Assessing and Improving Quality and Safety – HealthLeaders Media

Assessing and Improving Quality and Safety

Michael Zeis, for HealthLeaders Media , August 13, 2013

This article appears in the July/August issue of HealthLeaders magazine.

Healthcare leaders report increasing levels of experience with clinical quality and patient safety. They also have plenty of experience working with quality and safety metrics. Nearly two-thirds (60%) of respondents to our annual Clinical Quality and Patient Safety Survey do have in place all of the selection of eight National Quality Foundation prevention or reduction protocols we presented in our survey.

Many of those who do not have particular protocols in place plan to add them. For instance, 31% expect to implement the NQF protocol to reduce falls and fall-related injuries within the next 12 months. If all follow through, within a year 91% will have in place NQF protocols for fall reduction.

“A transition is occurring,” says William K. Cors, MD, MMM, FACPE, vice president and chief medical quality officer for the Pocono (Pa.) Health System, which includes the 215-bed Pocono Medical Center and other facilities. “We see the increasing numbers of people who are looking at NQF measures, for example, getting their arms around quality and safety metrics, with the assumption that the reimbursement systems of the future are going to be geared more toward such metrics.”

This broad exposure to quality and safety metrics and the processes that track them seem to be building a foundation in the art and science of quality and safety that, for many, goes beyond measuring and reporting, in such a way that quality and safety become ingrained in the organization’s culture.

A glut of measurements strains resources

Virtually all respondents (95%) claim either a great deal of experience or some experience with clinical quality metrics and patient safety metrics. Although 39% cite the quality of data among their top three challenges in reaching the next level of clinical quality, and 24% say that a lack of data is among the top three stumbling blocks on the path toward adopting an effective patient safety program, there seems to be no shortage of measurement and reporting tasks.

“We have countless people systemwide who look at our metrics,” says Michael Murphy, MD, chief medical officer of the 536-licensed bed Sharp Grossmont Hospital, which serves east San Diego County out of La Mesa, Calif. “We have a complete data warehouse, with a significant staff that handles all the data that goes into the warehouse and generates reports.”

“The measurement requirement has generated an infrastructure need,” Pocono’s Cors adds. “Every year I have another three, four, five metrics that are added to the things I have to follow. I’m not necessarily getting any more money for it, but I still have to provide staff to collect, input, and report the data.”

Timothy Morgenthaler, MD, patient safety officer at Mayo Clinic, a nonprofit health system based in Rochester, Minn., recognizes that some metrics have an administrative heritage and their appropriateness in a clinical environment can be questioned.

“There is often a gap between what administrative data shows and what is actually happening to patients,” says Morgenthaler. “If we go to our clinicians, who are at the heart of driving our quality and safety efforts, and we say the administrative data shows we aren’t doing very well, to be quite honest, that’s not very motivating to them. Clinicians are motivated to improve when presented with clinically accurate data.”

EHR as a step toward clinical decision support

Nearly half of respondents (47%) expect to increase spending on clinical decision support as part of their investment in quality and safety. Paula Santrach, MD, Mayo Clinic’s chair of clinical practice quality, says that establishing standard processes and augmenting with decision support where appropriate can contribute to clinical quality and patient safety.

“For all of the doctors who work here,” she says, “there is a common way of ordering a chest x-ray. We build these processes so that they happen consistently, and then we try to augment them with clinical decision support or other means in order to make care consistent and help providers do the right thing.”

With a majority of respondents seeing improvement in clinical quality due to their EHR (42% cite moderate improvement, 18% significant), there is reason for hope. Santrach observes that better integration of the EHR with provider workflows will yield still more improvements.

“When you try to really work with an electronic health record, it can be significantly harder to achieve your objective in terms of improving quality if there is a mismatch between clinical workflow and interacting with the computer. I think the EHR has helped us as an industry to some degree, but we could do much better if we had a better match between how the computer works and how providers work,” Santrach says.

Sharp Grossmont’s Murphy says that obtaining physician buy-in to EHR documentation tasks is easier because most see clinical decision support as a function that is enabled by the EHR. “It is the logical extension,” he says, but also cautions about alert fatigue. “There’s a difference between the system telling you that there’s an issue here and really having good clinical decision support.”

Keys to sustainability

A culture that fosters input is an important key to enhancing quality and safety in a sustainable fashion. In our survey, the stumbling blocks mentioned most frequently as standing in the way of effective patient safety programs were fear of punishment for self-reporting errors (35%) and fear of retaliation for reporting others’ errors (also 35%).

“If you want to have an effective safety program,” Santrach says, “you have to be a continuous learning organization. You have to be able to talk about your errors in a safe way and learn from each other, and you have to have leadership supporting you in doing that.”

Sustainability will become more important as organizations reach parity in quality and safety performance. Mayo’s Morgenthaler asks, “How do we get our performance from 90% to 99%? We want to because that’s translatable into lives saved. What we learned is that we needed some more things so the memory of how important this is doesn’t fade into yesteryear.”

Speaking about a venous thromboembolism prophylaxis performance effort, Morgenthaler identifies four items that support sustainability: building into the workflow immediate feedback via the EHR about whether performance requirements have been met, periodic feedback to practitioners about compliance, a phased and continuing education program, and transparency (communication) about successes and failures.

“It’s really become part of our culture and part of our processes,” he says, “so we have been able to maintain pretty high reliability on VTP. We apply that same type of approach to most of our endeavors.”

Reprint HLR070813-3


This article appears in the July/August issue of HealthLeaders magazine.


Michael Zeis is a research analyst for HealthLeaders Media. 

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