A partnership among cardiology, nursing, quality, and finance leaders resulted in significant savings and lower complications for cardiology patients at a Michigan health system.
At a Glance
- The effectiveness of a quality improvement (QI) program developed by Spectrum Health in Grand Rapids, Mich., is in many ways exemplified by its Acute Myocardial Infarction/Percutaneous Coronary Intervention (AMI/PCI) Improvement project, launched in 2003.
- Team structure played a major part in the AMI/PCI Improvement project's success.
- Indispensable members of the project team included two medical directors and a nursing director serving as team co-chairs, a quality medical director, a QI specialist, a data analyst, and a financial analyst.
The national imperative for healthcare organizations to decrease healthcare costs and improve quality continues unabated across the country. Even as the healthcare reform debate evolves, hospitals are rapidly preparing for anticipated changes in reimbursement and new requirements for quality and safety.
As part of this preparation, and fueled in part by independent rating organizations such as HealthGrades (which reports on hospital quality using a set of nearly 30 high-volume surgical procedures and medical conditions), the improvement focus on high-volume and high-cost patient conditions and procedures continues to gain momentum.
Spectrum Health in Grand Rapids, Mich., has developed a quality improvement (QI) program that focuses on 35 high-volume adult and pediatric conditions, including joint replacement. A key focus of Spectrum Health's quality efforts has been on improving care for patients receiving cardiac services, in particular, in large measure to uphold the organization's standing as one of the nation's leading centers for cardiac care.a Leaders of the Spectrum Health Meijer Heart Center partnered with the health system's QI department to achieve results that included nearly 100 percent compliance with evidence-based guidelines, reduced complication rates, reduced length of stay (LOS), reduced costs, several designations from HealthGrades, and certification from The Joint Commission.
How did the organization achieve these results? And how can other hospitals follow Spectrum Health's example? A look at the approach Spectrum Health used, including the individuals who worked together to form the quality initiative's support structure and some of the lessons learned along the way, can provide valuable insights for other healthcare organizations that are striving to achieve similar results.
Team Leadership, Structure, and Membership
In our work across the country, we've seen different levels of success in hospital-based quality programs. In our experience, the most successful teams have employed most of the tactics illustrated by this case study. Spectrum Health's Acute Myocardial Infarction/Percutaneous Coronary Intervention (AMI/PCI) Improvement project was a pilot initiative that was undertaken following the reorganization of the organization's quality program in early 2003. The project was an early opportunity for the organization to test the initiative's team structure.
Multidisciplinary improvement teams are widely regarded as the most effective structures for improving care for defined populations. Spectrum Health's experience with the AMI/PCI team corroborated this view, and the structural need for the multidisciplinary team's membership to mirror the specialties and clinical staff who care for patients with the procedure or condition under study.
At a minimum, the QI team should always include:
- The medical director and nursing director, as team co-chairs
- A quality medical director (QMD)
- A QI specialist (QIS)
- A data analyst
- A financial analyst
- Additional content experts
The additional content experts on the team typically might include individuals such as physicians, nurses, and pharmacists. Specifically, the AMI/PCI team included the following:
- Emergency department (ED) physicians
- The nursing director of cardiovascular services
- A clinical nurse specialist
- Nurse managers of the ED, catheterization lab, and cardiovascular nursing unit
- A pharmacist
- Nurses and other representatives from care management and bed management
At first blush, the extent of resources cited here may seem like overkill. But trust us-we have used a variety of support structures, some with fewer staff and some with more. And when we used fewer, performance often suffered. We found that we need all of our experts at the table to efficiently address the many questions and concerns that surface at team meetings.
In particular, it is often tempting not to include physicians at the beginning of such an initiative. Reasons often cited include sensitivity to how busy the physician is with his or her practice and a desire not to waste a physician's time. Unfortunately, this approach has unintended consequences. Once physicians are added, they will insist on revisiting all previous decisions and, invariably, the process will start over from the beginning. When nursing is not included, the same call for rework is likely to result.
Each member of the committee should have a clear role to play in advancing the initiative. To illustrate this point, let's consider in greater detail what the roles of the team members cited above should be, and how those members of Spectrum's AMI/PCI team contributed to the success of that initiative.
Spectrum Health's AMI/PCI initiative was co-chaired by the cardiology medical director, emergency department medical director, and cardiovascular services nursing director, who together led all meetings. This effective leadership team has been instrumental to the initiative's success since its inception in 2003.
With shared leadership among the two medical directors and the nursing director, joint ownership and joint accountability was established for team performance and resulting improvements. This type of partnership is critical because it recognizes that neither nurses nor physicians can reasonably be considered responsible for patient care in isolation, but that only through a team-driven process can patient care result in the best patient outcomes.
In Spectrum Health's case, the cardiology medical director was responsible for obtaining consensus with his physician peers on evidence-based guidelines, protocols, and order sets. He used one-on-one conversations (academic detailing) with colleagues for physician-specific issues and a variety of cardiology department meetings for discussion and agreement on the contents of order sets and protocols.
In the QI setting, the medical director ideally should hold enough sway with his or her peers to influence their movement toward the quality objectives and-most important-to gain consensus on evidence-based protocols and order sets. To this end, the medical director must be well respected by his or her colleagues and have excellent diplomacy and negotiating skills. Without these characteristics, a medical director is much less likely to be successful in leading a quality initiative.
Quality Support Staff
As noted previously, we found that it is best to have strong team support for a QI initiative. It is simply impossible for a single QI staff member to be an expert in all of the requisite areas and perform all of the functions that a high-performing improvement team requires. Recognizing this need for strong support resources, therefore, we recently returned to the triad model of support for our QI teams. Under this model, each team has active support from three individuals:
- A quality medical director (QMD) with advance training in QI, safety science, and outcome measurement
- A QI specialist (QIS) with exper tise in team facilitation and project management
- A data analyst with expertise in the specific quality reports used by the team
QMD. The QMD supports the team leaders, especially those with little experience in leading improvement efforts. He or she mentors the team leaders, plans meeting agendas (often in partnership with the QIS), recommends priority improvement areas, and helps set the pace for the team. Although the QMD attends all team meetings, his or her role is often behind the scenes serving in the roles described.
The QMD also bring a unique set of skills, the most important of which are his or her interpersonal skills. A QMD should be a well-respected opinion leader (by both nursing and physicians) and should have broad experience in holding previous medical staff or other leadership positions. The QMD needs to be a consensus builder and negotiator and have specific expertise in the evidence base of the team's specialty, including the use
of order sets, practice protocols, EMR decision support tools, and the quality reports used by the team.
At Spectrum Health, Brian Hotchkiss, MD, a pediatric orthopedic surgeon, and John Maurer, MD, an internal medicine physician, have served in this role. Both of these physician leaders embody all of the previously cited traits, but above all, they are viewed as "gentlemen's gentlemen" and "doctors' doctors." They also are outstanding and well-respected teachers. The instrumental role that their leadership as QMDs has played in helping Spectrum Health to realize its many successes underscores the high importance of the QMD in creating an exemplary quality program.
QIS. The QIS functions as the team meeting facilitator and the project manager. This individual ensures that forward progress is maintained and that the team meets milestones, deliverables, and goals. The QIS should ideally be one of the best and brightest in the organization-someone often described as a rising star. He or she should be energetic, hard working, and well respected.
The QIS should have experience and expertise in six specific areas:
- Clinical improvement methods and tools
- Lean or Toyota process redesign
- Safety science
- Team facilitation
- Outcome measurement
- Project management
Expertise can be demonstrated by a record of success in similar positions and certification in the areas described.
The QIS should also have mastery of the "soft skills." The role calls for a natural extrovert who is a "people" person, a diplomat, a negotiator, a mediator, and a consensus builder. A QIS also must be able to develop an amiable and effective working relationship with physician and nursing leaders and clinical staff. Having this ability does not necessarily mean the QIS must have a clinical background, however. Many successful QISs have come from a variety of backgrounds, including coding, psychology, industrial engineering, finance, and manufacturing.
Data analyst. The data analyst is the team's "go-to" expert on the content of clinical dashboards. He or she should be thoroughly versed in the data sources used to create the reports and the data production process, and be able to assist with the technical details of data interpretation. This individual is essential for successfully dealing with physician questions and objections to the data.
The analyst should also bring insight into the coding process, which is often required to understand how quality measures have been translated by the coding department from the documentation provided by the physician in the medical record. The data
analyst further should possess a good understanding of severity adjustment and the underlying statistics contained in the reports.
Where do you find a highly qualified data analyst? A good first stop is to "borrow" from the organization's experts in data reporting and production-that is, the finance department. Members of the finance staff make excellent candidates because the finance system is a primary source for the data used to create the clinical dashboards. Hence, these individuals possess expertise and insight into the source systems that become paramount in interpreting the reports used by the QI team.
In sum, the QMD, the QIS, and the data analyst are the folks who answer the challenging questions posed by the physicians in the meetings. They are essential to successful discussion of dashboard content and, therefore, are critical in maintaining both the team's forward momentum and the physicians' trust in the data.
A Word About the Financial Analyst
As Spectrum Health's quality program has evolved, the dashboards we use now contain a variety of cost information, such as cost of supplies, room and board (R&B), and pharmacy. They also contain direct costs due to complications. As a quality improvement team assumes a greater role in reducing the cost of care, the importance of the financial analyst's contribution increases.This individual's role is to work with team members to ensure that everyone understands how changes in clinical practice affect the cost of care and how the modeling works to calculate the cost of complications.
Although seemingly complex at first glance, the financial modeling of quality improvements, including complication reduction, standardization of clinical processes, and overall clinical outcome improvement, is really just an extension of the charge capture system. During the clinical improvement process, the financial analyst first provides a baseline of the identified condition, using whatever financial decision support system the hospital uses, from simply ratio of cost to charges to the most complex activity-based costing software.
The finance analyst then works with the team to identify the changes being recommended as reflected in chargeable events, such as supplies used, patient days, and additional procedures-basically anything that is assigned a revenue code. At that point, it is as simple as running a before-and-after analysis of baseline data as compared with postintervention cases. The beauty of this approach is that all the data necessary for a reasonably accurate summary of the impact of QI reside right in the hospital chargemaster.
Strategies to Accelerate Improvements and Team Performance
These strategies generally fall into three categories:
- Maintaining transparency using quality data
- Getting executive sponsors (the hospital's executive team) to play a more active role
- Engaging quality committees
Transparency of team performance. Spectrum Health maintains an organizationwide policy of transparency related to quality performance. Our clinical dashboards are distributed to executive leadership and clinical directors monthly. The dashboards are also reviewed by team leaders, quality leaders, team members, and members of all quality committees, including those of the board. For larger service lines or a Center of Excellence, such as cardiology, annual reports to the community are developed, distributed throughout our primary service area, and posted on our web site.
The practice of sharing our performance with a broad audience has had a powerful impact on our quality teams. First, the knowledge that information on performance is being shared with a broad audience, both internal and external, is a strong motivator to the team members to improve. Second, it serves as a source of pride for our staff and physicians when their performance is picked up by the media and reported in other venues. And third, the passion of both physicians and staff to continually improve is likewise reinforced by the knowledge that patients and their families will see this information.
An active role for executive sponsors. Executives who often fill the role of team sponsors include the CFO, CEO, chief medical officer (CMO), chief quality officer (CQO), and chief nursing officer (CNO). Their role is to provide "support" to the teams, often by ensuring that the teams have adequate resources and by removing barriers to the teams' progress.
Executives can play an even larger role by taking some simple steps. For example, we recommend that the executive sponsor call or touch base with team leaders at least monthly. These regular communications let the team know that their work is high on the executive's list of priorities. The calls or meetings can be used to learn about progress, provide encouragement, and remove any barriers preventing progress. Some executives schedule these calls on a monthly basis with the team leaders, while others place them on agendas of routine monthly meetings. A call of interest and support from the CFO can be seen as a significant vote of confidence by a medical director or nursing director leading a QI team.
In the early days of Spectrum Health's orthopedics QI initiative, our CQO would hold a monthly lunch with the team's medical director. They would discuss the progress of the team, next steps, and any help the director needed. They would also set
priorities among the various improvements contemplated by the team. We believe this was helpful in getting the team off to a good start.
Quality committees and other public forums. Quality committees can have a powerful impact on team performance by serving as a motivator for continued progress. At Spectrum Health, we have seen a direct correlation between team performance and regularly scheduled presentations (by the team leaders) to the Hospital Quality Committee and the Board Quality Committee. When this practice is routine, progress is fast and accomplishments are many because there is no more powerful incentive than knowing that the hospital's leadership is expecting to receive progress reports on a regularly scheduled basis. For this strategy to work, however, the forums must be kept positive, encouraging, and congratulatory. In such an environment, teams will view the exposure to executive leadership positively, as a reward for doing a good job, and look forward to participating in the meetings.
With this team structure, Spectrum Health's AMI/PCI initiative has achieved outstanding results. To speed the care of patients with ST segment elevation myocardial infarction (STEMI), the team focused on time intervals from patient arrival to key interventions. Before and after statistics are included in the exhibit.
Improvements were seen across the board, and door-to-balloon (D2B) times are now consistently less than 90 minutes.b For the 12 months through Sept.30, 2009, D2B time was less than 90 minutes for 97 percent of patients.
Hematoma rates dropped from 3.8 percent to 3.1 percent, an 18 percent decrease. Coronary perforation dropped from 1.8 percent to 1.0 percent, a decrease of 44 percent. Readmission within 30 days dropped from 8.2 percent to 5.3 percent, a 35 percent decrease during the study period. And length of stay declined from 2.48 days to 1.91 days, a 23 percent decrease. In aggregate, these four measures generated an estimated total savings of $1,370,023 through November 2008. The finance and decision support teams computed the average cost savings for each outcome by comparing cohorts of patients with and without the complication.
Although the financial savings is an important byproduct of the team's efforts, the drop in readmissions and several complications is the heart of this work.
There were several lessons that Spectrum Health learned as a result of this effort. In many ways, four of these lessons hold the key to success for any hospital's quality improvement efforts.
Passionate physician leadership is critical. Only with such leadership can consensus be gained among physicians on evidence-based practice, order sets, and dashboard measures. The medical director also should review dashboard performance with physicians one-on-one or in team meetings to help the physicians understand their performance and how it compares with that of their peers.
A strong partnership is needed between department medical directors and nursing directors. Such partnerships aid joint decision making on clinical protocols and unit operations. The existence of strong partnerships has been a key to the success of our highest performing hospital units and directly correlates with quality performance and Center of Excellence Designations, including the Meijer Heart Center's designation by Thomson Reuters as a top 100 cardiovascular hospital in nine of the past 10 years. Only 10 cardiovascular hospitals in the country have received this designation nine or more times. The joint efforts of our medical and nursing leaders were indispensable in this achievement.
Data from accurate and reliable clinical dashboards provide the fuel that drives the improvement engine. These dashboards must be consistently and routinely produced to provide a foundation for identifying improvement opportunities, tracking changes over time, quantifying results of interventions, and calculating cost savings.
A strong partnership with finance is critical to dashboard production and understanding the meaning of dashboard measures. The cost accounting and medical record coding databases are source systems for Spectrum Health's clinical dashboards. The active support, engagement, and training provided by the organization's financial managers enable Spectrum Health to produce clinical dashboards for any clinical condition or surgical procedure. It's not uncommon to have a dashboard in full production within 60 days after a physician requests the information.
John Byrnes, MD, is senior vice president, system quality, Spectrum Health System, Grand Rapids, Mich., and a member of HFMA's Western Michigan Chapter (firstname.lastname@example.org).
Joe Fifer, FHFMA, CPA, is vice president, finance, Spectrum Health Hospital Group, Grand Rapids, Mich., a member of HFMA's Western Michigan Chapter, and a former chairof HFMA's Board of Directors (email@example.com).
The authors acknowledge with appreciation the assistance of the AMI team and quality and data staff in the preparation of this manuscript.
Publication Date: Monday, March 01, 2010