The term "quality improvement" has become omnipresent in healthcare during the past couple of years. But how many patient care organizations have put their money and effort where their collective mouths are?
One group of executives and clinicians who've done so in a big way are those at Bronson Healthcare Group, an integrated health system in Kalamazoo, Mich. Indeed, Bronson's flagship hospital, Bronson Methodist Hospital, received the Malcolm Baldrige National Quality Award in 2005 from the Baldrige National Quality Program, administered by the National Institute of Standards and Technology, Gaithersburg, Md., a division of the U.S. Department of Commerce.
Among the achievements the Baldrige Program cited in awarding Bronson Methodist Hospital its award: the hospital's Medicare mortality rate decreased from 4.8 percent in 2002 to 3.5 percent for January-July 2005; patient satisfaction improved from 95 percent in 2002 to nearly 97 percent in 2004; and the hospital was included in Fortune Magazine's "100 Best Companies to Work For" in 2004, 2005 and 2006.
Of course, such national recognition doesn't come to just any organization. The staff and clinicians at Bronson have been working for several years at systematically improving every aspect of the organization's business, from clinical care quality to patient satisfaction to operating efficiency.
"The key thing the Baldrige criteria does is to cause you to formalize and define your approach to everything, and to integrate tactics," says Michele Serbenski, executive director, corporate effectiveness and customer satisfaction, for parent Bronson Healthcare Group. In other words, to take a strategic and systematic approach to quality improvement.
Meanwhile, says vice president and CIO Mac McClurkan, information technology is inevitably an important facilitator of change. "It's not about technology, it's not about bits and bytes, it's about process," McClurkan emphasizes. "That being said, if you do have technology in place, it's important to demonstrate that you have a well thought-out process for selecting, implementing, maintaining, securing, and using the technology. That's something very central to the strategic role of the CIO, and it's very central to what Baldrige is all about."
IT, CIOs, in spotlight
Industry experts say that the kinds of systemic improvements being made at Bronson are creating a model of organized quality improvement across healthcare, something that is desperately needed in a field that still acts like a cottage industry rather than one of the largest and most important sectors of the American economy.
With purchasers, payers and consumers all demanding greater accountability for quality; with an accelerating emphasis on patient safety; and with healthcare inflation surging, many agree that only systematic approaches will move patient care organizations significantly forward in key areas. And whether healthcare organizations are using Baldrige Award criteria, Six Sigma, Lean Healthcare management, Total Quality Management or some other technique or combination of methodologies, CIO leadership, through the strategic use of IT, will be essential to facilitating major change.
Just ask Charles Stokes, president of North Mississippi Medical Center (NMMC) in Tupelo, Miss. He and his colleagues were overjoyed to learn on Nov. 20 that their organization had received the Baldrige Award for 2006.
In order to succeed at systematic quality improvement, Stokes advises, "Make sure that your change initiative is directly tied to your mission and vision, and that it is data-driven. In the absence of data, any opinion will do. And CIOs have to be involved in it. The systems are too complex and the data is too important for them to sit on the sidelines. Our focus has been on five critical success factors: people, service, quality, financial strength and growth. The reason I think we were a recipient was because of our ability to focus on those five areas and produce measurable results in every one. Baldrige provides a framework for us to be able to focus on things that are important."
And, he quickly adds, only an objective, data-driven approach, one championed and co-led by an organization's CIO, can succeed over the longer term.
In fact, the organization's self development of an electronic medical record (EMR) was very much on the minds of the Baldrige award committee. Not only was the EMR's development cited as an achievement in itself, it was seen as a facilitator of quality improvement.
"At NMMC, a care-based cost management approach has provided cumulative gains of $11.1 million since 1999, largely as a result of reducing practice variations and medication complications," noted the committee. And, it added, "Debt has decreased from 26.7 percent to 21.8 percent in 2006 (year to date)."
Not surprisingly, the second of three national winners for 2006 (across all industries) is also an organization that has focused very strongly on systematic quality improvement. And it, too, is in healthcare. It is the San Diego-based Premier Health Alliance, which has achieved notoriety for its co-sponsorship of the Hospital Quality Incentive Demonstration Project with the Centers for Medicare and Medicaid Services (CMS) in the pay-for-performance sphere (see Healthcare Informatics' November 2006 cover story, "Catching the P4P Wave").
Setting a quality course
It is not surprising that increasing numbers of hospital-based organizations are adopting and internalizing Baldrige Award criteria — and often combining it with Six Sigma, Lean Healthcare management, and other strategies, in order to achieve specific gains.
"The whole purpose of Baldrige is to hold up role models for each industry," says quality consultant James Shaw. "I find it a very helpful tool in helping other hospitals clean up their act." In fact, says Shaw, president of Shaw Resources, Issaquah, Wash., a range of improvements must be made across patient care organizations comparable to the systemic improvements made in other industries in the past few decades. Administratively, "A much better understanding of process measurement is needed, and using measurement to make change. And that's everything from waiting times to simple things like escalation."
One of the most-cited examples, Shaw notes, is that of commercial aviation, where checklist-based safety procedures have transformed the industry and drastically reduced human error-based airplane crashes. As with the airplane safety example, automation will be an important element in healthcare organizations' drive to quality.
While Bronson Methodist Hospital, North Mississippi Medical Center, and Premier Inc. may provide especially dramatic examples of success with quality improvement, organizations all across the country are trying an impressively wide range of approaches in this area. Among those with demonstrable results:
At the Virtua Health integrated system in Mt. Holly, N.J., vice president and CIO John Bloomer confirms that the 1,062-bed health system has realized between $1 million and $3 million in annual net revenue improvement per year in the past few years, based on the implementation of Six Sigma and Lean Management strategies across a wide range of projects. Among other projects, "We found significant potential reimbursement hitting the floor each year in our emergency department because of sub-optimal coding," Bloomer says. Using a combination of intensive analysis and process improvement, and up-to-date information system implementation, he and his colleagues have been able to see immediate improvements in emergency department (ED) charge capture since rollout of the new ED IS began in the late fall. The organization has also significantly improved patient satisfaction in pre-admission testing areas through the systematic reworking of patient processing.
At seven-hospital OSF Healthcare in Peoria, Ill., patient safety officer John Whittington, M.D., reports that, in the past couple of years, using Six Sigma techniques, "We've done a lot of work on hospital-acquired pressure ulcers, and have driven down our rates to 3 percent, from much higher rates. That's world-class." The system has also aggressively attacked the universal problem of ventilator-associated pneumonia using Six Sigma techniques, reducing the rate of such pneumonia by 400 percent, from a rate of approximately 4 incidents per 1,000 ventilator days, to about 1 per 1,000 ventilator days. At the flagship OSF-St. Francis Hospital, some individual units have been able to go for whole months without a single incident, he adds.
At 366-bed Decatur Memorial Hospital in Decatur, Ill., Linda Fahey, R.N., vice president and chief nurse executive, notes that her organization turned to Six Sigma methodology for assistance after the hospital's CEO learned of the impressive strides that Lafayette, Ind.-based Caterpillar construction and agricultural equipment company, which operates a plant in Decatur, had made using that process. Using Six Sigma techniques, Fahey and her clinician colleagues were able to improve the availability of routine medications, from 78.6 percent availability to 86 percent availability, and to improve medication delivery times from 109 minutes to 21 minutes for medications available in the dispensing cabinets on patient care floors.
Lean Healthcare. A quality methodology derived from the Lean Manufacturing management philosophy, which focuses on reducing seven types of waste. Applied to healthcare, it aims to view the healthcare system through the eyes of the customer and focuses on reducing/eliminating suboptimal processes that do not deliver value.
Malcolm Baldridge National Quality Award. In 1987, Congress created the Malcolm Baldridge National Quality Award (MBNQA) to encourage quality in American companies. Healthcare organizations can apply for the award and have their leadership, strategic planning, and process management (among other areas) evaluated by a team of industry leaders for excellence and opportunities for improvement.
Six Sigma. A quality methodology created within Motorola Inc. to help increase quality processes within organizations. It focuses on process defects and how organizations can manage those defects to improve quality assurance practices.
Total Quality Management (TQM). TQM's goal is to improve quality and lower costs in organizations by focusing awareness on quality in organizational processes at all levels.
What is it about the various quality improvement methodologies that leads to results? Whether it's Six Sigma, Lean Management, Baldrige Award criteria, some other methodology or using a mix of different ones, those who've done formal quality improvement work to improve clinical care quality, improve the efficiency of clinicians and staff, or enhance customer satisfaction all say it's about being organized, strategic, and analytical.
"The primary thing about Six Sigma is that it causes you to thoroughly measure your process, and then causes you to select the right processes that will impact your process," says Decatur Memorial's Fahey. "And with Six Sigma, you have tools to statistically manage your data."
Fortunately, the number of organizations in the industry working to help patient care organizations make major quality improvements is growing every day. And data systems work is a part of what some of those organizations are doing with hospitals and health systems.
"I think the uniformity of data is imperative," says John Wiesendanger, CEO of Quality Insights of Pennsylvania, Wayne, Pa., which operates as the Medicare QIO (Quality Improvement Organization) for hospitals in Pennsylvania, Delaware, and West Virginia. Hospitals will still have to work out individualized quality improvement strategies, but the data will be easier to use. Indeed, agrees Donald Wilson, M.D., Quality Insights of Pennsylvania's medical director, "Uniformity of data has been one of the biggest breakthroughs in the past few years," with organizations such as CMS and the Oakbrook Terrace. Ill.-based Joint Commission on Accreditation of Healthcare Organizations moving towards harmonization of the kinds of quality data they're measuring.
CIOs have a pivotal role to play in all this. They have both the opportunity and the expertise to lead on the data issue in a strategic and comprehensive way. And such leadership will be key, says Roger Resar, M.D., who splits his time between duties as a senior fellow at the Boston-based Institute for Healthcare Improvement and implementing quality improvement at the Rochester, Minn.-based Mayo Clinic.
The Eau Claire, Wis.-based Resar explains that though many organizations have "built the will" for systemic quality improvement, "Most organizations fail in executing the plan." CIOs, he declares, will be lynchpins in the execution of these very broad quality improvement initiatives.
"I think the big takeaway for CIOs is that the CIO can add a lot of value with regard to the critical measurement, analysis, and knowledge management aspects of all this work," says Bronson's McClurkan. "The CIO is first and foremost a systems thinker." And CIO leadership will not only move organizations forward in the vital quality improvement area, it will increase the perceived value of CIOs in their organizations, he concludes.
Mark Hagland is a contributing editor based in Chicago.