Hospital Quality Program Survey: What's Your Score

This self administered assessment poses statements regarding specific attributes within areas that Maverick Healthcare Consultants has determined to be critical "quality markers." It is designed to help you move beyond a "gut feel" to see how your organization stacks up against a variety of critical dimensions of quality. Hopefully you will learn something that challenges your assumptions about what it will take for your organization to establish a true environment of quality and patient safety.
For each of the following statements, score yourself as follows based on your reaction to the statement:

4 points: Strongly Agree
3 Points: Agree
2 Points: Disagree
1 point: Strongly Disagree.

After recording your reaction to all 15 statements, add up your total and refer to the evaluation at the bottom of the form.

______ The ability to provide demonstrably high quality patient care is a key element of our Strategic Plan.

______ We have a strong imperative for quality improvement in our organization, driven by our Executive Leadership.

______ We have effectively defined what constitutes "quality," and have developed a robust set of objective measures to monitor it on a routine periodic basis.

______ We have an aggressive set of quality performance goals.

______ Our quality measures include consideration of care processes, outcomes and resource utilization.

______ We periodically benchmark our quality performance against other organizations and find that our performance is similar to "Top Performers."

______ With regard to Joint Commission accreditation, we are "survey ready every day."

______ We routinely provide quality performance information to our Board, our employees and Physicians, and to the community.

______ Our employees and physicians believe we have effective and efficient clinical care processes.

______ Our care processes are based on current medical "best practice" evidence.

______ Our We have the organizational skill and capacity to develop and implement effective quality performance improvement initiatives.

______ Our approach to quality assurance incorporates "concurrent intervention" techniques.

______ We have tools and technologies that enhance our caregivers' ability to provide quality care at the point of care.

______ We have a "culture of safety" that is understood and embraced by all employees.

______ Our Physicians understand and are aligned with our Quality Management strategy.


_______ TOTAL SCORE


54 - 60 Top Performer. Your organization understands the core elements of Quality Management and is well positioned to remain a leading quality provider in your market. Quality is inherent in your culture and you are continuously improving your performance. What to do next? Consider developing a Quality Innovation or Accelerated Quality Implementation program to infuse a fresh new level of effectiveness into your quality management organization.

48 – 54 Aspiring Performer. You are a solid quality provider, but the competition is not far behind. What to do next? Assess how your organization rates against each of the five Critical Quality Markers to clearly define your organizations strengths and weaknesses, and develop your Blueprint for Strategic Quality Management Success.

< 48 Challenged Performer. While you recognize that quality is important, your organization's culture, processes and infrastructure do not support effective quality management. Quality performance is mixed, and significant improvements are elusive. What to do next? Consider developing a comprehensive Quality Management Strategy to create a tailored program that will transform your organization's quality and patient safety culture and capabilities.

The Program - Hospital Quality

Much the same way collegiate athletics structure, measure, and define their respective programs, hospital quality professionals can benefit by following a similar approach.

For example, a typical college football program consists of standard domains of work and accountability. The program continuously strives to improve the areas of work and levels of effectiveness so that it may achieve a comprehensive, robust and sustainable product; that is not personnel dependent. The program measures its success via outcome measures such as: graduation rate within 4 years, transfer rate, NCAA violations incurred, conference titles, and overall winning percentage, to name a few.

- Coaching
- Recruiting & Retention
- Scheduling
- Academic Counseling
- Housing
- Conditioning and Weight Lifting
- Athletic Facility Management
- Alumni Relations
- Transportation
- Media & Communications
- Contracts & Apparel
- Graduation Rate - outcome measure
- Winning Percentage - outcome measure

Yet, a program doesn't truly exist (nor does it reach levels of sustained success) until all domains of work, expectations, and accountability are connected and aligned to one central mission. The mission must be transparent and embraced throughout. Until such a time, the program more accurately resembles beads on a table without a string. Of course, depending on the levelness and frictional surface of the table, the beads could roll and drop to the floor.

You may recall in my previous postings the acronym STEEPE: Safety, Timeliness, Effectiveness, Efficiency, Patient-Centered, and Equity.

The Program - Hospital Quality
Mission: Continuous Improvement for the betterment of the patient
Domains of Work (in no particular order):

• Joint Commission/State Accreditation (continual readiness) -- STEEPE
• Core Measures -- Effectiveness, Timeliness
• Hospital Outpatient Measures - Effectiveness, Timeliness
• Never Event Reporting -- Safety Hospital Outpatient Program -- Effectiveness, Timeliness
• Patient Satisfaction (HCAHPS & Press Ganey) -- Patient Centered
• Hand Hygiene -- Effectiveness, Safety
• Hospital Acquired Infections (SSI, UTI, VAP, CLBSI, Sepsis) -- Safety, Effectiveness
• Near Miss Reporting (Medication Administration) - - Safety, Effectiveness, Efficiency
• Patient Falls -- Safety
• Medication Reconciliation -- Safety, Efficiency
• Never Event Reporting -- Safety
• OR Quality (Surgical Checklist, On-Time Starts, Turnaround Time) -- Safety, Efficiency, Effectiveness
• Percentage of Patients Leaving AMA -- Equity
• Average Wait Time in ED -- Timeliness, Efficiency, Patient Centered
• Medical Staff Quality (OPPE, % Medical Case Reviews Deemed Appropriate, Medical Record Delinquencies equal or greater than 30days) -- Equity
• Risk-Adjusted Mortality (O/E ratio) -- outcome measure
• Readmissions (15 day, 30 day) -- outcome measure
• Scorecard/Dashboard reporting -- competency measure
• Regular Reporting to the Board of Directors --competency measure

The healthcare quality professional must be relentless and connect these beads to a centralized string.

Does your hospital have a Quality Program?

How Do You Know . . .

A set of questions to ponder:

How do you know when you have successfully built a robust and sustainable Hospital Quality Program? How should "program" be defined in this context? How does a hospital determine when they have a comprehensive program in place versus disparate and broken processes. Do we have a national measure or metric that is easily portable and instructive across large and small hospitals? In the market place, how can a payer, a consumer, a provider, or a patient evaluate Hospital A from Hospital B and discern which has a better program, rather than comparative process measures such as: beta blockers at arrival and smoking cessation counseling? Furthermore, how does an organization (or for that matter the marketplace) measure the competence, the effectiveness, and success of a Director of Quality Management, a Vice President of Quality, or an executive of performance improvement?

-soft on people, hard on processes

Hospital Quality Overwhelming, But Necessary

Whether one works in a large urban teaching hospital or a small rural community, the professional life and responsibility of the Healthcare Quality Professional is arduous, and often times overwhelming.  The national hospital quality agenda contains essential elements such as: continuous preparedness for Joint Commission accreditation and/or state conditions of participation, data reporting transparency, ongoing physician practice evaluation, patient satisfaction benchmarking, bedside medication verification, computerized physician order entry, electronic medical record implementation, infection control, case management, responding to patient grievances, and effective information management, to name a few.  How does one effectively manage these program elements so that the RIGHT patient, receives the RIGHT care, at the RIGHT time?

Ask any of my peers throughout the country, and they will tell you there are several organizational ingredients that contribute to successful program development and implementation.  Furthermore, I would argue that program sustainability is severely compromised without all five (5) of these ingredients firmly place.  You will find that the Institute for Healthcare Improvement (IHI) provides first-rate research and recommendations in how to incorporate many of these ingredients into your organization.

• Substantive engagement by the Board of Directors, which is reflected by the agenda outline and time spent on Quality and Patient Safety
• Senior Management stewardship and accountability for Quality and Patient Safety operations and strategy, which is demonstrated by the utilization of transparent scorecards or a system dashboard
• Proper buy-in and support of the CFO with the Quality and Patient Safety hospital strategy
• Partnering with the medical and nursing staffs to deliver the clinical elements of the program.  The President of the Medical Staff, the Vice President of Medical Affairs, and the Chief Nursing Officer and Director of Quality, should work closely on matters pertaining to clinical performance improvement.
  
• Proper funding and staffing of Information Technology services

I shall provide further depth to each of these ingredients in future blog posts.

-soft on people, hard on processes