"In a healthcare system's most mature state, everyone owns quality," says Baylor Scott & White Health's chief quality officer. So if everyone owns quality, why have a CQO?
This article first appeared in the May 2016 issue of HealthLeaders magazine.
When David Ballard, MD, PhD, MSPH, FACP, assumed the role of Baylor Health Care System's first chief quality officer in 1999, he says he was the second healthcare executive in the country to hold the title. Today, Ballard calls the CQO title a "must-have" for all health systems to show their commitment to quality care.
"The explicit business case for a CQO is more obvious in 2016 than it was in 1998," says Ballard, who retains the CQO title with the Texas-based organization now known as Baylor Scott & White Health, which now has 41 hospitals, more than 950 patient sites, and more than 6,600 affiliated physicians. "A key pathway to reducing per capita costs of healthcare will be to achieve continuous improvements in the health of populations while delivering effective care and reducing ineffective care, healthcare waste, and harm to patients." And he says CQO is the role necessary to lead this charge.
Ballard travels the country to teach other health systems how to structure their CQO positions, acknowledging that the approach differs based on an organization's size and priorities. "In a healthcare system's most mature state, everyone owns quality," he says.
So if everyone owns quality, why have a CQO? "Because the future of health systems rests on the ability to continually improve on the care they provide patients, and they must have someone in a leadership role to make that happen," Ballard says.
At Baylor Scott & White Health, he also serves as president and founder of the organization's STEEEP Global Institute and practices the Institute of Medicine's STEEEP concept, which he wrote about in several books, including Achieving STEEEP Health Care. STEEEP refers to safe, timely, effective, efficient, equitable, and patient-centered care. Part of Ballard's job is to ensure that all of the organization's 40,000 employees are well versed in STEEEP and consistently apply its principles.
Quality is now one of the four pillars for compensation at Baylor Scott & White Health, requiring employees to have goals and accountability in this critical area, he says.
Creating relationships
Ballard's direct reports—who include a chief patient safety officer, a chief patient experience officer, a chief health equity officer, and a chief clinical effectiveness officer—answer to the CEO and collaborate with other members of the C-suite, including the CFO, CNO, CMO, COO, and CIO. "To be effective as a CQO, you have to be a connector, relate to a whole lot of people, and be comfortable getting things done through dotted-line relationships," he says.
"You have to be able to motivate those around you to seek change and do change with the patient as the center of your work."
To reduce high-risk cardiac surgery mortality rates, Ballard worked closely with health system leaders, hospital leaders, cardiac surgeons, and operating room staff to institute a second-opinion rule. Together they sorted out benefits and likely risks for certain cardiac patients, ensuring clinicians could optimize a patient's functional status—such as addressing lung or kidney issues—prior to surgery. "Employees have to be empowered to prevent a surgeon from taking someone for elective cardiac surgery without a documented second opinion who has at least an 8% risk of dying," he says. "You need full alignment across the organization to achieve objectives."
At UPMC, the Pittsburgh-based health system with 20-plus hospitals and 5,100 licensed beds, CQO Tami Minnier, RN, MSN, FACHE, considers relationship-building a key factor in the success she's had in the role over the past decade. "You have to be able to motivate those around you to seek change and do change with the patient as the center of your work," she says.
Leading and supporting
Minnier, who previously served as vice president of patient care services and CNO at UPMC Shadyside, a tertiary care hospital, says promoting from within is the ideal approach. "I think there are individuals who can come in from the outside and be successful as a CQO, but in general, because this is such a relationship-based position, having internal experience gives you an advantage," she says.
Her influence in the clinical, regulatory, and safety arenas now stretches deep into UPMC. For example, when the Centers for Medicare & Medicaid Services announced it would release a sepsis management bundle, Minnier worked with ICU service line leaders across the system's hospitals to prepare for and educate everyone on the changes ahead of the new measure. She also worked with IT to insert the new protocols into the electronic health records system.
"It's one thing to hand down information on the regulation; it's another to implement it effectively," she says. After the bundle went into effect in October 2015, Minnier began gathering data and feeding it back to clinicians to determine how well the teams are performing and what protocol changes are still necessary to achieve the best possible results.
"Ultimately, the CQO is a supporting function, and the operational leaders who oversee management of clinical areas have to be the ones to drive change," she says. "We are partners in helping them achieve their goals."
An evolving role
For many years, Minnier had little guidance regarding the role of the CQO, but she sees the industry starting to come to consensus. "CQOs will be very key in the upcoming decade as healthcare moves from volume to value," she says. "We have yet to define value and quality, and the CQO can serve as an excellent resource as we navigate this transformation in healthcare."
One area where a CQO's expertise would be useful: simplifying systems. "We continue to have large, complex, and overbuilt systems, and a CQO's knowledge on the process side of quality could go a long way to solving that," she says.
While Minnier stops short of saying that CQOs should own clinical systems, instead referring to her collaborative relationship with UPMC's IT team, other organizations use a more defined approach.
J. Michael Kramer, MD, MBA, senior vice president and CQO at Spectrum Health, a 12-hospital health system in Western Michigan with 184 ambulatory and service sites, says in order to achieve highly reliable outcomes and quality goals, clinical informatics and quality teams need to be tightly aligned. "If we're going after particular quality measures, we have to know how to hardwire them into the infrastructure and processes of care," he says. "Value-based healthcare depends on it."
Kramer, who reports to the executive vice president/CMO, focuses quality on four key areas: informatics and the ability to embed quality into the systems; process improvement; transparency in analytics; and transparency in professionalism. He presents in-person quarterly reports to the board and is a member of the CEO's leadership council.
"Many of the functions I perform are delegated from the CMO," he says, calling the CQO role "forward-thinking." The CQO role must be "strategic in supporting value and triple aim, and sophisticated in developing education and board engagement. This is not feasible for the CMO alone nor is it possible for the CQO without deep partnerships with operations and clinical leaders."
Creating structure
When he became CQO three years ago, Kramer consolidated 14 disparate quality teams and elevated them to the system level. He standardized care through the electronic medical records systems. "How can you zero in on readmissions when you can't establish a true length of stay across the health system?" he says.
Kramer says the overarching responsibility of his 140-member team—which includes specialists in clinical informatics, quality improvement, and analysis and data abstraction—is to provide meaningful data to the organization. They have improved the system's dashboards for gauging quality, which were based on the Healthcare Effectiveness Data and Information Set (HEDIS), by introducing core quality measures such as mortality rates and episodes of care as well as cost and patient experience.
To that end, 23,000 employees now have access to quality, cost, and patient experience dashboards that feature data from 500 quality measures so they can analyze critical information such as catheter-associated UTI, sepsis, and venous thrombosis rates.
Kramer also centralized the majority of the registries clinicians report into across the organization "so that we understand what data is available for quality reporting as well as understand the sensitivity of that data in the context of privacy and security," he says. Information includes registries operated by the Centers for Disease Control and Prevention as well as U.S. News & World Report's pediatric rankings.
Although Kramer says he is eager to be involved early on in new initiatives, he also is content, once processes are established, to hand off projects to clinical leaders who can sustain them. For instance, his team helped build predictive analytics models for the sepsis bundles but then shifted responsibilities to a rapid response team.
Kramer says the next challenge for Spectrum Health is to standardize the health system's professional practice capabilities, aiming for a common management model across the whole system. An example of this is to have common bylaws across the medical staff, he adds.
Passing on the CQO title
While many quality leaders opt for the CQO title, Leigh Hamby, MD, MHA, chose to head up quality in 2013 from the position of CMO at Piedmont Healthcare, which has six hospitals in the Atlanta area and serves nearly 2 million patients.
Hamby, who had been CQO at Piedmont from 2007 to 2013, has corporate oversight for all safety and quality initiatives. His CMO-specific responsibilities, he says, are a small slice of what he does as CMO because Piedmont is well developed at the hospital level with respect to traditional CMO matters. "The CMO at corporate level is going to do two additional things beyond the traditional CQO: building population health and moving from volume to value," he says, noting that "ninety percent of what I do is what a CQO would do, not a traditional CMO. Quality is truly our prime directive here."
That directive was solidified in 2015 when one of the system's hospitals received a lower score than expected on the Leapfrog Hospital Survey. "Our CEO was clear that I would call the shots on devising a strategy to turn it around," he says. That clarity from the top has helped his team avoid turf wars, according to Hamby.
His goal for quality has been to steer away from what he calls "counting and measuring," to using process engineers to figure out "how to move the needle" on improvements. "I want to spend less time thinking about accrediting bodies and more time on quality improvement," he says.
As part of this information overhaul, Hamby took the opportunity of the CIO leaving a few years ago to bring all of IT, including the CMIO, under his CMO umbrella. "It's such a critical part of what we do," he says. "If IT people aren't linked in to quality initiatives, then quality leaders can only opine on what they would like the technology to do. Our team can get it done."
This realignment of resources has been instrumental for systemwide efforts such as reducing and eliminating hospital-acquired infections. For instance, having oversight enabled his team to effectively winnow the organization's scorecard from 200 metrics to 42.
"We only consume resources for things related to the scorecard, so I'm charged with saying no a lot," he says. For example, a group within the organization asked him to look at the issue of advanced directives, and he told them, "You're going to have to connect that problem with something on the scorecard for me to pay attention to it."
His team works to identify common denominators among reporting programs, including CMS, Leapfrog Hospital Survey, and the CDC's National Healthcare Safety Network to develop metrics that have the broadest applicability to patients. For instance, instead of just focusing on CAUTIs in the ICU for CMS reporting, the system tracks CAUTIs across all of Piedmont's facilities.
While many say the CQO title is the best way to demonstrate commitment to quality in a health system, Hamby says his situation proves any combination of a C-level title with quality responsibilities can be effective.
Baylor's Ballard points out that "in smaller organizations, people have to wear multiple hats so they might not have someone at the corporate level who can focus exclusively on safety or perhaps the patient experience." Even so, they should start to formalize the function by developing quality structures and tactics that are as effective and efficient as possible, he says.
To Kramer, CQOs are a necessity in organizations because "there is too much change and complexity in healthcare to leave this to leadership that is also managing complex recruitment, practice relationships, mergers, integration, bundled payments, and EMRs," he says.