The Clinical Quality Challenge

In our Annual Industry Survey, leaders cited monitoring quality along the care continuum as their single greatest challenge regarding clinical quality improvement. How is your organization addressing this challenge?

Kathleen Sanford, DBA, RN 
Senior Vice President and Chief Nursing Officer
Catholic Health Initiatives
Englewood, CO

On identifying solutions: We started mostly as a hospital company and we are growing more into a continuum company so we knew we needed an infrastructure that wasn't just hospital-based. And we knew we needed to have the tools and the metrics to make that happen. So we set up a national and a regional infrastructure for that. And we actually restructured or retooled job descriptions
at the national office to make sure that we had people who are actually responsible for that.

On expanding the continuum: Each of our seven regions has a CEO and we decided each region needed a CMO and CNO, and a large part of their job is building the infrastructure to make sure that whatever quality measures we decide on, whether in the hospital or throughout the continuum, they are responsible for making sure the practices are put in place and that everything is done the same way across the country. All of our quality metrics come up through our service lines. And if we partner with someone who is not employed by CHI, part of our due diligence is seeing what they are doing in those areas. We want to make sure we're partnering with people who are working on quality.

On involving patients: We determined about three years ago that patients need to be a part of this, so we have national and regional patient and family advisory councils. They advise us on how to make things better. They look at the quality results in our regions. They also have experiences that they can share with us.

Mary Anna Sullivan, MD
Chief Quality and Safety Officer
Lahey Health
Burlington, MA

Quality along the care continuum and readmissions are really the same thing. It is figuring out how to take care of all of our patients in what we call the interstices. It's not when they are in the office or in the hospital; it is all those in-between times where we need to figure out how to offer real longitudinal care and be able to assure ourselves and our patients that we are offering the highest-quality care in the right setting.

That includes a huge focus on patient engagement and recognizing that we can have the best of intentions and follow great standardized evidence-based medicine and get everybody doing it just right, but unless we are really partnering with our patients and they are truly engaged in their own care, then we are not going to be hitting our mark either.

We are looking now at total medical expense, which means you can't just look at the hospital and clinic visits. You have to focus on whether the patient is getting the best care possible in the least costly appropriate setting.

We're looking at the patients who are dealing with multiple comorbidities including behavioral health and figuring out how to embed behavioral health into primary care and do community outreach so that the folks who are not doing well and who are least likely to get themselves to appointments don't get lost.

Alan H. Rosenstein, MD, MBA
Internist and Medical Consultant
for Healthcare Management
San Francisco, CA

The most important thing is to recognize, given the complexities in the environment, that there are many different touch points for the patient. Physicians and care providers, the nurses and care managers and discharge planners and pharmacists, all need to coordinate and have a consistent plan for the patient that everyone is able to understand so they can set the expectations to provide the best possible care and reduce any chance of complications or hospital readmissions.

Determining who leads the care coordination is a critical issue. I've done a lot of work trying to get physicians to understand the importance of communicating and coordinating with their peers and the staff and with the patients and their families. Unfortunately, what happens is when patients get into the hospital they may be taken over by a hospitalist or an intensivist, and they may bring in a cardiologist, a disease specialist, or a surgeon, and everybody is either treating a disease or an organ but somebody has to take responsibility for the overall management of the patient, and that needs to be the primary care physician.

Pam Harmon
Chief Nursing Officer
Rooks County Health Center
Plainville, KS

When it comes to clinical quality, we identified several problems with our readmissions and we have been able to meet guidelines on lowering readmissions. We have a social worker who we now have call all of the patients and do follow-up surveys.

The day patients come in, we start discharge planning. We find out what they will need, what they have in place at home, what types of things we can set up to make it work for them. We get physical therapy, occupational therapy, speech therapy: We have them all evaluate our patients. Then our social worker does discharge planning reviews every two or three days until the patients are ready to go home, and we meet with all of the multidisciplinary people to make sure that all things that we can identify are identified. When they are discharged, we call and ask, "Did you get your prescriptions? If you're getting services, have they showed up? Are you able to function at the level you thought you should be able to function at?"

This is a small community and we know the patients and we know the families and we know where some of the weak links might be. Not everything is right here in our hospital and available for all of our patients. But before they go home, we have it set up and ready for them.

In our April Intelligence Report, the top challenge cited by leaders for their primary care redesign efforts is to get patients engaged in their own care. Why is this so difficult, and what steps is your organization taking in this area? E-mail John Commins at jcommins@healthleadersmedia.com to be featured in this future Council Connection piece.