Healthcare Value

John Byrnes

Under-resourced quality departments are the leading cause of poor hospital performance.

That's a bold statement, and it's not just my opinion-it's common throughout America's hospitals. It is a primary reason that organizations fail to achieve their quality goals.

It takes people to do work-and just as we aggressively manage the financial performance of our organizations, we must aggressively manage their quality and safety performance. Doing so requires dedicated staff with contemporary skills that match today's national agenda.

Vinod Sahney, PhD, a nationally known quality expert and a founding member of the Institute for Healthcare Improvement and the Group Practice Improve-ment Network, underscored this point when presenting at the Colorado Hospital Association's October 2012 Patient Safety Leadership Congress. He eloquently addressed the need for adequate resources and appealed to executives to make this concern a priority.

Think of it this way: If a hospital's quality performance is not in the top quartile and it has yet to realize multimillion-dollar savings from its quality program, then it is missing a great opportunity to remove waste and inefficiency from its organization. Every dollar saved through quality improvement drops directly to the bottom line. From a cost perspective, keep in mind that each avoidable complication costs a hospital $10,000, on average, and that each sentinel event can create hundreds of thousands of dollars in claims exposure.

Finance professionals can play an important role in ensuring that adequate resources are deployed.

Staffing a Contemporary Quality Department

A well-organized hospital quality department includes staff with several distinct skill sets. In the very least, the staff should include individuals in the following positions.

Quality specialist. The quality specialist functions as facilitator and project manager for large-scale improvement projects. He or she facilitates team meetings and ensures that progress is maintained and that milestones and deliverables are met. This specialist should be among the best and brightest individuals in the organization-with clear qualities of being highly energetic, hard-working, and well-respected.

The quality specialist should have experience and expertise with project management and team facilitation, as well as with established quality improvement methods. Specifically in the latter case, the specialist should be skilled in the use of evidence-based medicine to improve clinical outcomes-e.g., lower rates of complications and mortality-and in the application of Lean, Six Sigma, and/or Toyota process improvement methods to eliminate waste and improve efficiency.

The quality specialist should also have mastery of the "soft skills." This role calls for a natural extrovert who is a diplomat, negotiator, and consensus builder. To achieve meaningful results, the specialist must be able to develop highly effective working relationships with physicians and nursing leaders and lead discussions on the merits of various medical treatments (evidence-based medicine) and nursing interventions.

The specialist does not necessarily require a clinical background. Successful quality specialists have come from a variety of backgrounds, including coding, psychology, industrial engineering, and finance. In fact, I recommend mixing it up and assembling a department with several quality specialists from a variety of backgrounds.

Data analyst. The data analyst is the team's "go-to" expert for quality data. Charged with creating the reports used by improvement teams, this individual must be an expert in the organization's administrative and clinical databases. He or she should have technical expertise in data analysis and statistics and in interpreting data. He or she also should be comfortable working with all types of data, whether they are contained in cost accounting systems or the electronic health record, or abstracted through chart review. The analyst should be able to offer insight into the coding process regarding how quality measures derive from the physicians' documentation in the medical record. Finally, he or she should possess a good understanding of severity adjustment and the underlying statistics used in the reports.

Where do you find a qualified analyst? I like to "borrow" analysts from the finance department. Finance professionals are excellent candidates because the cost accounting and coding systems are the primary data source for the majority of clinical dashboards.

These individuals also are essential for dealing with physician questions about and objections to the data. They can explain the strengths and weaknesses of the data sources, the audit and validation process, and the risk or severity adjustment methods applied to the data.

Safety specialist. A well-staffed quality department will include a number of safety specialists with specific expertise in safety science, safety culture transformation, and the design of high-reliability organizations. These individuals should lead initiatives to reduce errors, sentinel events, hospital-acquired conditions, and never events. Their efforts can decrease the number of events leading to claims and the number of claims paid. Positioned on the front line, a safety specialist's objectives are to make the hospital safer and move it toward six-sigma performance as quickly as possible. Such specialists train front-line staff and develop unit-based patient safety officers who will serve as the go-to resource for each clinical unit.

Right-Sizing the Quality Department Staff

I have reviewed staffing models for more than 100 organizations in my career-some large, some small, and many in the middle. Some are highly effective, "top 100" hospitals, while others fall woefully short of respectable performance levels. And in those organizations with poor performance, I can always count on finding two deficiencies: understaffing and a paucity of staff with the skills and expertise outlined previously.

Here are the benchmarks that are essential for any organization that aspires to having an award-winning program with multimillion-dollar returns:

  • Quality specialists: one FTE/100 beds
  • Data analysts: one FTE/two quality specialistsa  
  • Safety specialists: one FTE/200 beds

Exemplary quality departments also are likely to include a number of positions not discussed here, including the following:

  • Infection prevention specialists: one FTE/100 beds
  • Part-time quality medical director: one-quarter FTE/250 beds
  • Accreditation specialists (well-versed in requirements of The Joint Commission and CMS): one/hospital
  • Medication safety specialist (PharmD): one/hospital

In short, hospitals require staff resources such as these to excel under the current national quality agenda and to achieve better patient outcomes, a better patient experience, and a lower cost of care-that is, the Value Proposition.

John Byrnes, MD, is chief medical officer, Sisters of Charity of Leavenworth Health System, Denver, and a member of HFMA's Western Michigan Chapter (


a. These analysts are in addition to the staff required for core measure reporting (chart review) and registries requiring chart abstraction or review.

Publication Date: Monday, December 03, 2012

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