Abha Agrawal, M.D., chief operating officer and vice president of medical affairs at Norwegian American Hospital in Chicago, has a very impactful story to share about quality transformation in hospital care delivery and operations. Recruited by Jose R. Sanchez, who in October 2010 became president and CEO of the 200-bed community hospital, Agrawal joined a senior executive team determined to transform what had been a floundering care facility into a model of the new healthcare. Dr. Agrawal arrived a year and a half ago, as the push for transformation was gaining speed, and proceeded to use all of her considerable energy to help the executive team move from a situation in which the Joint Commission had been threatening to strip Norwegian American of its accreditation over patient safety and cleanliness problems, to one in which the hospital, which serves an underprivileged community on Chicago’s Near Northwest Side, is becoming a model of care delivery transformation.
Dr. Agrawal will be giving the closing presentation on Wednesday, June 11, at the Health IT Summit in Chicago, to be held June 10-11, sponsored by the Institute for Health Technology Transformation (iHT2). (Since December 2013, iHT2 has been in partnership with Healthcare Informatics, through its parent company, the Vendome Group LLC.) She spoke with HCI Editor-in-Chief Mark Hagland recently regarding her involvement in clinical transformation at Norwegian American Hospital. Below are excerpts from that interview.
The journey that you and your colleagues at Norwegian American Hospital have been on has been quite a remarkable one, hasn’t it?
Yes, and it’s really been about progress around a blend of quality and patient safety improvement, and the electronic health record. So… I started here a year and a half ago. It’s been one of the most challenging yet rewarding experiences for me professionally. This is a hospital that had very serious challenges and might have been on the verge of closing two years ago. We were in a financial hole, losing money every year; there were regulatory challenges and citations from CMS [the federal Centers for Medicare and Medicaid Services]. The [patient safety and care quality] scores were low. Three or four years later, it’s a true story of transformation on multiple accounts. On the financial side, which is very important, well, you know the old saying about no mission without margin. In fact, we have closed two years in a row in the black; the same for this fiscal year. In fact, we made a small profit last year, which is a tremendous accomplishment for a hospital like this.
Abha Agrawal, M.D.
How did that happen?
Our primary focus was quality. We made a very deliberate decision that if we are not providing quality care, we were not going to improve financially; and vice versa. When I arrived here, we got an “F” from the Leapfrog Group, which is the lowest score you can get. Even before receiving the score, one of the most pressing tasks I had before me when I joined was to improve quality and safety. So we put structures in place, created quality metrics and dashboards, quality committees, and really created a campaign of engaging the staff and raising awareness over how crucial this was.
In fact, I put a sign on my desk that says, “How does it help the patient?” Any discussion, if it doesn’t answer the question, how does it help the patient, I didn’t want to pursue it. I made the statement that quality should become a part of our DNA. As a result, in one year, by last year, we went from F to C, and this year, to B. So we’ve gone from an F to a B in two years. And on a personal note, that was the first time I danced with joy over getting a C, personally. My parents would have been embarrassed. We physicians are high achievers! But we were above average on quality, on value of care, and we had about a 250-400 percent improvement on quality, resource utilization, and value of care. That was a tremendous achievement.
How did you achieve that?
My CEO chose me because of my background; in my former role in New York, I put tremendous emphasis on quality and patient safety. That’s when I started to edit my book on quality and patient safety as well. And you know, there are no shortcuts. We established a team, hired a very good director of quality; built a quality team; have a new chief nursing officer, and have a number of new nurse leaders. And then we created momentum, I would say, around quality and safety. That needed to become a part of our culture. Every town hall meeting we had, we talked about quality and safety. We started senior leaders’ rounds, where several of our senior executives would round on a unit on a monthly basis; and each one of us adopted a unit and rounded on that unit once a month.
So we created this whole movement to make quality and safety a part of our fabric. I personally went to every departmental meeting and town hall, and talked about quality. And there are many more people talking about it now, and my little sign is being replicated everywhere. I think people got inspired by that singular focus on improving the quality of care for the patient. Our singular mission is to provide the highest quality of care for every patient in Humboldt Park. And this is a socially disadvantaged area; but our patients still deserve the highest quality of care we can provide.
So accomplishing this requires people to take on that personal level of responsibility for quality, and it requires going from the bottom up and from the top down, in all directions. The board was instrumental in all this; it was very engaged. Our chairman of the board was born at this hospital and was part of this community. And we created the governance and committee structure; but the board was most supportive of our quest for quality, including providing governance support and committing resources. And our chair was given an award from an industry magazine for his leadership of a medium-sized hospital. And I was given the ACHE [American College of Healthcare Executives] Healthcare Leadership Award in February.
We also hosted the first safety net quality symposium in October 2013; we had about 200 people attending; it was a day-long event. Julie Hamos, the director of healthcare and family services for the state of Illinois, as a keynote speaker. And our board chair, who believed in the hospital, said, just a few short years ago, it would have been unthinkable for Norwegian to host such an event. And we said, we’re not just going to survive, we’re going to make it our mission to provide excellent care. So we created the slogan, excellence beyond survival. And we are in a Joint Commission year and created buttons for all our staff saying, ‘excellence beyond compliance.’ So that’s part of the cultural change. It takes time and it is a slow, tedious journey, but everything we are doing, we are focusing on excellence.
So when did you go live with an EHR?
About three years ago, we had almost nothing in the way of an EHR. We are still progressing, but went live with CPOE [computerized physician order entry] last year in August; we did barcoded meds administration beginning last year. We’re progressively doing more and more physician and nursing documentation. And lab results, and radiology, went live about two and a half years ago. We attested to Stage 1 of meaningful use last year. We have a really robust medication reconciliation as of last year. Our EHR is from Meditech. And we’re also leveraging technology for revenue cycle improvement as well.
In terms of our financial goals, we had three: to grow business; reduce costs; and improve our revenue cycle efficiency—three financial goals. And we’ve approached that methodically and consistently. So the combination of all three led to the financial results. And quality was critical to financial improvement, because without good quality, we couldn’t grow our business. We couldn’t ask physicians to bring their patients to us if we had an “F” in quality.
You obviously have had a ‘burning platform’ for moving ahead on both quality and financial improvement. So what have been the biggest lessons learned so for on this journey of transformation?
Yes, if ever there was a burning platform, we had it! I’ve learned two things. And none of this is novel; what I’m saying to you we’ve both heard from everyone. But two things. First, leadership is truly instrumental; and having the right team of people at all levels, but particularly at the leadership level, is critical. You really accomplish very little without leadership. So you have the right team of leaders feeding a virtuous cycle and making things better and better. So having the right people and providing the right leadership, that is essential. And committees and meetings and metrics, and so on, all those are important of course. And the second lesson is around teamwork: teamwork within every department, and across departments.
And the teamwork element ties into so many other elements. For example, how do you improve quality when nurses are missing supplies? How do you make sure the central line bundle is done right without the right supplies? And you wouldn’t think that that the materials management people would be so important to clinical quality improvement, but they are. We have a multidisciplinary huddle every morning, one that includes people from many disciplines, including nurses, social workers and case managers, facilities people, environmental services, supplies and materials management people, pharmacy, and if IT is needed, IT will go there. But what is important to know, especially in an organization where all processes have not been streamlined, is that if processes have not been fixed in ancillary departments, the clinical quality of care can suffer. So you need to have all pieces of the puzzle working right to get clinical quality right. Clinical quality is more all-encompassing than you might think.
What would your advice be for other healthcare executives working towards massive quality improvement?
Have a strong vision that you believe in; this is not for the faint of heart. If you don’t believe in it, the challenges will bring you down. You have to absolutely be convinced of what you are doing and why you are doing it. That’s one. I get up every morning and think about the fact that Norwegian American Hospital is the economic engine of Humboldt Park; we are the largest employer in the community. We have about 1,000 employees, not including physicians. So I’m responsible not only for the 120-130 patients in-house at any given time, but also for the staff, for their families, for this community. That is a good enough reason for me to say every morning, I’m going to give it my very best, because it matters; it matters to a whole lot of people.