done. Nurses know they need to do assessments on every patient. "The number of people you have to touch, the number of times each day—that makes it very difficult." There has been some success, though. In fall prevention, one hospital is using simulations with patients, nurses, and physical therapists to identify potential risks that aren't evident through daily nursing care. Other facilities focus on particular kinds of patients, such as those with delirium, who are at particularly high risk of falls.
On the other side, though, are some of the more successful projects that the hospitals have engaged in, like reducing elective deliveries before 39 weeks. "That project was really just getting physicians to say no, you aren't going to do it," Court says. It involves getting a champion—in this case a physician—who will drive the change.
"There are always apocryphal stories about why you have to have an early delivery, but we have to convince them that stories can't become a rationale for improper early deliveries. You have to have people in the middle who are willing to have hard conversations with your medical staff," Court says.
Doctors respond to science, and data supports reducing these: 5% of planned early deliveries result in an infant being admitted to a neonatal intensive care unit, adding more than $15,000 in costs for an average case. There are now medical criteria used for such deliveries, and scheduling processes that make it difficult for a doctor to put an early delivery on the calendar without meeting those criteria.
Court says that improving patient and public education is also helping, and the state is partnering with March of Dimes to help "turn off the public demand" for early elective deliveries.
One way that Court says hospitals are keeping staff from thinking about the quality push as "another thing on the to-do list" is by creating a compelling story for staff. Making something personal, appealing to their hearts—she notes that one hospital used the phrase "40 weeks, chubby cheeks" relating to its efforts to stop early elective deliveries. It's something that puts a picture in your head, rather than a number.
She also thinks that while focusing on outcomes measures is important, it can leave a gap in front-line staff knowledge of their performance. "Process drives outcomes," Court says. "Doing small tests of change requires testing processes, which means that we need to measure those, too." The program will be focusing on process measures in the coming year, in part as a way for staff to get some real-time feedback on their performance. They may not see outcomes move on a graph quickly, which—as in cases like fall prevention—can be disheartening. But they can see their improvement on the processes that are known to reduce the likelihood of falls.
Court says everyone knows the things that need to be done to improve care and safety—or they can easily find it out if they don't have it memorized. There are evidence-based methods available. Your job as a quality manager is threefold, according to Court:
First, understand your culture's readiness to adopt change. If it's change-averse, try putting a face on the data. It can make it more real. Finding a person to tell a story about a preterm birth or a hospital-acquired infection can make a difference.
Second, understand where you need to improve. Do your gap analysis. Court says when you know what you are lacking, make a plan for improvement. "This is where you steal shamelessly from organizations and units that are doing it well. Learn from success."
Last, understand your real role. "You lead the work, but the people who own the process need to own the work," Court says. "The nurse manager or clinical expert should be in charge of the project. You should be the back-up. Because only that clinical person can hold other clinical staff accountable to get something done and to hold the gains when you have."
There is a fourth that Court thinks of, too: learn to love the little. "We are all about instant gratification in our society and don't have a lot of patience and persistence. So learn to focus on small tests of change, and realize that if you don't solve something this time, you can try something else. Change isn't a straight line. There are bumps in the road. And there are always things that don't go the way that you want. Some problems take years to get to where they are. You can't expect to change behaviors and work patterns to something different overnight.
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