When on Jan. 18 in Washington, D.C., executives and leaders of the Charlotte, N.C.-based Premier health alliance held a live-plus-telephonic press briefing to announce three years of results from the organization’s ongoing QUEST High-Performing Hospitals Collaborative program, one of the member hospital executives participating was from the McLeod Regional Medical Center in Florence, S.C., the flagship of the 771-bed McLeod Health, whose five hospitals see patients from across a broad service center that encompasses parts of northeastern South Carolina and southeastern North Carolina.
Donna Isgett, R.N., M.S.N., senior vice president, corporate quality and safety, at McLeod Health, spoke of her health system’s enthusiastic participation in the QUEST program, whose broad results had encompassed remarkable gains in patient safety and care quality, the use of evidence-based care protocols, and cost-effectiveness, over three years of performance improvement work. McLeod was one of 157 hospitals that had been charter participants in the QUEST program and that had been able to document strong results across the board.
Among the results documented at McLeod Regional Medical Center over the past three years have been the following:
< A 28-percent reduction in the hospital’s mortality rate from a 2.37-percent rate to a 1.91-percent rate, with an estimated 276 lives saved over three years
< A 22-percent reduction in per-case cost, from a baseline case mix-adjusted cost per discharge of $6,925 to a cost per discharge of $5,377 (with a $1,546 relative reduction in cost) over three years
< A 7.1-percent increase in the use of evidence-based care delivery over three years
Recently, Isgett and Coy Irvin, M.D., chief medical officer and vice president medical affairs, at McLeod Health, spoke with HCI Editor-in-Chief Mark Hagland, regarding their organization’s participation in the QUEST program, and what the lessons learned so far from that participation. Below are excerpts from that interview.
With regard to the 28-percent reduction in expected mortality rate over three years, how does that translate into actual lives saved? What's more, you've also achieved very meaningful cost savings within the same time span.
Donna Isgett, R.N., M.S.N.: Our flagship hospital has a census of 416 patients today [the day of this interview]. We probably have about 60-65 deaths a month here, and we’re saving about 15 patient lives a month at this facility. Meanwhile, on the cost side, we were able to save about $1,500 in cost per case over three years.
Donna Isgett, R.N., M.S.N.
What made you decide to participate in QUEST?
I was here at the time of the founding of the program; and in fact, I sat in on the design team for QUEST. As you know, Premier is a group of not-for-profit hospitals, and we’re one of the owners. And they said, we have to get healthcare as close to perfect as it can be. They used an accelerated design process, and they flew me and others in from across the country in order to participate in the discussions, and it involved not just providers but also payers, as well as representatives of such groups as the National Quality Forum and the Leapfrog Group and agencies and organizations such as AHRQ [the federal Agency for Healthcare Research and Quality] and the Joint Commission.
And over a couple of days, we designed this idea of a totally transparent group, where we’d all share data, and where we’d reduce costs, reduce mortality, avoid harm, improve the use of evidence-based care, and improve the patient experience, in that context.
Now, we’ve always been a hospital very dedicated to quality. We had won the Quest for Quality from McKesson and the AHA in 2010, and we were one of seven organizations involved in the grant with the Robert Wood Johnson Foundation called Pursuing Perfection, which was managed by the Institute for Healthcare Improvement ran that grant for RWJF. So quality has always been top-of-mind for us, and so we naturally participated.
What have been the biggest challenges in your participation over the past three years?
Coy Irvin, M.D.: The biggest challenge has been to try to use the infrastructures we had in place in order to get the doctors involved, so we could really get down to the correct way to do it, because there’s so much variability in process; getting the docs involved in figuring that out for us was huge.
Coy Irvin, M.D.
Isgett: And we had taken on mortality reduction within a diagnosis, but had never taken on global reduction of mortality as a whole. So, mortality reduction within AMI [acute myocardial infarction] or sepsis—taking that on and then broadening it out to a whole—we weren’t sure how we would be able to connect mortality across diagnoses. But the physicians and nurses jumped in and participated.
Irvin: It was led by our cardiologists, and then the nurses and others in various areas, such as pharmacy, the emergency room and surgery, became involved; we had physicians, nurses, and pharmacists all involved, depending on the specialty.
Isgett: Just to take one example, we came up with ‘rovers’—ICU nurses staffing the ICUs 24/7, who have been ‘roving’ and monitoring high-risk patients. That group of patients has included those on their own pain pumps, those who had recently been transferred out of the ICUs in the past 24 hours and into regular floor beds, patients who were in restraints for some reason, patients who had had a rapid-response call. Rovers would go and evaluate each patient determined to be at risk, and the rovers have also functioned as our rapid-response team. Using the team of rovers offers a perfect example of the kinds of mechanisms we’ve been employing in order to address mortality issues. We started with as-expected mortality, and developed solutions, such as the use of rovers; and once we’d achieved improvements, we ended up teaching classes for people from other organizations participating in the QUEST program. That shows you how the continuous improvement model works [in the QUEST program].
Irvin: And the nice thing about rovers is that the program acted proactively.
These types of solutions really are based on commonsense kinds of approaches, aren’t they?
Isgett: Yes, but I’ll be very frank: when I saw the outcomes with other hospitals getting significantly lower than expected mortality ratios, that was the first time it occurred to me that it could go to the next level [with regard to mortality reduction]. Because we were good, we were as expected. And that’s where the beauty of data comes in. If one hospital in the program achieved lower-than-expected mortality, we would all flock to them to find out what had happened.
What about the issue of getting buy-in from physicians? Can you comment on the data that you’ve been sharing with the physicians in order to get their buy-in and participation?
Irvin: Consider the data that the payers have; they haven’t always shared that data in the past. Now, we’re collecting the data and sharing it with the doctors directly. And the only way to get them involved is to show them the data and ask them to look at it and then let them decide where to go with it and what to fix. And sometimes, for example, you look at data across 10 surgeons doing appendectomies, and some may be high-cost and some low-cost, and they can sit down together and analyze things, and look at mortality and outcomes as well. And we can figure out what we can and should do differently, and is it order sets or protocols, or early intervention? The physicians really need to be involved every step of the way.
What were some of the key things the doctors did find that created change?
Irvin: One of the things learned relates conceptually to the use of checklists, something that Atul Gawande, M.D., has written and spoken about. For example, we found that when the doctors failed to make use of the stroke order set in their ordering process, they would almost always forget at least one thing. So getting them to see that standardization is not a bad thing, as you’re handling fairly complicated patients, was one advance. In addition, such things as antibiotic management and tracking were important, because, say, we might find out three days into an antibiotic administration regimen that a patient needs a different antibiotic, or maybe the timing might need to change. Or in another area, questions might come up as to how to handle ICU patients—where is the best place to take them from the ICU? Even if your processes work well nine out of ten times, it’s important to examine what’s going on and to address the issues that emerge.
In other words, a lot of the success in the program seems to have come about through efforts to systematize and standardize care through the use of data analysis?
Isgett: Absolutely. We had used some data prior to QUEST, but we had looked at the data one disease at a time, but not across diseases. And at first, it almost seemed insurmountable that you would find the common denominators across diseases. And actually, the physicians who had made up that mortality committee in our organization were past chairs of disease-specific quality improvement groups.
Irvin: One of the challenges is moving forward to look at populations. One of the things a doctor is trained to do is to look at the individual patient. When I’m with Mrs. Smith, I’m worried about what’s going on with her. When we’re looking at this kind of data and doing analysis, we’re looking at an entire population, and that’s not something that physicians are trained to do. So to get them to look at that population and take that information, and put that into use, and see it as part of a treatment plan, is where we as physicians really need to get to the next level.
You’ve explained to me that you’re upgrading your electronic health record [EHR] right now, and that right now, your evidence-based order sets are still primarily paper-based, correct?
Irvin: Yes. And the beauty, once we transition to our new EHR, is that we’ll be able to see how and when the doctors have used the evidence-based order sets. And once everyone is on CPOE [computerized order entry], we’ll find things we need to fix and fix fast, so we’re building into the system mechanisms to help us figure out what’s going on and how to fix it.
Isgett: Today, Dr. Irvin spoke with the doctors about the use of the stroke order set; and today, all those charts are on paper, and you have to pull them manually. So going electronic will really move us so far forward in our growth on evidence-based care quality.
What would your advice be to the CIOs and CMIOs, with regard to how effectively leveraging IT can support initiatives such as QUEST?
Irvin: In reference to quality, I think they need to recognize how important they are in getting the right data and information to the physicians: it has to be accurate and it has to be up-to-date. It has to be not from six months ago, but from last week. The other thing is that when you do CPOE or computerized records, you’re changing their workflow. So now you’ve slowed them down, you’ve interrupted their day, and they’ve got to relearn what they’ve been doing for 30 years, especially the older people. And a lot of times, the IT people will say, well, it works well, it works as designed. But we’ve spent a huge amount of time talking with the IT folks about how to make it work for the doctors and the other clinicians.