Four-hospital system standardizes indicators
Consolidated management made it possible
A multihospital system has a broader base of patients from which to acquire data on outcomes and establish benchmarks. Here’s the catch: To take advantage of this opportunity, the system must standardize its indicators across hospitals. Unfortunately, that’s easier said than done.
At Meridia Health System in Mayfield Heights, OH, a team of quality improvement professionals used TQM principles to modify basic organizational structures and integrate them into a new and better system of collecting, measuring, and analyzing data. The Meridia Health System comprises almost 1,500 beds, four hospitals, home health services, three skilled nursing facilities, and full rehabilitative services.
The first step in the process was to analyze the present systems, explains Carlyle Kane, RN, director of accreditation and former quality standards manager for the system. The team assessed these areas of each facility:
• departmental/interdepartmental dynamics;
• medical staff organization;
• committee and reporting structure;
• understanding of quality improvement;
• level of commitment to quality improvement;
• chain of command.
"You have to ask these things right at the beginning because you have to be very respectful of the way they have done things," Kane says. "You truly have to merge them and be willing to give and take on things."
Next, the team designed and wrote a performance improvement plan that incorporated the system’s philosophy, mission, and goals; provided for all external review organizations; and committed the system to the use of QI as a management tool. Of course, top management had to make a commitment to QI and staff empowerment, Kane says.
New structure tears down walls
The next step involved breaking down the silos. "Departments and entities look at themselves as individuals, and they deal in ups and downs’ instead of acrosses,’" Kane explains.
Now, instead of a vertical form of management in which each hospital has its own president, six or seven vice presidents, and upper-level managers such as nurse managers and department directors, Meridia has:
• one chief executive officer for all four hospitals;
• a president of each ancillary service or service line, such as radiation oncology and the cardiac/open-heart program;
• a site administrator for each hospital the only four vice presidents left in the system.
"What we have now is much more interdepartmental," Kane says. "For example, because the vice president of ancillary services is over all four hospitals, there’s no encampment, it’s much more friendly, and the left hand knows more of what the right hand is doing. It’s easier to accomplish something systemwide when you have an ultimate manager. We have site administrators, but they also [perform] vice president duties for service lines like oncology, radiology, or laboratory services." These systemwide "point people" for each ancillary service are in charge of QI and data collection. They hold entity-level people accountable for turning in reports.
Each hospital has its own culture, background, and neighborhood, but from the management aspect the system is like a big building without walls, she continues. "We just have to make sure that any performance indicators translate down to the entity-specific level to help the patient at the front line."
Departmental indicators
The next step was developing sets of agreed-upon systemwide departmental indicators, entity-specific departmental indicators, and benchmarks.
"Just make the indicator the same. It’s a no-brainer, and it’s not negotiable," Kane says. The final decision on what to monitor although it may have been made at an upper level was based on a culture of TQM and empowerment.
"The information that they obtained was from the people on the front line. They looked at the data, and got feedback from the people who are out there collecting it, working with it, and dealing with these situations," she says.
Fortunately, many indicators, such as returns to intensive care within 72 hours, readmission within 30 days, and infection rates, are standardized anyway. The ancillary service outcomes were the ones the team really needed to hammer out. The Meridia team developed standardized, systemwide indicators for these services:
• laboratory;
• radiology;
• nursing;
• surgical.
The trick to dealing with systemwide outcomes measures, Kane says, is to take them to the systemwide level for benchmarking and comparative purposes but make sure they are brought back down to the entity level for translation into quality improvement action plans.
"When you’re dealing with ancillary service indicators," she advises, "you can’t lump all hospitals together in the examination of that data. You have to have it entity-specific or you can’t translate it into action if you need an action plan. If your denominators are too large, what you end up with is [that] the very bads’ and very goods’ are buried, your bell curve just flattens out, and you can’t tell where you need to fix things."
Develop your own specific indicators
Of course, there are always some indicators that are unique to each entity. Services or problems that are entity-specific can’t be measured "apples to apples." For example, only one Meridia hospital has a radiation oncology department; the others, therefore, wouldn’t have indicators for measuring radiation oncology processes. The team developed entity-specific departmental indicators for these areas:
• emergency services;
• surgical services;
• radiation oncology;
• population-specific issues.
"When we first merged as a hospital system about five years ago, each one did things differently," Kane says. "The more you kind of meld the hospitals, the more they should do things similarly. Now, if one hospital’s census drops, personnel can shift to the other hospitals so we can keep people employed. It behooved us to standardize many of these things so employees would be much more comfortable going to other hospitals, without having to remember all new policies, procedures, forms."
As part of the process, the team standardized all forms from indicator descriptors and departmental reports to action plans and minutes formats across the entities as well. They also hammered out a standardized reporting schedule and report structure.
According to Kane, the team’s work has resulted in better patient care, cost savings, and improvement in communication. "First of all, when you work together, you become this big think tank. Two minds are better than one," she says. The cost savings come from downsizing the management structure tremendously. For example, where there were once 36 vice presidents, there are now six. In addition, centralizing has allowed the system to reap the benefits of increased purchasing power.
Kane says the system worked with the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, in developing this nontraditional systemwide outcomes project. Yet she admits the system’s next Joint Commission survey "is going to be a challenge.
"We had a systemwide survey last time, but it was an organized survey from hospital to hospital," she says. "What we would like to do is spend four or five days at corporate, do all of our service lines, do our major managers, show them the books, samples, and program, because many of them are identical in regard to departmental policy at each place. Then only spend about two or three days doing facilities, staff, frontline people. But I don’t know if they’ll go for that."
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