NAHQ Report: Building Strong Workforce Involves Improving Healthcare Quality Education

The National Association for Healthcare Quality is helping organizations like the Veterans Health Administration implement improvements

Healthcare quality has been misunderstood and underused for too long and is the missing component in most conversations about the challenges facing healthcare today. So states the National Association for Healthcare Quality's Healthcare Quality Workforce Report, released in October.

In the wake of the American Hospital Association's workforce report released in November, HealthLeaders spoke with NAHQ Executive Director and CEO Stephanie Mercado, CPHQ, about how that quality component is the linchpin to building and keeping a strong workforce. This interview has been edited for brevity and clarity.

HealthLeaders: A takeaway that leapt out on the video summary of the report on your website was that hammers don't build houses, but people do.

Stephanie Mercado: That's right.

HL: Your report is all about the fact that we have all these marvelous information tools now, but we have a workforce that seems at times unable to use or optimize the use of those tools to really make the kind of difference we need to see in healthcare. That includes bending the cost curve, employee retention and all the things we write about over and over again. What was the origin of the report? How did you decide at this time that you needed to do this kind of survey or fact finding? And how did you go about gathering the evidence that you present?

Mercado: Let me rewind the tape a little bit further. I joined the organization about eight and a half years ago. And at that point in time, there were a handful of healthcare quality leaders. CQO [chief quality officer] roles were almost nonexistent. There were a few VPs you'd hear about, but most of the time it was directors and managers and coordinators of quality.

One of the things that occurred to me was how different the educational pathways are for people working in healthcare quality. I had previously come from the American Orthopedic Association and American Academy of Physical Medicine and Rehabilitation, where there are well-worn academic pathways for training – medical school, residency, fellowship, board certification, licensure, the whole thing. But the same is not true for people working in healthcare quality.

Stephanie Mercado, CPHQ, executive director and chief executive officer of the National Association for Healthcare Quality. Photo courtesy NAHQ.

People working in healthcare quality generally are more like-minded than they are like type. And they're usually put into the role because they were really good at something else. I saw a chief quality officer position description the other day sent to me by a recruiter, and it said "MD required and quality experience preferred." And I thought, how could this even be right?

The whole reason why NAQH exists, and of course the impetus for the report, was to say we've got a lot of people and a lot of investments have been made over the years advancing quality, safety, and value. And yet, we do not have any standards for how we educate and train these individuals. That's the reason why we do all of our work.

We started by developing the Healthcare Quality Competency Framework, that has the eight dimensions, 29 competencies, and then, unpublished, 486 skills, stratified against foundational, proficient, and advanced levels. With the framework in hand, we know what work is supposed to be getting done out there in healthcare quality. Creating the standard and validating that standard twice in the market was the first step.

Once we had the standard validated, we were then able to start assessing both individual contributors and contributors within teams. That is really what you see in the workforce report. The first few data tables that you notice are from our aggregated national dataset. And the ones in the appendix are actually from healthcare organizations that we work with, to come in and help them understand how to leverage their workforce, through a solution we offer called Workforce Accelerator. At the end of the day, there's no technology implementation or consultant that will replace a coordinated competent workforce. And so that needs to be the focus of for sustainable systems.

HL: The report includes a data analytics data point, which was that 57% of respondents indicate analytics as part of the responsibility, but most work at lower levels of competency.

Mercado: Well, that is big. All of these competencies must be present in a high-performing organization. And I'm just pulling up health data analytics in particular. So 57% say that they work in that domain, and only 20% are performing at advanced ends of the competency spectrum.

HL: So why the gap here? They're not being trained properly?

Mercado: Oh, so many things. But yeah, there is not a well-worn academic pathway or even training solution that gets people ready to do this work. We have been saying what needs to change in healthcare for more than six decades – what needs to be measured, what we need to be doing, what technology needs implemented, all of these things, but we haven't said how. The whole how part of the equation has been left largely addressed.

The how gets back to hammers don't build houses, people do. A lot of times healthcare leaders, with very good intentions, will deploy technical solutions and then suffer from challenges with operator error because the people don't know how to use the tool. Safety event reporting software is the thing that helps identify risks and events in a hospital. It's a way to engage the workforce. And they will report things like, if there was actually an incident, like a slip and fall or anything like that, that goes into there.

And then there's also things like they put in near-misses or good catches, like, hey, there's water on the floor. And they enter it into the system to say it needs to be cleaned up, or we almost gave a patient the wrong medicine. They implement that into the event reporting. But guess what they don't do: Most organizations do not train their workforce on how to identify those risks and events. So now you have a whole software solution, which is very well-intended and necessary in healthcare, but the competencies required to identify those risks and events have not been part of the solution.

HL: One of the AHA report's recommendations is to foster professional development, expertise, and leadership skills by offering interdisciplinary training across organizations, departments, and sites of care. That would seem to intersect quite nicely with what you're urging.

Mercado: We are 100% on the same page with investing in continued professional development. We would expand upon that to say what we need in order to do that well is create some more of the standard operating procedures of how teams work together.

We have been working with a variety of healthcare organizations, first in pilot, most recently in beta, and are now moving past beta to actually go into healthcare organizations and implement this model.

For example, we are working with the Veterans Health Administration. The VHA implemented NAHQ's implementation model for this, which we call the Workforce Accelerator. VHA did that in beta with us with three of their VISNs [VHA regions]. They just expanded with us, and the VHA now has all 18 VISNs working on the workforce accelerator program with us. So the entire VHA infrastructure is now aligned to this effort. And it also represents the first time that the VHA has ever centralized quality.

This is really big news, that the largest health system in the country is working with NAHQ to deploy this solution with success. Not only are they having organizational success, but individuals are feeling more engaged and more supported at their organization. They're creating succession plans for staffing and things like that. It's been a real success story at the Veterans Health Administration. And we have others -- Bon Secours Mercy Health, Valley Medical Center -- and many other organizations are working with us on this and it is working. We're really excited about that.

HL: How does this effort increase the likelihood that population health efforts are going to be successful at healthcare organizations?

Mercado: Let me tell you a story to answer that.

One of NAHQ's board members works at ChristianaCare. And for a long time, she led the department of quality. And she was so good at it and so effective as a leader, when they got involved in population health, many years ago, they asked Patty, who's my board member, Patty [Patricia] Resnik, to go lead the population health initiative. When she arrived in the population health department and was stitching together her team and getting everything situated and organized, what she realized was that the people who were there didn't have skills in quality and the skills that you need to have an effective population health program. You need to understand data, and you need to be able to do performance and process improvement. You need to be able to understand the different payment models and how you can support populations and measure those outcomes. How you can improve things like vaccination schedules and annual mammograms and all those things? Those are quality skills.

HL: To what degree are the analytics tools a part of the problem? Hammers are hammers. We all know how they work: they pound nails. In the case of technology deployed in the healthcare space, they're not simple. They're tough to evaluate and compare. We often hear this drumbeat of well, you're just using the wrong tool. If you just use this other tool, things are going to be better. And now it's gone beyond use this other tool – it's use this other AI with this other data set and you'll be successful. To what degree has the industry have allowed itself to be distracted by this endless discussion of what's the right tool? Are any of them good enough if you train people adequately on how to use them?

Mercado: They might be. Technology's job is to enable people to do their best work. Technology does not replace, in and of itself, people doing the work.

HL: It's critical thinking skills, too. It's not just their sheer competency with using the tool. It's how critically do they think – how they're able to make connections between things they might not otherwise connect.

Mercado: Absolutely. One of our competencies is in data, health data analytics, collecting data from disparate sources, being able to understand the relationship between it and then moving on to make that information useful and actionable. There's not a technology solution that does that without a human driving the thinking behind that.

HL: We're in an industry that's more and more hammered by spiraling costs, reduction in payments from Medicare and others. In such an environment, how do you persuade organizations to answer the call to action? Can you tell them with any certainty, based on your early work with VA and others, this is going to pay such dividends, that you'll wonder why you never did it earlier. Is it that straightforward? What's the cost involved? And what's the return on investment involved in making this workforce investment?

Mercado: We're researching right now the best way to quantify the value of activating these ideas. What we do know is people and organizations that are working with NAHQ to advance a coordinated, competent workforce, they are continuing to work and they're expanding their work. And they are not only seeing a difference in their quality infrastructure and having a more positive effect, but they are hearing from the workforce that the workforce feels supported, valued, recognized, to do their best work.

HL: You mentioned 486 skills, as yet unpublished. Are you going to publish those?

Mercado: We haven't published them for a couple of reasons.

Number one, we believe that the high degree of variability in healthcare delivery is very much related to the high degree of variability in healthcare quality competencies, so we're not going to solve for the end state problem without moving upstream and getting these competencies figured out. We have also observed that when we do push information into the market, because it is needed, it is needed very badly.

Since we released the report, a handful of weeks ago, I believe we're up to about 4,000 downloads of that report, and lots of sharing. No one person needs a list of 486 things to do. An organization needs it all, because they deploy that holistically. So we only get back to organizations that work directly with us.

HL: Academia has played a role in training the workforce. Should they be also playing a role in this? And how?

Mercado: From an academic, higher-ed perspective, in clinical disciplines we have done a good job at training our clinicians on clinical competencies for quality, how to clinically do their job well. But there is a high degree of variability in non-clinical competencies, in the training there. Even within nursing, they do it, [but] they're working on getting a more standardized way.

So it would not be fair to say they don't have it, but we have a long way to go in terms of standardizing the non-clinical competencies – performance and process improvement, health data analytics, population health, care transitions – the non-clinical competencies. NAHQ works with a handful of nursing programs right now to hardwire our non-clinical competency-based training into nursing curriculums.

It's actually listed in this document which groups we're working with – George Washington, Georgetown, University of North Texas, Western Governors, etc. There are such things as quality and safety Master's Degree programs, but we are not graduating very many people through those programs. So we need a bigger commitment to Master's level training in the discipline of quality and safety as well.