Avoid quick fixes for improvement: Don't let surveyors find reoccurring problems
Take the next step to sustain your gains
It's a situation you don't want to have during a survey by The Joint Commission — surveyors discovering previously identified problems are still occurring. Or just as bad — the problem was fixed but the solution was only temporary.
"We are finding that some previously non-compliant elements of performance are found in subsequent surveys," says Mark E. Schario, The Joint Commission's senior field director for surveyor management and development.
Quality professionals need to pay close attention to the improvement process and the coordination of the details surrounding it, says Schario. "If you have non-compliance with a standard related to patient safety and you are not implementing improvements, then you can be placing patients at risk," he says.
After the evidence of standards compliance is submitted, the organization may then track performance with measures of success for the standard that was non-compliant.
"That's the first step where things can fall off," says Schario. "After a survey, a lot of organizations say, 'They found something wrong,' and they rush quickly to fix it. Then they have trouble keeping that improvement sustained," he says.
Since Joint Commission surveyors view recurring problems as a potential leadership issue, they expect that hospital leaders keep their eyes on sustained improvements. "They will want to make sure that leadership has a plan so improvements do not fall though the cracks," Schario says. "Just finding out there is a problem and putting in a fix is only part of it; you have to sustain those gains and monitor it. And that is the responsibility of leaders in the organization."
Quality professionals have the tough job of "managing upward" to make sure that leadership has priorities established, says Schario. "Organizations will tend to drift away from key issues, especially for areas like the National Patient Safety Goals, which we have found a lot of noncompliance with," he explains.
Since surveyors are aware of past recommendations, they will be looking to see if prior problems still exist during patient tracers. "That is where a surveyor is really going to do a more detailed exploration," says Schario.
If a problem is identified as a recurring problem, it can become attached to the leadership standards. "Surveyors will take the view that leaders are really responsible for this. If we found a problem, it was supposed to be fixed, but here it is again —that's when you will get a lot of discussion at the leadership level during the survey," says Schario.
Sustained performance is really what it's all about, says Schario. "A lot of people think performance improvement is just going to the next level. But to reach that next level, you need to sustain improvements you have already made," he says. "That is really where hospitals need to be focused."
The Joint Commission's tracer methodology is very effective at finding recurring issues, adds Schario. "You are going to an organization and looking not at documents, but at the provision of care. Our primary focus is the point of care, and reoccurring problems are going to be discussed in the following context: 'If you fixed them in the past, talk to me about why they keep occurring,'" says Schario. "It will all come down to what we observe when we perform a patient tracer activity."
Here are effective strategies used by quality professionals to ensure that necessary changes don't fall through the cracks:
• Challenge your data
At Christus Spohn Health System in Corpus Christi, TX, once an area has been identified as needing improvement, a group of staff is gathered to look at the issues surrounding the problem, including both frontline staff and managers. The leader of the group, usually a manager, guides the team to look at the issues, then brings the information back to the leadership group to look at the issues from the system perspective.
"Based on the nature of the improvement opportunity, we include the physicians, licensed independent practitioners, and other pertinent departments into the discussions to ensure we have the correct information and perspectives of their areas," says Pamela Hockett, RN, MSN, vice president of clinical quality.
Once a solution is determined, its impact is evaluated and a plan developed to roll it out to the various areas, based on the complexity of the issues.
To avoid loss of momentum, specific target deadlines are used, to prevent the issue from becoming lost among many other priorities. "Although the pressure of the deadline can be difficult, it forces the decision-making process and minimizes the 'analysis paralysis' that occurs with challenging issues," says Hockett.
Data are most helpful when they are vigorously challenged with questions, says Hockett. "The more questions we pose to the data and its process of collection and interpretation, the more likely the data will be a true presentation of what was measured," she says.
For example, tracers are performed on the unit level to ensure regulatory compliance of the environment and staff. "If the results of that activity were to be accepted at face value, it would indicate that we were at 100% compliance every month," says Hockett. "If you question the data, as we did, we realized that the tracer process was not as robust as it should be. We needed to have staff trace units that they do not usually work on and have them rotate."
Having staff trace in unfamiliar territory produced a fresh set of eyes to more accurately score the tracer and provided a more accurate picture of compliance.
Have multiple staff review the findings, to help the group identify issues that are measurable and significant to the organization. Challenging data in this way gives you the chance to adjust processes in the data collection and interpretation phases. "Data is a valuable tool in driving changes, but it must be accurate in order to drive changes in the right direction," says Hockett.
The hospital recently reformatted its organizational structure with a service line approach. Service line directors meet weekly to discuss operational issues and projects to improve patient care. "Having a multidisciplinary approach to the process improves the odds that the change will be embraced by the health care team," says Hockett.
• Use report cards
At Franciscan Health System in Tacoma, WA, a LEAN process improvement project is designed by the actual staff involved. An intensive workshop is held, followed by sequential Plan-Do-Study-Act cycles to fine-tune the improvements. Sixty and 90 day follow-up workshops are held to sustain achievements.
"We have committed to rapid process improvement as a systemwide response when system design fails," says Tony Haftel, MD, the organization's vice president for quality.
All requests for process improvement go through the clinical effectiveness department, and a process improvement facilitator tracks all requests and facilitates all projects. This individual provides LEAN training to all levels of staff, assesses opportunities for improvement, does initial screening of requests and monitors the progress of teams.
To ensure changes are made, "cascading" report cards are used. "These are intensive for all of our service lines, and are benchmarked against national and local indices, and also our parent health system," says Haftel.
Each service line works off a "local" report card with 15-20 parameters relating to clinical outcomes, safety, satisfaction, and fiscal performance. Each of these service lines reports up to an aligned interdisciplinary team.
This brings several related service lines, such as the emergency department, trauma, and critical care, under a single team. That team tracks only the three to five most important parameters from the reporting service lines, which reports to the quality council. "Therefore, there may be hundreds of parameters tracked at the service line levels, but only about 20 — the most important — get reported up through to the system quality council," says Haftel.
The service line reports are filtered up through the quality chain — shared with the interdisciplinary teams first, then the medical executive committee, and then on to the board. "At each echelon of this hierarchy, only the most significant data is passed on," says Haftel. Examples are mortality rates, return to hospital rates, complication rates, return to OR rates, length of stay, cost per case, anything related to the Centers for Medicare and Medicaid Services and The Joint Commission outcome reporting, and patient satisfaction data.
• Use a "trigger" tool to ensure progress
At OSF St. Joseph Medical Center in Bloomington, IL, opportunities for improvement, once identified, are forwarded to the quality and safety council — an oversight group comprising administrative staff, medical staff department chairpersons, and directors of key service areas — for their recommendations as to how to proceed. For example, they may make a recommendation to form a team or send the issue to the specific unit involved or medical staff department for action steps.
To avoid delays, a "referral" is made for the issue, using a Situation, Background, Assessment, and Recommendation format. Once the recommendation is received from the quality and safety council, this is added to the referral. Follow-up on the recommendation is accomplished by the quality resource management department in the form of a memo to the person or department involved.
"The referral is a paper 'trigger' tool to the quality resource management department to assure feedback on progress," says Kathy Haig, director of quality/risk management/patient safety officer. The paper itself is filed after the meeting into a folder for the specific group needing to provide the input or address the recommendation. For instance, if a recommendation was made for the department of medicine, the referral would be put into that department's folder to be sure that the issue was addressed at their next meeting.
Additionally, the hospital's operations council reviews the quality and safety council meeting information to assure quality, safety, and service at the microsystem level.
"They have responsibility to not only be aware of the recommendations, but to assure and monitor the action steps being taken in a timely manner," says Haig. "So if the quality and safety council makes a recommendation to a certain group, the operations council does follow-up to make sure action is being taken. Whoever collected the data initially would continue to see if improvement is being noted."
• Team up with an administrative sponsor
At Williamsburg, VA-based Sentara Healthcare, when an opportunity for improvement is identified, the organization employs the appropriate performance improvement method to accomplish the task, such as Six Sigma, LEAN, root cause analysis, or rapid cycle improvement teams.
If the performance improvement opportunity is deemed appropriate to benefit all the hospitals, a systemwide team is formed, with representatives from each facility to participate in the process redesign as needed.
"If an issue is initially expected to predominantly impact one facility, a local hospital-based team will be developed," says Carol L. Sale, RN, MSN, director of performance improvement. "However, opportunities that spread to the other facilities are always considered as the team progresses."
Performance improvement teams have an administrative sponsor who follows the team and receives regular updates on progress and data management as needed. "This administrative sponsorship provides oversight and helps keep momentum going for the team," says Sale.
For example, when the decision is made to do a root cause analysis, the executive sponsor meets with the quality manager. They develop a charter with expected outcomes and timelines. The administrative sponsor helps determine the best compilation of multidisciplinary team members, and periodically meets with the team to review progress toward the expected outcomes of the charter.
Key strategic initiatives are integrated into system and hospital quality goals, which are reviewed via monthly performance improvement council meetings and are directly linked to individual annual performance reviews.
Initial data indicating a need for improvement provide a baseline for the team to begin their work. As the team assesses the data, they identify gaps in the current process that need to be addressed. "Use of rapid cycle and other performance improvement methods allows teams to collect data as changes are being implemented, to determine impact and adjust improvement strategies moving forward," says Sale.
• Focus on "high-yield" opportunities
At Jewish Hospital and St. Mary's HealthCare in Louisville, KY, the Lean Sigma process is used to implement high-leverage improvements and sustain gains. "We have developed a tool we call a 'prioritization matrix' to help us identify opportunities," says Mark Dean, PhD, vice president of performance improvement. "An executive steering group uses this tool to ensure we focus on high-yield opportunities."
A high-yield opportunity is one for which a minimal investment in time and money will yield a high rate of return, explains Dean. The return may be financial, but it also can mean a significant improvement in patient care.
For example, the hospital had a lot of demand for additional lab work, but was limited by the capacity of the central processing unit. "With a minimal investment of time and dollars, we were able to achieve a 90% improvement in central processing area time, reducing the cycle from 19 minutes to 1.3 minutes," says Dean.
This increased the lab capacity by 16% with no additional FTEs, enabling the lab to perform 2,500 additional lab tests per week. The percentage of inpatient labs completed by 7:30 a.m. increased from 65% to more than 80%, improving patient care and physician satisfaction. "That is what I call a high-yield opportunity," says Dean.
Next, a "kaizen" event, also called a rapid improvement event, is initiated to rapidly study the process and implement improvements without long delays or loss of momentum. "We plan for and document follow-up actions on a tool called a 'rapid improvement newspaper,' and hold regular follow-up meetings to ensure we follow through with our improvement ideas and hold the gains," says Dean.
The rapid improvement event is a five-day process in which team members focus on the smaller parts of the process and what actions can be taken to improve patient value and satisfaction.
The result is significant process improvement, increased patient satisfaction and staff satisfaction, and improved patient care, says Dean. "When you get all of the right people in the room with all the right ideas to make change, and they study the process innately and have the motivation to take action and make change, you're bound to be successful," he says.
[For more information, contact:
Mark Dean, PhD, Vice President, Performance Improvement, Jewish Hospital & St. Mary's HealthCare, 410 S. First St., Louisville, KY 40202. Telephone: (502) 587-4975. Fax: (502) 587-4956.
Tony Haftel, MD, Vice President, Quality, Franciscan Health System, 1717 S. J St., Tacoma, WA 98405. E-mail: [email protected].
Kathy Haig, Director, Quality/Risk Management/Patient Safety Officer, OSF St. Joseph Medical Center, 2200 E. Washington St., Bloomington, IL 61701. Telephone: (309) 662-3311, ext. 1347. E-mail: [email protected].
Pamela Hockett, RN, MSN, VP Clinical Quality, Christus Spohn Health System, 600 Elizabeth St., Corpus Christi, TX 78374. Telephone: (361) 881-3662. Fax: (361) 881-6312. E-mail: [email protected].
Carol L. Sale, RN, MSN, Director of Performance Improvement, Sentara Healthcare, 100 Sentara Circle, Williamsburg, VA 23188. Telephone: (757) 984-8142. E-mail: [email protected].]
It's a situation you don't want to have during a survey by The Joint Commission surveyors discovering previously identified problems are still occurring. Or just as bad the problem was fixed but the solution was only temporary.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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