Achieving Highest Quality: The Necessity of Both Investment and Leadership

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Achieving Highest Quality The Necessity of Both
Investment and Leadership

• June 22, 2006
• Steve Osborn, MBA, MHA, CPHQ
• VP, Quality Compliance and Improvement
• Saint Vincent Health Center, Erie, PA
• [phone]
• SOsborn_at_svhs.org

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Saint Vincent Health CenterErie, Pennsylvania
As a non-profit health care organization and one
of the top five employers in the region, Saint
Vincents faith-based mission is dedicated to
providing the highest quality care, while
focusing on our community at large.
Statistics Hospital Beds
451 Admissions 17,500 Emergency Room visits
68,000 Operating Revenue 221 million
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Premise of Presentation

• Individual quality programs (such as the
  Premier/CMS Demonstration project) can be
  achieved by focused effort either from the top
  or from the Quality Department.
• However, sustained deep quality improvement takes
  (1) investment by the hospital (in staff,
  databases, and education) and (2) leadership
  integration.

Is this a Sprint or a Marathon?
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Overview

• Achieving Highest Quality The Metrics
• Achieving Highest Quality The Methods
• Infrastructure and Staffing Investment
• Leadership
• Both are necessary

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Looking for Long Term QualityPublic and
Quasi-Public Data

• Premier/CMS Demonstration Project
• CMS Hospital Compare/JCAHO Core
• State Agency Pennsylvania Healthcare Cost
  Containment Council (PHC4)
• Mortality and Readmissions
• Mortality and LOS over time
• Other Internal Projects (used with insurer P4P
  program)

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Premier/CMS Demonstration Project Results
Year 1 Pay For Performance Bonus 192,000 Year 2
Pay for Performance 97,000 CMS Hospital
Compare and JCAHO Core Measures Similar
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Premier/CMS DemonstrationProcess Composite
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PHC4 State Quality Agency Hospital Performance
Report
Most hospitals have more negative than positive
trends, due to PHC4 methodology
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Saint Vincent Mortality and LOS Over Time
Based on Atlas Clinical Severity Adjustment
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Other Quality ProjectsCentral Line Infection
Reduction
Post Intervention 3.8 Infections/quarter
Baseline 8.3 Infections/quarter
Note this change in performance is statistically
significant (P lt 0.001) using a t Test
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Other Quality ProjectsNosocomial DVT Reduction
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Other Quality ProjectsCABG 30 Day Readmission
Rate
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Achieving Highest QualityThe Methods

• Infrastructure Staffing Investment
• Informatics/Database administrators (1993)
• Includes data abstracting and data entry (1989)
• Clinical Data Analysts (1995)
• Other Traditional Quality
• ICPs, JCAHO Coordinator, Med Staff Quality
• Care Coordination Department
• Outcome Care Managers (1998)
• Lean Six Sigma Program (2005)
• Leadership

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Infrastructure InvestmentInformatics - Database
Support

• Director and 3 Database Administrators
• Quality and Outcomes Databases
• Outcomes Measures Atlas, Premier
• Heart Center Database (Apollo) expanded use
• Registries ACC, STS Infection Control (AICE)
• Homegrown Databases
• Internal Patient Safety Incident Reporting
• Internal Medical Staff Quality and Complications
• Quality Projects DVTs, MRSA Infections, etc.
• Medical Records Department Databases (e.g.
  Coding)
• IT Liaison

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Infrastructure InvestmentInformatics Data
Capture

• Quality Data Capture
• Abstracting 3.7 FTE
• Data Entry/Clerical Support 2.0 FTE
• Project Areas
• State mandated severity system (Atlas)
• Evidence Based Practices (EBPs)
• Special Projects (JCAHO, Infection Control, etc.)
• Abstracters liaison to each EBP
• At this point, give case by case feedback to EBP
  Case Manager
• Work with medical records for lost records

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Infrastructure InvestmentInformatics - Clinical
Data Analysis

• Clinical Data Analysts (3.0 FTEs)
• Position created in 1995
• Skills in data analysis, graphing, statistics
• Analysts Assigned Areas
• Product Lines (e.g. Heart Center Orthopedics,
  etc.)
• Evidence Based Practices
• Medical Staff Quality
• Nursing Quality
• Patient Safety

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Infrastructure InvestmentOther Quality
Department Staff

• Infection Control Practitioners (2.5 FTEs)
• Medical Staff Quality (1.3 FTEs)
• Peer Review support
• Complication identification and trending
• JCAHO/DOH Coordinator
• Department Secretary

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Infrastructure InvestmentCare Coordination
Department

• Outcomes Care Managers (7.2 FTEs)
• Case Management program begun in 1998
• Always linked to quality initiatives
• Assigned EBP Focus Area, but Unit Based
• Twice Daily Quality and Safety Huddles on Units
• Also have fiscal utilization roles
• Utilization Management
• Social Work
• Dieticians

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Infrastructure InvestmentLean Six Sigma
Facilitators

• Lean Six Sigma Program Commitment (January 2005)
• Phase I of Program
• RFI and Selection of Consultant to help with
  initial education and coaching (University of
  Buffalo)
• Two Facilitators Hired (June 2005)
• Four Projects Initiated (July 2005)
• ED Throughput OR Throughput
• Nursing Supply Availability Open Heart
  Readmissions
• Phase II LSS Leadership Training (May July 06)
• Didactic 8 hour Lecture Change, Lean, Six Sigma
• Workshops to translate into plan. By Senior
  Leader.

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Quality Investment Staffing Summary
Part Time to Quality Program Significant help
from PI Educator and Risk Manager With Benefits
Approx. 2.1 Million in Staffing
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Hospital Leaders

• Quality Department is really 4 cost centers
  working in an integrated fashion
• 3 Quality Leaders report to 3 Senior Leaders
• Chief Nursing Officer
• Executive VP (2 in Organization) - Responsible
  for Quality and Product Lines
• Chief Medical Officer
• Exec VP and CMO are physicians
• Quality Leaders meet weekly
• Quality Department staff meet monthly

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Chief Executive Officer
Coordinated Quality Department
Executive Vice President (Quality and Product
Lines)
Senior Vice President Chief Medical Officer
Senior Vice President Chief Nursing Officer
Vice President Quality Improvement (LSS) Patient
Safety and Regulatory Compliance
Director Quality Informatics
Director Care Coordination

• Lean Six-Sigma (LSS) Implementation
• Medical Staff Quality
• Infection Control
• Patient Safety Program
• Regulatory Agency and Accreditation Readiness
• Outside Agency Liaison and Monitoring

• Outcomes Care Management
• Utilization Management
• Discharge Planning/Social Work

• Clinical Data analysis
• Nursing Quality
• Quality Informatics Data capture, abstraction,
  and entry
• Database administration
• IT/CIS Integration Liaison

Helping the Saint Vincent Community deliver
quality and value
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Medical Staff Leaders

• Peer Informal Leaders Active in EBPs
• Infectious Diseases physician - Started Pneumonia
  team in 1998
• Cardiologist (Hospital Executive VP)
• Championed Cardiology and CV Surgery database
  development
• Committed to ACC and STS registries (1999)
• Brought Guidelines in Applied Practice (GAP) from
  ACC to Hospital in 2001 First used for AMI and
  CHF
• Chief of Anesthesia - Operative Beta Blocker
  program (2003)
• 2nd Infectious Disease Physician - Central Line
  Infection Reduction Team (2003)
• OR Medical Director - VP of PA Medical Society
  and Champion for Surgical Care Improvement
  Program (SCIP)

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Leadership Roles

• Senior Leadership
• Sets agenda Sets bar high Approves EBPs
• Provides organization-wide integration
• Quality Department Leadership
• Works across organization
• Provides expertise (Measurement, Stats
  Analysis, PI Methods)
• Leads day-to-day Quality Department staff
• Medical Staff Leadership
• Committed to Evidence Based care Endorse each
  EBP
• Willing to provide EBP leadership
• Quality Steering Council Comprised of staff
  from all three areas, plus operational leaders
  and staff

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Board Quality Committee

• Regular reviews of
• Premier/CMS Demonstration Projects
• CMS Hospital Compare
• Lean Six Sigma Projects
• Patient Safety Serious Events, FMEA, Trends in
  data.
• Other Quality results (e.g. mortality,
  complications, infections, etc.)

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Evidence Based Practice Info Flow
Board Quality Quality Steering Committees
Patient Care Staff
Medical Staff
Outcomes Care Manager
Physician Champion
EBP Team
Overall Reports
Physician Reports
Unit Reports
Clinical Data Analysis
Database Administration
Data Abstracting Entry
External Agencies
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Achieving Highest QualityThe Means

• Significant Infrastructure and Staffing
  Investment
• Real Leadership
• Need both to make it work
• Leadership without staff and infrastructure
  investment is simply slogan, exhortations and
  targets
• Quality staff without leadership becomes
  unfocused and non-strategic activity

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Questions? Comments?