Operating Room Safety Checklist

Listen to this video as the surgeon (Toronto General Hospital) and his surgical team executes the World Health Organization's (WHO) Surgical Safety Checklist. The Institute of Healthcare Improvement (IHI) has challenged all US hospitals to a "sprint." The checklist should be implemented in the operating room theatre by April 1, 2009.

You might want to start with a single surgeon and evaluate several consecutive cases before spreading the tool to your entire surgical department.

Don't wait. Pursue excellence today.

Near Misses, Far Catches

What is the best approach in gathering accurate and actionable information regarding "near misses" in a hospital setting?

Reporting "near misses" should be a basic expectation in a healthcare provider environment. However, if a punitive culture exists staff are less likely to report these events. Furthermore, if the reporting process is complex and involves paper-pushing, a higher degree of under reporting may result.

Indeed, "near misses" do occur in hospitals (i.e. patient falls and medication administration errors) Yet, when they happen, are the proper individuals alerted? If so, does the alert initiate a timely response so that education and process improvement are executed to minimize a repeat event? It is imperative that the healthcare quality professional evaluate the processes and systems that bottleneck this reporting and find remedies.

For further details visit http://www.psqh.com/sepoct07/nearmisses.html

The current literature claims that an effective "near miss" reporting process is an essential element to a first-rate hospital quality program.

In synthesis, the mechanism (paper or electronic) a hospital chooses in reporting "near misses" is equally significant to how the information is managed and aimed toward to continuous improvement.

What If . . . There was a Hospital Quality Score

In 2001 the Institute of Medicine published their second great work entitled, Crossing the Quality Chasm. In that work, the IOM defined six (6) dimensions of healthcare; the essentials in yielding a "quality" healthcare product. These dimensions can be easily remembered via the acronym STEEPE:

• Safety
• Timeliness
• Effectiveness
• Efficiency
• Patient Centeredness
• Equity

What if there was a Hospital Quality Score (HQS) that could be applied to all U.S. hospitals?

This score would be comprised of indicators that aligned with each of the six dimensions. The National Quality Forum (NQF), Leapfrog, and The Joint Commission, collaboratively, could develop the hospital-specific indicators and provide the necessary definitions and mathematical algorithm.

The HQS could be used by both CMS and commercial payers to assess provider and organizational quality.

These dimensions are applicable across the board. However, the HQS could be divided into classes (i.e. Large Urban, Large Urban Teaching, 350-450 beds, 349-250 beds, 249-150 beds, Rural, Critical Access) to account for hospital size.

What would be the response from the American Hospital Association (AHA) if a hospital quality score was presented to the market? Clearly, commercial payers would use such a score to negotiate contractual rates. CMS could use the score to leverage reimbursement rates. Furthermore, the HQS could be publicly reported in the same manner in which Core Measures are currently.

Yet, the HQS could not feasibly change month to month. The score would be submitted twice a year and reporting (including benchmarking) would mirror such a process.

What if . . .

Washington D.C. Mall - The Quiet Before the Wave of Hope and Emotion; January 20 2009

Watch the brief video as it spans across the Washington Mall.

MLK Jr. Day, A Reflective Prelude for a Historical 2009 Inauguration

Listen, as MLK III, bridges the generation of his father with the historical context and rise of Barack Obama.

Red, Green, Yellow . . . Does it work?

Developing a meaningful hospital-wide dashboard is an essential task for a senior leadership team to address. Yet, pursuing a dashboard and implementing a dashboard are not strategies. Rather, these are examples of tactics. The dashboard, itself, should be aligned to the strategic objectives.



Thus, there is an assumption that the 1 year, 3 year, 5 year strategic objectives of a hospital are sound and meet the challenges of the marketplace while maintaining a patient-centered mission. For the purposes of this blog post, allow me to indulge in this assumption.



In the quality improvement industry, we often say with authority "you only improve, what you measure." This may be true. Implicitly, it is understood that items being measured must mean something to someone or some department of business. Yet, we must raise the standard higher and go further.



The science of measurement needs to be understood by healthcare quality professionals. Measurement is important (i.e. rules, rates, ratios, mean vs median, pchart, xchart, trends, normal variation vs outliers, and standard deviations, to name a few.) However, separation between professionals does not come with simply knowing how to measure, but rather knowing what to measure, when to measure, and knowing when to stop measuring.



It is within this measurement space that a healthcare quality professional can bring value to an organization.



Are dashboards an effective tool to guide and instruct performance improvement? If designed and executed properly, I submit that they can be. The equilateral Triangle of Effectiveness consists of the following legs:

• Transparency


• Empowerment


• Accountability

The goal is to achieve sustained effectiveness and efficiency so that patient care delivery is optimized.

Paul Levy CEO of Beth Israel Deaconess Medical Center

Paul Levy is a fierce and effective leader, a role model in the industry of hospital management. He is out in front of his executive peers in exercising one of the most important patient-centered-values . . . transparency.

Listen, to the video, as Levy provides insight into his methods of raising transparency and quality standards within a major urban center. As one might imagine, competitors have not taken kindly to his brand of leadership. In his attempt to shed light, he has increased the heat on the neighboring boston medical centers.

Definition Please, Q?

A colleague approached me in the hallway, yesterday, and asked if I could define "Quality." Brilliant! This is the best question that I have been asked since the new year.

At the end of the day, do we all agree on the same definition? How can you improve what you cannot define? How can one ask others to join in the effort, if one cannot articulate the product?

Webster's Dictionary defines Quality as: having a high degree of excellence; superiority of kind.

The colleague and I went on to have a spontaneous 15 minute chat about Quality, and its application to the hospital setting. A synthesis of my response:

• Quality is not a process, but rather an end product. The product should be engineered to meet the voice of the customer (VOC). In a hospital, there are many customers and "voices" converging simultaneously on care delivery, each day, at any one time. For example, customers include: patients, patients' families, nurses, physicians, and Medicare to name a few. However, if we position the patient as the primary customer, then our work product or our "Quality" must be appropriately designed, tested, and continuously improved to meet expectations. Keep in mind customer expectations may evolve over time.

• A common statement utilized in the industry is: ensuring the right patient, gets the right care, at that right time. Well, if this statement reflects the expectations of the patient and the healthcare industry (an advocate for the patient) then quality professionals need to work to design processes and systems that yield a favorable and reliable product = quality. When not met, the organization yields defects, waste, or poor quality.

• Therefore, all service departments (including information technology, environmental services, social services, materials management, to name a few) contribute to the processes which in turn yield . . . Quality. It is everyone's principle business objective.

A Must Read

If you haven't read Atul Gawande's 2007 book, "Better: A Surgeon's Notes on Performance," please invest today. You will not be disappointed. I believe it is required reading for healthcare quality professionals, let alone clinical providers.

However, do not take my word for it. Listen, as this plastic surgeon praises Dr. Gawande for his scholarship and relevance.

I had the pleasure of meeting Atul Gawande, MD at the most recent Institute of Healthcare Improvement National Forum in Nashville, TN. Dr. Gawande is championing the surgical safety checklist that will be a germane element of the new IHI campaign: The Improvement Map.

You may visit Dr. Gawande's website at www.gawande.com

Quality Quintet

Indeed, all hospital employees, regardless of rank, should be embassadors of quality for the benefit of patients and their families.

In previous posts, I have written about the essential roles of the Board of Directors and the C-suite. Individual roles are important, however, regular communication, teamwork, accountability, and consensus are even more critical to building a top performing organization.

I believe that there is a core group of leaders within a hospital that must share common ground in order for the Quality and Patient Safety strategy to be successful.

I call this core group the Quality Quintet. I recommend its members to be:
- Chief Operating Officer
- Chief Medical Officer (or VPMA)
- Chief Nursing Officer
- Director of Quality (or VP)
- President of Medical Staff

These clinical and administrative leaders must invest their time and energy in learning about the most germane elements of the quality and patient safety hospital agenda. In turn, they must use this knowledge/information to communicate with one another and build trust. The ultimate goal is to etch out a winning strategy that will yield first-rate patient outcomes.

Again, those organizations that are often cited as top performing (i.e. Mayo Clinic, Hackensack University Medical Center, Sutter Auburn Faith Hospital, Beth Israel Deaconness Medical Center, Cincinnati Children's Hospital and Cooley Dickinson Hospital, to name a few) each have a highly functional and supported Quintet that works in sync.

To this end, it is strongly recommended that members of the Quintet meet regularly and seek clarity and consensus.


Some hospitals accomplish this structure via their respective Hospital Quality Committee or Medical Executive Commitee, or Senior Leadership. Others have established a separate work group soley for the purposes of the Quintet. In either case, the objective is to design methods so that both administrative and clinical leadership work in concert.

In synthesis, I challenge those eligible organizations to strive to develop a Quality Quintent, if not already in tact. Successful execution of the Quality and Patient Safety strategy depends on it.

Patient Safety, Bar Must Be Raised

The CFO Can Not Be A Loner, Quality Demands Inclusion

When one thinks about quality and patient safety, the role and impact of the Chief Financial Officer doesn't immediately come to mind. Well, this mindset is beginning to change. In fact, some organizations have already made the transformation, for the better.

As the business case for operational efficiency and process waste reduction becomes stronger within the hospital, the need for CFO (and COO) engagement is essential. Moreover, increased patient safety has been found to occur within those hospitals that reduce variation and waste. The correlation is meaningful. Consumers and payers have their eyes open.

Organizations can no longer afford to continue emphasizing the monthly financial statistics while relegating quality and clinical performance to the periphery. I submit that those senior management teams who don't adapt to the changing environment will find themselves less competitive and burdened with decreases in patient loyalty, market share, and favorable contracting from commercial payers.

Indeed, there needs to be a marriage between finance and quality improvement within the hospital.

A temperature reading:

• Does your CFO (and or COO) attend your monthly hospital quality committee meetings?
• Is your CFO well-versed and understand the organization's quality and patient safety objectives?
• Does your CFO perform weekly/monthly rounds of the hospital, including clinical areas?
• Is your CFO a member of your hospital Board sub-committee - - Board Quality Committee?
• How would you describe the relationships between your CFO and the Director of Quality and/or Vice President for Performance Improvement?

What is the thermometer reading?

The Girl Effect

Accountability

     In a hospital, as with any organization, accountability starts at the top.  The Board of Directors must demand accountability from the CEO.  In turn, the CEO must demand accountability from the C-suite (i.e. CFO, CNO, HR, CMO, CQO, CIO).  

I would argue that Quality and Patient Safety is not relegated, solely, to the clinical departments of a hospital. Quality is job #1.  Therefore, "quality" is everyone's primary business, regardless if the work product is information systems, communications, human resources, or environmental services, to name a few.

In the short-term accountability may be raised and effectively measured through the use of scorecards or system dashboards.  However, sustained accountability and results, over time, come only from a fundamental shift or change in culture.

Consensus Statement:  the senior management team should be held accountable to organizational results and the performance of their subordinates.

If the readership agrees with the statement written, above, then what are the best methods for consistent execution?  I am aware and respect the fact that this topic of executive leadership has been well researched.  I do not claim originality of thought, in this domain.  However, I have observed instances where the twine of accountability had been frayed, if not completely severed.  Over the years, I have synthesized my reading and professional experience into what I call the 3 Cs.  The 3 Cs are, as follows:

• Communication
  
• Collaboration
  
• Continuity
  

I submit that if the CEO and his/her C-Suite embrace and promulgate a culture consisting of the 3 Cs, accountability is likely to be a lasting by-product.