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Three Quality Improvement Tactics to Help Ensure Success and Sustainability
The Joint Commission Journal on Quality and Patient Safety Timeliness and Efficiency
Three Quality Improvement Tactics to Help Ensure Success and Sustainability Marcy Carty, MD, MPH; Emily S. Patterson, PhD
I
n this issue of The Joint Commission Journal on Quality and Patient Safety, Melton et al. describe the journey that Lakeland Regional Health (Lakeland, Florida) undertook to substantially improve patient flow through the emergency department (ED), reducing the average length of stay almost in half and reducing the percentage of patients who left without being seen (LWBS) by almost 10-fold. Most importantly, these improvements were sustained for more than two years. The article, “Impact of a Hospitalwide Quality Improvement Initiative on Emergency Department Throughput and Crowding Measures,”1 describes three tactics that should be incorporated into quality improvement (QI) efforts to successfully spread culture change, meet measurement goals, and sustain change. As pointed out in the Melton et al. article and other ED flow literature, several studies have clearly shown that ED crowding compromises quality of care. 2,3 As such, it is an imperative that patient flow is addressed systematically throughout hospitals and skilled nursing/rehabilitation facilities. The Joint Commission encourages a focus on patient flow improvements via the Leadership (LD) Standard LD.04.03.11. (“The hospital manages the flow of patients throughout the hospital”), with specific reference to the ED in Element of Performance 6 (“The hospital measures and sets goals for mitigating and managing the boarding of patients who come though the emergency department.”)4 In addition, the Centers for Medicare & Medicaid Services has implemented a core measure set on flow metrics within the ED, allowing for hospital comparisons and incentive programs to use the measures.5 Given this national attention, it is no surprise that many EDs and hospitals in the United States have undertaken to “decant” the ED via chartered committees with specific, measurable goals. Through this work, many best practices have been identified and implemented, with variable success in achieving multiple targets or in sustaining the improvement.6 However, there are some clear examples of significant improvement in patient flow, and it is important to understand what differentiates these efforts from other less impactful ones.7,8 We will use the Melton et al. article to describe the three critical tactics, to which we referred at the outset, that they used to help ensure their success: (1) clearly articulated board December 2016
accountability for the entire hospitalwide effort; (2) alignment of the outcome measures with the multiple, often ill-aligned, clinical incentives inherent in our current fee-for-service and value-based care models; and (3) application of discrete event simulations, an industrial engineering method, to increase the feasibility of the process changes before they were even trialed. First, going forward, hospital and health system boards of directors must be deeply engaged in the quality, safety, and clinician engagement opportunities in an organization. The Joint Commission standards for leadership clearly hold the board, as well as senior leaders and medical staff, accountable for the care delivered in clinical care settings.4 However, in reality, it sometimes is apparent that boards may meet the Joint Commission standards on paper but that their level of knowledge of, as reflected in deep discussion, and articulated accountability for safety and quality is often lacking. For example, Vaughn et al., who surveyed boards and senior leaders at more than 450 hospitals, found that at 72% of the hospitals, board members spent a quarter of their time or less at meetings discussing QI opportunities and efforts; at only 5% of the hospitals, did board members spend more than half their time discussing quality and safety.9 At Lakeland Regional Health, the board of directors was directly involved in setting goals for improved throughput measures, and they articulated the critical importance of these goals by formally communicating achievement of the goals as the number one corporate health system priority. The board also committed to supply the appropriate technological, human, and budgetary resources needed to meet the goals they set out. Finally, the board created ongoing accountability of senior leaders by asking for monthly data calculations and quarterly board progress reports. This deep level of board engagement creates a cascade of accountability that can be felt by the frontline staff, leading to improved cooperation and teamwork. Second, Melton et al. created targets that allow clinicians some discretion at times when poorly aligned incentives would have otherwise forced the clinician to admit the patient quickly rather than allowing him or her to arrange for an alternative plan, which likely takes longer but is more ideal for the patient and the system, such as patients in a Pioneer Accountable Care Volume 42 Number 12
Copyright 2016 The Joint Commission
531
The Joint Commission Journal on Quality and Patient Safety Organization who could be directly admitted to a skilled nursing facility. Ensuring that national, payer (where applicable), clinician, and health system goals can be aligned is incredibly powerful and will spur increased engagement and sustainability. We recommend that leaders think carefully about the measures they use to define success for QI initiatives, as the wrong measures can deter engagement and create workarounds. Finally, the hospital funded the development and use of discrete event simulations, a method commonly used by operations researchers and typically required training for undergraduate industrial engineers. Of note, the use of this method required hiring an expert consultant not already employed at the hospital and reallocating resources on the basis of the generated recommendations at strategic bottlenecks in the process. In-house environmental services staff were able to be shifted to peak hours without the hiring of additional personnel. Perhaps most importantly, systemic changes were not limited to cost-neutral strategies. On the basis of insights gained from the simulations, substantial investments in additional adult and pediatric beds were made. Finally, the use of the “bed ahead” strategy was an innovative application of a traditional systems engineering concept. With “structured flexibility,” the subsequent disposition for patients was identified in a structured manner earlier in the process, while also maintaining flexibility to modify the plan on the basis of new information. Health care leaders and physicians are facing many shortterm, possibly disruptive, changes in payment structures (for example, MIPS [Merit-Based Incentive Payment System]/ MACRA [Medicare Access & CHIP Reauthorization Act of 2015]),10 technology, and clinical/pharmaceutical innovations. Given the pace of change, identification and implementation of process changes and delivery system redesigns must be efficient and effective. We believe that the role of the board, the health care system, and clinician incentives and the tools that are used to design the interventions are critical to the success and sustainability of significant process changes. We urge leaders to follow in the steps of Melton et al. and use these tactics maximally as they begin large-scale redesign efforts. J
532
December 2016
Marcy Carty, MD, MPH, is Vice President, Network Performance & Innovation, Performance Measurement and Improvement, Blue Cross Blue Shield of Massachusetts, Boston, and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety. Emily S. Patterson, PhD, is Associate Professor, Division of Health Information Management and Systems, School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety. Please address correspondence to Marcy Carty, [email protected].
References
1. Melton JD III, et al. Impact of a hospitalwide quality improvement initiative on emergency department throughput and crowding measures. Jt Comm J Qual Patient Saf. 2016;42:533–542. 2. Agency for Healthcare Research and Quality. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. McHugh M, et al. Oct 2014. Accessed Oct 10, 2016. http://www.ahrq.gov/research /findings/final-reports/ptflow/section1.html. 3. Fee C, et al. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med. 2007;50:501–509. 4. The Joint Commission. 2016 Comprehensive Accreditation Manual for Hospitals (E-dition). Oak Brook, IL: Joint Commission Resources, 2015. 5. Centers for Medicare & Medicaid Services. Hospital Compare. Accessed Oct 10, 2016. https://www.medicare.gov/hospitalcompare/search.html. 6. Zocchi MS, McClelland MS, Pines JM. Increasing throughput: Results from a 42-hospital collaborative to improve emergency department flow. Jt Comm J Qual Patient Saf. 2015;41:532–542. 7. Sayah A, et al. Minimizing ED waiting times and improving patient flow and experience of care. Emerg Med Int. Epub 2014 Apr 14. 8. Welch SJ, Allen TL. Data-driven quality improvement in the emergency department at a level one trauma and tertiary care hospital. J Emerg Med. 2006; 30:269–276. 9. Vaughn T, et al. Engagement of leadership in quality improvement initiatives: Executive quality improvement survey results. J Patient Saf. 2006;2:2–9. 10. Centers for Medicare & Medicaid Services. MACRA: Delivery System Reform, Medicare Payment Reform. Accessed Oct 10, 2016. https://www .cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value -Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs .html.
Volume 42 Number 12
Copyright 2016 The Joint Commission
Three Quality Improvement Tactics to Help Ensure Success and Sustainability Marcy Carty, MD, MPH; Emily S. Patterson, PhD
I
n this issue of The Joint Commission Journal on Quality and Patient Safety, Melton et al. describe the journey that Lakeland Regional Health (Lakeland, Florida) undertook to substantially improve patient flow through the emergency department (ED), reducing the average length of stay almost in half and reducing the percentage of patients who left without being seen (LWBS) by almost 10-fold. Most importantly, these improvements were sustained for more than two years. The article, “Impact of a Hospitalwide Quality Improvement Initiative on Emergency Department Throughput and Crowding Measures,”1 describes three tactics that should be incorporated into quality improvement (QI) efforts to successfully spread culture change, meet measurement goals, and sustain change. As pointed out in the Melton et al. article and other ED flow literature, several studies have clearly shown that ED crowding compromises quality of care. 2,3 As such, it is an imperative that patient flow is addressed systematically throughout hospitals and skilled nursing/rehabilitation facilities. The Joint Commission encourages a focus on patient flow improvements via the Leadership (LD) Standard LD.04.03.11. (“The hospital manages the flow of patients throughout the hospital”), with specific reference to the ED in Element of Performance 6 (“The hospital measures and sets goals for mitigating and managing the boarding of patients who come though the emergency department.”)4 In addition, the Centers for Medicare & Medicaid Services has implemented a core measure set on flow metrics within the ED, allowing for hospital comparisons and incentive programs to use the measures.5 Given this national attention, it is no surprise that many EDs and hospitals in the United States have undertaken to “decant” the ED via chartered committees with specific, measurable goals. Through this work, many best practices have been identified and implemented, with variable success in achieving multiple targets or in sustaining the improvement.6 However, there are some clear examples of significant improvement in patient flow, and it is important to understand what differentiates these efforts from other less impactful ones.7,8 We will use the Melton et al. article to describe the three critical tactics, to which we referred at the outset, that they used to help ensure their success: (1) clearly articulated board December 2016
accountability for the entire hospitalwide effort; (2) alignment of the outcome measures with the multiple, often ill-aligned, clinical incentives inherent in our current fee-for-service and value-based care models; and (3) application of discrete event simulations, an industrial engineering method, to increase the feasibility of the process changes before they were even trialed. First, going forward, hospital and health system boards of directors must be deeply engaged in the quality, safety, and clinician engagement opportunities in an organization. The Joint Commission standards for leadership clearly hold the board, as well as senior leaders and medical staff, accountable for the care delivered in clinical care settings.4 However, in reality, it sometimes is apparent that boards may meet the Joint Commission standards on paper but that their level of knowledge of, as reflected in deep discussion, and articulated accountability for safety and quality is often lacking. For example, Vaughn et al., who surveyed boards and senior leaders at more than 450 hospitals, found that at 72% of the hospitals, board members spent a quarter of their time or less at meetings discussing QI opportunities and efforts; at only 5% of the hospitals, did board members spend more than half their time discussing quality and safety.9 At Lakeland Regional Health, the board of directors was directly involved in setting goals for improved throughput measures, and they articulated the critical importance of these goals by formally communicating achievement of the goals as the number one corporate health system priority. The board also committed to supply the appropriate technological, human, and budgetary resources needed to meet the goals they set out. Finally, the board created ongoing accountability of senior leaders by asking for monthly data calculations and quarterly board progress reports. This deep level of board engagement creates a cascade of accountability that can be felt by the frontline staff, leading to improved cooperation and teamwork. Second, Melton et al. created targets that allow clinicians some discretion at times when poorly aligned incentives would have otherwise forced the clinician to admit the patient quickly rather than allowing him or her to arrange for an alternative plan, which likely takes longer but is more ideal for the patient and the system, such as patients in a Pioneer Accountable Care Volume 42 Number 12
Copyright 2016 The Joint Commission
531
The Joint Commission Journal on Quality and Patient Safety Organization who could be directly admitted to a skilled nursing facility. Ensuring that national, payer (where applicable), clinician, and health system goals can be aligned is incredibly powerful and will spur increased engagement and sustainability. We recommend that leaders think carefully about the measures they use to define success for QI initiatives, as the wrong measures can deter engagement and create workarounds. Finally, the hospital funded the development and use of discrete event simulations, a method commonly used by operations researchers and typically required training for undergraduate industrial engineers. Of note, the use of this method required hiring an expert consultant not already employed at the hospital and reallocating resources on the basis of the generated recommendations at strategic bottlenecks in the process. In-house environmental services staff were able to be shifted to peak hours without the hiring of additional personnel. Perhaps most importantly, systemic changes were not limited to cost-neutral strategies. On the basis of insights gained from the simulations, substantial investments in additional adult and pediatric beds were made. Finally, the use of the “bed ahead” strategy was an innovative application of a traditional systems engineering concept. With “structured flexibility,” the subsequent disposition for patients was identified in a structured manner earlier in the process, while also maintaining flexibility to modify the plan on the basis of new information. Health care leaders and physicians are facing many shortterm, possibly disruptive, changes in payment structures (for example, MIPS [Merit-Based Incentive Payment System]/ MACRA [Medicare Access & CHIP Reauthorization Act of 2015]),10 technology, and clinical/pharmaceutical innovations. Given the pace of change, identification and implementation of process changes and delivery system redesigns must be efficient and effective. We believe that the role of the board, the health care system, and clinician incentives and the tools that are used to design the interventions are critical to the success and sustainability of significant process changes. We urge leaders to follow in the steps of Melton et al. and use these tactics maximally as they begin large-scale redesign efforts. J
532
December 2016
Marcy Carty, MD, MPH, is Vice President, Network Performance & Innovation, Performance Measurement and Improvement, Blue Cross Blue Shield of Massachusetts, Boston, and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety. Emily S. Patterson, PhD, is Associate Professor, Division of Health Information Management and Systems, School of Health and Rehabilitation Sciences, College of Medicine, Ohio State University, Columbus, and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety. Please address correspondence to Marcy Carty, [email protected].
References
1. Melton JD III, et al. Impact of a hospitalwide quality improvement initiative on emergency department throughput and crowding measures. Jt Comm J Qual Patient Saf. 2016;42:533–542. 2. Agency for Healthcare Research and Quality. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. McHugh M, et al. Oct 2014. Accessed Oct 10, 2016. http://www.ahrq.gov/research /findings/final-reports/ptflow/section1.html. 3. Fee C, et al. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med. 2007;50:501–509. 4. The Joint Commission. 2016 Comprehensive Accreditation Manual for Hospitals (E-dition). Oak Brook, IL: Joint Commission Resources, 2015. 5. Centers for Medicare & Medicaid Services. Hospital Compare. Accessed Oct 10, 2016. https://www.medicare.gov/hospitalcompare/search.html. 6. Zocchi MS, McClelland MS, Pines JM. Increasing throughput: Results from a 42-hospital collaborative to improve emergency department flow. Jt Comm J Qual Patient Saf. 2015;41:532–542. 7. Sayah A, et al. Minimizing ED waiting times and improving patient flow and experience of care. Emerg Med Int. Epub 2014 Apr 14. 8. Welch SJ, Allen TL. Data-driven quality improvement in the emergency department at a level one trauma and tertiary care hospital. J Emerg Med. 2006; 30:269–276. 9. Vaughn T, et al. Engagement of leadership in quality improvement initiatives: Executive quality improvement survey results. J Patient Saf. 2006;2:2–9. 10. Centers for Medicare & Medicaid Services. MACRA: Delivery System Reform, Medicare Payment Reform. Accessed Oct 10, 2016. https://www .cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value -Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs .html.
Volume 42 Number 12
Copyright 2016 The Joint Commission