Quality approach, hard-wiring, repetition lead to excellence
Director says one key is focusing on frontline staff
With so many conditions and processes to worry about, not to mention all the organizations that require performance data, it's a wonder that a quality manager can keep a handle on all of them. But at Payson (AZ) Regional Medical Center (PRMC), the quality team seems not only to be addressing all of them, but also to be excelling in several areas at once.
For example: PRMC has achieved close to 100% compliance with the Centers for Medicare & Medicaid Services (CMS) core measures; it recently received a 94% score on its Joint Commission survey; and it was recognized as one of the "Top 100" hospitals by Thomson Reuters for the second time in four years.
There's an underlying philosophy behind all this success, explains Becky Nissila, RN, MBA, director of quality management and regulatory compliance. "My motto is, 'Quality happens at the bedside,'" she says. "I'm an administrative person who sits up on the food chain, but that's totally not what quality is about. My main gig is getting knowledge and tools to the people who deliver the care."
Seeking perfection
Nissila says that for the CMS core measures, "Overall, we're at 99.2% or 99.3%; our lowest in the last year was 98.6%. My big goal is a 100% a quarter." If that goal is achieved, she says, "I told everybody there will be a big cookout at my house." However, she's quick to add, "The major motivator is doing the right things for the patients."
At this point, Nissila notes, processes and protocols to assure best care practices are "hard-wired," but it wasn't always this way. "Repetition builds definition," she explains. "People have to hear it and see it. The things we put into place made it impossible for people not to address."
When a new initiative is put in place, she says, there is first general education for the staff. "We say, 'OK, here are our new measures, here's what we have to meet,'" she says. "We explain that this is the outcome we have to get to, and here's what we do in our daily processes."
The people who do the work create what the process looks like staff nurses, techs, and so on, Nissila says. "We create the initial plan, educate the staff, and then try it. If the initial plan doesn't work, we tweak it."
Once the information is disseminated, she adds, "It has to be walked, talked, and made part of everyday work in the hospital; that's how you get it hard-wired. Everyone gets quizzed on it; it's addressed every day. Not a day goes by that we don't have a core-measure patient in the hospital, so we have to be there to talk the talk, make sure people understand the processes we have in place, and that they follow through."
Once the staff have the information and tools they need, says Nissila, "You have to hold them accountable. We say, 'You have the knowledge now; this is the expectation, and it's non-negotiable it's part of your job.'"
When someone is not doing what's expected, she says, "It becomes a counseling session. You can ask, 'Is there a reason you did not do this? Is there something we're not aware of?'" The "whole," Nissila explains, is much smarter than the "one."
But now that the staff are so close to 100% compliance, is continued improvement really possible? "At this point, our failures are so few and far between that we can look at each failure and ask how it happened, and what we need to do differently," Nissila explains. "Did the process fail or did a person fail? Then we know if we need to re-do the process or if it's an education issue."
Most recently, for example, "We figured out we needed to tweak documentation, so we did heavy-duty education of ER physicians," she says.
How does Nissila know when there has been a failure? "I have a person in my department whose whole job pretty much is to be the core measure 'guru' for the whole organization," she explains. "She does open chart audits because you have to catch the failures when they happen."
Nissila acknowledges that she's fortunate to be able to dedicate an FTE to do an audit on every core measure patient in the facility, but adds that "an individual like this does not need to be in the quality department." In fact, she adds, "In my opinion, the optimal people are charge nurses, or case managers, because they are in the charts every day."
Have your ducks in a row
When it comes to being constantly prepared for an unannounced Joint Commission survey, says Nissila, "Presentation is everything; how you present when they walk in the door when they enter is huge. You have to have things in place and your ducks in a row."
In some ways, this preparation is similar to the core measures approach, she continues. "Your staff in particular need to speak National Patient Safety Goals," Nissila says. "It's the same deal; you have to walk it and talk it. I try to weave it into my conversations and fit it in any time I can when I'm on the floor or doing a chart. You have to keep it in the forefront so it becomes part of your culture."
Other forms of preparation, she adds, involve documentation. "The Joint Commission has a list of documents they want," she notes. "They're already prepared, and during the whole year we update them. We had two huge box files of these documents, and we put a plan in place. This way, when they walk in the door, so and so knows to bring the board minutes, while someone else brings other documents."
Every year, Nissila continues, the department puts together a giant binder of all performance improvement data. "When they walk in the door I have three years of PI [performance improvement] data for them," she notes. "They don't look at all of it, but they see you have it together. That is so, so, so key."
Preparation also involves how your staff look when The Joint Commission walks in the door, Nissila notes. "We even did drills about their arrival," she shares. "The first people they see are volunteers; you have to rehearse the way you're going to perform as if it were music. Then, when it happens, you'll be more prepared to bring it off smoothly."
So, for example, the volunteers are trained on how to alert everybody. "The Joint Commission does not need to know we let everyone know they're here," Nissila says. "We did a couple of drills on that."
In addition, says Nissila, education plays an important role. "This helps make sure documentation is the way it should be," she notes. "At every medical staff meeting, I talk to the doctors and discuss what we need to do and tell them how much we appreciate them."
The bottom line, she says, is that "it was not by chance that we did well; it was by design."
Showing you care
The "Top 100" award, according to PRMC, recognizes a recipient "as having achieved excellence in clinical outcomes, patient safety, satisfaction, financial performance, and operational efficiency." The key to recognition for patient satisfaction, says Nisilla, is the adoption of a program from The Studer Group called "Community Cares."
"Rounding totally makes a difference," she asserts. "That means hourly rounding on patients by your staff and having your leaders round as well the director, and sometimes, administration." Patients, she explains, are asked how things are going, whether the staff are meeting all their needs, and how they can make them totally satisfied.
"We use a lot of scripting," Nissila shares. "When you ask those questions, people are totally shocked and impressed; they think, 'Wow, they really care!' People need to perceive that their caregivers genuinely care about them. Studies have shown that you can be the best surgeon around, but if you are curt, people will not be satisfied."
As for the outcomes, says Nissila, using evidence-based medicine is a must. "You've got to look at things and try to improve; do not be afraid to look at the hard things," she advises. "Sometimes you have to rock the boat to make it better."
[For additional information, contact: Becky Nissila, RN, MBA, Director of Quality Management and Regulatory Compliance, Payson (AZ) Regional Medical Center. Phone: (928) 472-1238. Fax: (928) 472-1295.]
With so many conditions and processes to worry about, not to mention all the organizations that require performance data, it's a wonder that a quality manager can keep a handle on all of them. But at Payson (AZ) Regional Medical Center (PRMC), the quality team seems not only to be addressing all of them, but also to be excelling in several areas at once.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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