This case study first appeared in the report Hospital Quality Improvement: Strategies and Lessons From U.S. Hospitals by Sharon Silow-Carroll, M.B.A., M.S.W, Tanya Alteras, M.P.P., and Jack A. Meyer, Ph.D., Health Management Associates.
Setting
Legacy Good Samaritan (LGS) hospital is part of the Legacy Health System (LHS), which includes two tertiary hospitals, three community hospitals, the largest children's hospital in Oregon, as well as primary and specialty care clinics, hospice care, and a full-service research facility.
We selected LGS because our analysis of Medicare data over 2002–2004 (the "study period") identified it as among 100 hospitals showing greatest improvement in a quality measure based on risk-adjusted mortality, morbidity, and complication rates. LGS displayed marked improvement during the study period in both quality and efficiency measures. Within Legacy Health System, LGS is considered the “testing ground.” It is where many new protocols are implemented and evaluated before being rolled out across the system. The hospital's patient mix includes 42 percent privately insured patients, 46 percent Medicare, 8 percent Medicaid, and 4 percent uninsured.
Impetus for Quality Focus
Concerns over Fragmentation, LOS, Lack of Coordination
Concerns at LGS grew in the late 1990s over fragmentation of care in the intensive care unit (ICU), an increase in length of stay (LOS) for certain conditions, and course of care processes that made it difficult for nurses to coordinate care for their patients.
New Evidence and Awareness of Hospitalist Benefits
At around the same time, the system's senior management realized that creating a hospitalist service could set the stage for implementation of a more efficient care model, which would in turn lead to improved quality. The term “hospitalist” refers to hospital-based physicians who become the physician-of-record for inpatients and then return the patients to the care of their primary care providers when they are discharged. Advantages include the ability to react quickly to changes in medical status and coordinate inpatient care "in real time throughout the day."
It was becoming clear at that time that patients were receiving fragmented care due to the inability of the hospital staff to gather information from the admitting private practice physicians, who were often busy with their office patients. While residents traditionally filled that role, the state had recently passed legislation limiting the number of consecutive hours residents could work. Senior management began to consider developing an integrated delivery system in the Kaiser Permanente model, where all physicians are hospital employees, in order to solve this efficiency problem and improve quality at the same time. Senior management came to view the hospitalist system as the "new age of care delivery," one that would offer benefits both in terms of quality of care and potential cost savings. Bringing hospitalists and intensivists, or hospitalists who specialize in the care of critically ill patients, into the system led to a more multidisciplinary approach to care.
Actions to Improve Quality: Structural and Cultural Changes
During the period of 2002–2004, quality improvement innovations that took hold at Legacy Good Samaritan were largely the function of a cultural shift, whereby the hospital went to significant lengths to develop a system based on multidisciplinary modalities of care for both acute and chronic conditions. Within the context of this cultural shift, LGS developed a stepwise methodology for developing, implementing, and testing new processes, policies, and treatment protocols before rolling them out across the health system.
Recruitment of Hospitalists
As noted above, LGS began to hire hospitalists and intensivists, which significantly changed patient care and coordination. As more of these providers were recruited, they drove a cultural shift in the institution that allowed for a more multidisciplinary approach to care.
Rejuvenation of the Critical Care Committee
In 2001, shortly after the intensivist and hospitalist services began, LGS recommitted to strengthening the role of their Critical Care Committee (CCC), which had in recent years ceased to be active. The reorganized CCC included 30 representatives from a number of system-wide departments, including nursing, pharmacy, physicians, administrative leadership, infection control, and respiratory therapy. While major decisions are made by the entire committee, subcommittees (focusing on hyperglycemia, respiratory care collaborative, critical care nursing, and other areas) form to address certain elements of care as they arise. This structure became the template for other system-wide committees, such as the medical interdisciplinary quality council and the women's collaborative care council, which formed to address other needs across the system.
The new CCC became a functional forum for the development and testing of policy and procedures in an efficient way. Today, the CCC and other committees and councils develop not only new policies and procedures, but also the processes for implementing and evaluating them. The rollout and implementation of these procedures is then done on a hospital-by-hospital basis.
Systematic Implementation of Best Practices
LGS developed a step-by-step process for putting new protocols that reflected best practices onto the hospital floor. The establishment of a protocol to lower the incidence of hyperglycemia illustrates the multilayered and thoughtful process that developed slightly prior to and during the study period. In 2001, the hospital's quality department became aware of the impact of good glucose levels on patient outcomes. It pulled together representatives from the intensivist service, quality improvement, nurses, endocrinology, and pharmacy to create a CCC subcommittee that could come up with new ideas for how to lower blood glucose levels in certain patients. The first step was to develop a protocol for managing hypoglycemia in the ICU. They got buy-in for the draft protocol design from the CCC and ICU, and developed training procedures for ICU doctors and nurses. When the protocol was rolled out at LGS's ICU, results were apparent immediately. Staff, however, were extremely dissatisfied with the protocol and were given a public forum in which to vent their feelings (discussed further below). The subcommittee brought the protocol back to the CCC, where it was completely reengineered to reflect staff concerns. Interviewees noted that in the process of modifying the protocol, additional research came out on the optimal blood glucose levels for improving patient outcomes, which allowed them to update the protocol according to the latest evidence.
Another example is the development of a best practice bundle (BPB) for critical care, which was tested in LGS's ICU. The BPB includes a checklist of best practices addressing respiratory care, ventilator-associated pneumonia, sepsis, deep vein thrombosis (DVT) prophylaxis, and peptic ulcer prophylaxis, which the multidisciplinary team is supposed to complete for each patient in the ICU. Team members are given a check sheet on which to mark whether the patient's bed was elevated, whether they took the DVT and peptic ulcer prophylaxis, and other steps. While originally recorded on paper, the system is now computerized, and managers can check compliance rates every day. Critical care BPB has decreased the rate of ventilator-associated pneumonia: before implementing the BPB, the LGS ICU experienced 11 patients that developed ventilator-associated pneumonia per 1,000 ventilator days; post-BPB, the rate dropped to two patients per 1,000 ventilator days. Because of the success of the critical care BPB, LHS is working on a surgical care best practice bundle to meet the goals of the Surgical Care Improvement Project (SCIP), a national collaborative to address surgical complications with the intent of decreasing those complications by 25 percent by 2010. There are also potential plans to develop a woman's best practice bundle focusing on perinatal care, based on recommendations from the Institute for Healthcare Improvement.
Prioritizing the Role of Bedside Nurses
Administrators realized in 2001 that the role of bedside nurses was critical to any quality improvement initiatives they would hope to implement. Thus, with every new protocol tested, they began with an education and training module for these nurses. A significant portion of the training focused on helping nurses understand the effect they can have on patients' health outcomes. The training also focused on empowering nurses to collaborate with and encourage doctors who were not following the new protocols. Establishing goals for nurses helped motivate them to "push" physicians who were still using the old methods. When those goals were reached (e.g., a significant reduction in pneumonia rates), it was widely noted throughout the hospital and the nurses were celebrated. Creating this nurse-centric culture has had a cyclic effect on the way quality improvements are handled, with nurses now being a major source of new strategies for improvement.
Using Technology to Improve Quality
Two of the most important structural changes cited by the LGS representatives were the implementation of preprinted orders for standardizing care processes for dealing with heart failure, myocardial infarction, and community-acquired pneumonia, as well as automating pharmacy orders to reduce medication errors. In addition, between 2002 and 2004, LGS conducted an inventory of its data and technology systems to better understand what resources it had and how best to use them. Based on that inventory, LGS decided to utilize the Sci-health data tracking software, which allows them to quickly collect, analyze, and evaluate data on a variety of quality measures (see "Monitoring Results," below).
Keeping Employees Happy, Making Sure All Voices Are Heard
The interviewees repeatedly cited the need for staff to buy in to new protocols in order for their implementation to be successful. To achieve that buy-in, the staff have to be able to voice their concerns during the rollout phase. Of course, care is also taken during the initial development stage to come up with tools that staff will easily be able to integrate into their practice. Members of the CCC have become well versed in what does not work when it comes to rolling out a new protocol: making it mandatory; rolling it out across the entire hospital untested; creating something that makes people's lives harder by requiring them to fill out additional paperwork; and not making achievements readily attainable. Interviewees noted that for each new protocol, the department in which it was being tested would come up with immediate measures that would allow the nurses and doctors to see within a day or two how their work was affecting patient care.
Monitoring Results
National Measures and Collaborations
LGS and the entire Legacy Health System use a variety of measures to monitor quality improvement for various conditions. They collect data according to the 17 National Hospital Measures, which evaluate how well hospitals are providing recommended treatment for heart attacks, heart failure, and pneumonia. Heart attack measures include such actions as providing aspirin and beta blocker at arrival and discharge, and offering smoking cessation advice and counseling. Pneumonia measures include timing of antibiotic dispensing, oxygen assessment, and pneumococcal screening and vaccination if necessary. In addition, LHS reports performance data in accordance with the Hospital Quality Alliance, the National Quality Forum, JCAHO, CMS, the Leapfrog Group, Patient Voice, and others that relate to specialty organizations.
Since the 2002–2004 period, Legacy Health System has been participating in additional national quality and patient safety efforts, such as the Institute for Healthcare Improvement's (IHI) 100,000 Lives Campaign, which as of June 14, 2006, prevented 122,300 avoidable deaths and institutionalized new standards of care. LHS is implementing all six of the interventions recommended by IHI. LHS is also continuously working to implement the annually updated JCAHO National Patient Safety Goals.
Regional Efforts
Since 2005, LHS has participated in the Washington State Hospital Association Safe Table Learning Collaborative, which is a statewide patient safety program focused on improving rates of hand hygiene among health care workers by involving patients as partners in their own care and on implementing rapid response teams. It has also been a member since 2005 of the Oregon Patient Safety Alliance, which aims to improve care through the use of evidence-based practices for AMI, CHF, pneumonia, and surgical care.
Challenges and Obstacles
Dissatisfaction with Initial Protocols
Despite all of the hard work behind developing what they thought would be well accepted protocols, CCC members found that putting what was on paper into practice generally led to negative feedback from nurses and doctors. They learned a valuable lesson in this process: the system will only be reformed if they take the time to "road test" a protocol, and are open to making sometimes dramatic changes in response to provider suggestions and input.
Financial Implications
Initial Financial Challenges
The hiring of hospitalists and intensivists was the engine that drove LGS's initial movement into quality improvement. Yet when this move was considered initially, there were significant financial barriers. These practitioners were expensive to employ, and it was approximately two years before their reimbursement levels matched what the health system spent on them. The benefit to the system, however, was considered worth more than the cost in that it enabled LHS to build a foundation of coordinated, multidisciplinary care. As senior management predicted, patients cared for by hospitalists have shorter lengths of stay and end up costing the hospital less—despite the fact that hospitalists tend to care for a sicker population than does the private practice community.
In terms of the overall financial picture, quality improvement does not have its own budget line item. QI initiatives are viewed as an aspect of coordinated care and, as such, funding for these initiatives is integrated into the hospital's operating budget.
Legacy Health System has a system-wide quality department that provides infrastructure support for the hospitals. This department is responsible for integrating quality into IT practices, pharmacy, and other areas so that the individual institutions do not have to support their own efforts. Implementation of specific initiatives, however, is hospital-specific, and each has to be supported by the individual hospital. Funding for that comes out of the operating budget for the department within the hospital in which the program is being tested.
Lessons
Emphasize the Effectiveness of New Protocols and Celebrate Success
LHS made implementation of new protocols the central focus of its push to improve quality of care and patient safety, requiring staff to change already-established practices and protocols. The leadership recognized the importance of the human factor in making these new efforts successful, and for each new protocol, they designed ways of measuring immediate effectiveness. One example was taking daily counts of improved hypoglycemia levels, which made the staff (particularly the bedside nurses) feel that they were making a real and powerful difference in patients' lives. Nurses were (and continue to be) celebrated with parties and other morale-boosting events when they reached department goals.
Seeing Value in Everyone's Experiences
The improvements in quality and efficiency over time seen at Legacy Good Samaritan are indicative of the leadership's determination to bring all relevant voices and experiences to the table in order to create a multidisciplinary care continuum. To do so, they committed to viewing all staff experiences as inherently valuable. This in turn led to buy-in from the staff, who felt their needs and voices were heard.
Public Policy Can Help
Interviewees at LGS suggested a number of ways in which public policy could contribute to the improvement of quality and patient safety in hospital settings. One way would be to establish tax credits for malpractice insurance for providers who participate in pay-for-performance programs and other quality improvement initiatives. They also suggested federal support for the development of P4P programs that provide bonuses for reaching goals, rather than holding back a portion of already-established payment rates. Finally they said physicians need a reason to get involved in quality improvement activities, and that the public policy realm could play a role in educating providers and helping them see how improving quality could affect their own practice favorably.
Acknowledgments
The authors would like to thank the following individuals at Legacy Health System who generously offered their time and insights for this case study: Mark Kestner, clinical vice president for quality; Lewis Low, M.D., F.A.C.P., medical director, inpatient medicine service; and LuAnn Staul, M.N., R.N., C.N.S., C.C.R.N., director, critical care nurses and critical care system.
This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.