One of the nation’s leading collaborative quality and efficiency improvement programs, the QUEST program sponsored by the Charlotte-based Premier healthcare alliance, offered up voluminous testimony as to its effectiveness on March 19, as Premier leaders gathered in Washington, D.C. unveiled the latest results from the program, which they said confirmed the value of data-driven, mission-focused healthcare delivery reform taking place in patient care organizations nationwide.
Indeed, the marquee data points that Premier senior executives, including president and CEO Susan DeVore and senior vice president-public affairs Blair Childs, noted, were these: had every U.S. hospital participated in this program, 950,000 lives and about $93 billion could have been saved over the past five years. As it is, the 333 U.S. hospitals currently participating in the QUEST program (QUEST began with 157 participant organizations in 2008) have saved 92,000 lives and $9.1 billion over the past five years, reduced central line bloodstream infections by 59 percent, and falls and pressure ulcers by 64 percent, as they’ve shared data across a broad set of clinical outcomes and cost-of-care measures, all aimed at the following goals:
> Reducing patient mortality by at least 31 percent
> Reducing the average cost of care to less than $5,690 per discharge
> Reliability delivering care to patients across evidence-based care measures in the areas of heart attack, heart failure, pneumonia, and surgical care at least 95 percent of the time
> Improving the hospital experience so that patients would rate their stays favorably and would recommend a facility to others at least 73 percent of the time
> Reducing preventable harm events
> Reducing readmissions by 12 percent
Praise from Donald Berwick, M.D.
Donald Berwick, M.D., a healthcare leader who was best known as CEO of the Cambridge, Mass.-based Institute for Healthcare Improvement (IHI) before serving as acting administrator of the federal centers for Medicare & Medicaid Services in 2010-2011, was on hand to praise the work of the QUEST program and to offer his perspectives on its contributions to healthcare delivery reform.
“I think QUEST is undoubtedly a breakthrough” for healthcare delivery improvement in this country, Berwick told the assembled members of the press. “It’s a breakthrough first for American hospital care, given how unexpectedly good the results are. And, given what Susan [DeVore] has indicated about expanding the project out to the continuum of care, it could be a breakthrough for all of American healthcare,” Berwick said. “By focusing on systems and processes, QUEST focuses on very important elements of care design and delivery, evidence and patient engagement. It does connect the best of clinical and delivery science with the best of healthcare delivery,” he said, emphasizing that “The alternative to the design-and-redesign approach” to care delivery and operational improvement exemplified by QUEST “is not a good one, and that is, just cutting and cutting and cutting, while relying on current processes” in care delivery. But when the leaders of patient care organizations engage in intensive, data-driven, evidence-based process improvement, he said, real change takes place, with simultaneous improvement in clinical outcomes and lowering of operational costs. “In fact,” he said, “I believe this ought to be the approach for all of American healthcare. It’s a strain on hospitals, because, moving away from volume-based payment, more care will move out beyond the inpatient hospital,” he added. But the intention of Premier executives to push the QUEST program far out into outpatient care is both a necessary and a laudatory step, he said.
QUEST participating-hospital leaders speak
Premier’s DeVore and Childs, and Dr. Berwick, were joined in Tuesday’s live press conference at the Premier Washington, D.C. offices, and via phone link, by two senior executives of QUEST-participating hospital organizations, Tamera Parsons, vice president of quality and patient safety at Mountain States Health Alliance of Northeast Tennessee and Southwest Virginia (based in Johnson City, Tenn.), and Thomas Macaluso, M.D., chief quality officer at Memorial Healthcare System of South Broward, based in Hollywood, Fla.
In the press release announcing the QUEST results, Parsons was quoted as saying, “Healthcare has big opportunities for improvement. And QUEST has shown that change is not only possible, it’s probable under the right conditions. By setting high standards, comparing performance to others, transparently sharing results and creating open forums for idea exchange, hospitals can test and scale improvements that benefit all and ultimately help transform our health system. Participating hospitals are passionate about designing powerful, innovative advances in healthcare.”
Macaluso, whose six-hospital system has been participating in QUEST since 2010, said, “I see the strength of the QUEST program really in three ways. First, I see it in the encouragement of executive sponsorship in these efforts to improve care and reduce cost. The second is the ability to share what I consider sophisticated comparative data, again to help drive change. We say [at our organization], if there’s no data, there’s no improvement. And QUEST is providing comparative data that’s helping us to drive change. And the third,” Macaluso said, “is the ability for us to collaborate with colleagues in other organizations to drive change and improve care. Our changes mirror those of others. Our hospitals have had achievement in evidence-based care, mortality, and harm events.”
Both Parsons and Macaluso spoke extensively about the challenges and opportunities involved in driving clinical and operational performance forward in their organizations, as well as the broad opportunities involved in collaborating with the other 331 QUEST hospital organizations.
One area of particularly intense focus at Memorial Health System, Macaluso noted, has been the organization’s CHF readmissions project, aimed and reducing inpatient readmissions for patients with congestive heart failure. “The project,” he said, “began with an opportunity identify different categories of strategies to help reduce avoidable CHF readmissions. These strategies came directly from QUEST phone calls. We focused on four areas of strategies: first, the immediate prevention of a clearly avoidable readmissions; second, patient education and communication; third, medication reconciliation; and lastly, transitional care.” Among the strategies he and his colleagues implemented to support the CHF readmissions avoidance effort have been expanding case management coverage in the ED to a target 24 hours weekdays and 16 hours on weekends; evaluating and admitting CHF patients to observation status when appropriate; and having ED case managers review potential Medicare admissions for appropriate status and potential readmission avoidance.
The goal at Memorial Healthcare System was a 20-percent reduction in avoidable CHF readmissions. “So far, Macaluso reported, “we’ve achieved that goal at our flagship regional hospital, which has lowered that rate from 36 percent to 23 percent.” Other facilities in the system are achieving variable results so far on that measure, he added.
Parsons described in detail a variety of initiatives under the QUEST umbrella taking place at her 13-hospital system, and went into particular depth describing her team’s realization that, when it came to overall mortality statistics, she and her colleagues had uncovered a real “opportunity” area in improving sepsis-related mortality. “Where we were falling short was identifying patients with sepsis early enough with evidence-based tools to prevent their deaths,” she noted. “We were finding that it was upwards of a day or more to identify our opportunity. So we went into the best practices sharing work.” And, making full use of all the tools and data available in the QUEST program, including process maps and lists of interventions, she and her colleagues have dramatically reduced sepsis-related mortality in several of their facilities.
IT foundation seen as critical
Asked by Healthcare Informatics about the importance of a strong IT foundation to facilitate all this work, Memorial’s Macaluso readily agreed. “Unfortunately,” he said, “we’ve not been able to find a risk assessment IT tool that helps us identify patients at risk any better than common clinical sense. But three of our hospitals are now live with the Epic EHR; and the rest will go live next month. We already have been reaping benefits from that,” he said, adding that the inpatient and outpatient EHR “is an enormous tool from a data-gathering perspective. For someone in my position, it’s really a wonderful tool in terms of extracting data, identifying patients; for example, we’re able to put a banner on the first page of a patient’s EHR saying, for example, this is a CHF patient or with a history of difficulty of intubation. And we utilize what QUEST has offered, but we have invested in other types of business intelligence tools. As I’ve said, if we can’t look at this and show comparative data to our physicians, we can’t make any progress.”
Responding to the same question with regard to progress more broadly among the QUEST hospitals on quality improvement, Premier’s DeVore said, “when you think about the six dimensions we’re measuring, there’s data coming from a lot of sources. And we had to develop the QUEST reporting capability, via Quality Advisor,” as well as a number of other solutions, including a physician performance program, an assessment of harm solution, real-time alerting for safety and harm work, and an operational waste report program.
“And so,” DeVore noted, “we’ve made significant investments on behalf of the QUEST and other Premier members, in those capabilities. We also have fundamentally rebuilt our data platform to obtain data from all sources, including integrating EHR data from everyone. We view this as being vendor-agnostic, in that we have to put the raw data together. So we’re evolving all of the technology capabilities together with the collaborative capabilities. And per the discussion of QUEST 3.0, when we get into bundled cost measures, and others, we intend to have the capabilities for that.”