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
St. Mary's Health Care System recently celebrated its 100th year of service in Athens, Georgia. Located 70 miles from downtown Atlanta, it operates 165 beds (with a capacity of 195), and has about 10,000 inpatient admissions annually. It is a member hospital of Catholic Health East (CHE), which operates in 11 states from Maine to Florida. Their patient population is 41 percent managed care, 37 percent Medicare, 12 percent Medicaid, and 8 percent uninsured.
We selected St. Mary's 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. St. Mary's displayed marked improvement during the study period in terms of both quality and efficiency measures.
Impetus for Quality Focus
New Chief Executive Officer
A new CEO arrived at St. Mary's in 2000. Prior to his arrival, the hospital was losing market share, staff turnover was high, and levels of employee, patient, and physician satisfaction were in need of improvement. According to interviewees, the arrival of the new CEO, Tom Fitz, brought a new determination and support for quality improvement (QI). In turn, the years 2002–2004 saw a significant increase in the implementation of new programs and initiatives (see "Actions to Improve Quality," below).
Losing Patients, Market Share, Staff
In 2002, St. Mary's continued to lose market share, particularly in obstetrics, which included gynecology, labor and delivery, and both newborn and intensive care nurseries. They experienced high staff turnover and physician dissatisfaction. A new nursing director was selected through an extensive process, which included input from both staff and physicians. She was able to turn the obstetrics unit around through increased education and by striving for excellence. A new Family Birth Center was built with 16 labor and delivery rooms, two cesarean section operating rooms, and 12 neonatal intensive care unit private rooms, with day-bed accommodations for parents. In addition, the hospital senior leadership, along with a strong director group, revised the unit's mission and values to be more focused on patient care, and developed a shared vision for the future of other areas at St. Mary's Health Care System.
Actions to Improve Quality: Structural and Cultural Changes
Creation of Patient Safety Committee and Quality Council
Following the release of the IOM report, To Err Is Human, St. Mary's created a physician-led, multidisciplinary, Patient Safety Committee. Its mission was to bring the hospital's practices in line with the JCAHO Quality Measures National Patient Safety Goals and to address other issues related to patient safety in order to enhance the quality of care. While the committee does not necessarily oversee all QI efforts, its establishment elevated these issues and reflected their higher priority in the hospital's changing culture.
The Quality Council was reorganized in 2004. Chaired by the director of quality and performance improvement, the council includes senior leadership as well as department directors. It meets monthly to examine data presented by all of its committees: AMI Core Measures, heart failure, stroke, pneumonia, patient safety, infection control, patient grievances and satisfaction, medical errors, and falls. The council uses these data to identify problem areas and discuss new strategies for quality improvement as well as strategies for translating existing programs that are working for one condition or department across the institution. The actively involved Board of Directors receives a quarterly quality report providing a top-level overview with key metrics, which they call "the dashboard."
Implementation of Protocols Based on Core Measures
New protocol development at St. Mary's is not a centralized function of any one department, but rather a responsibility of several. Data drive the recognition of quality-of-care issues in need of quality improvement. For example, in response to a high risk of stroke in the region and a need for rapid response to achieve positive outcomes, St. Mary's developed a multidisciplinary approach to stroke care, which led to their recognition as the region's only JCAHO-certified stroke center.
Interviewees noted that St. Mary's is a community hospital and, as such, responds to situations raised by the community population it serves. Recently, Athens was listed in a national magazine as one of the top five places to retire; subsequently, hospital staff have begun to plan for the types of care and services required by the 55-and-over population. It is predicted that this population will grow by 42 percent in the county over the next few years.
Once an issue is identified, the hospital establishes a multidisciplinary team consisting of physicians, frontline staff, and administration. In many cases, the performance improvement (PI) solution that is developed utilizes evidence-based medicine and research. For every new Core Measure or PI project tackled, St. Mary's administrators identify a frontline staff champion and a physician champion who will make it their job to see the program to completion, with support from members of the appropriate Patient Safety and/or Quality Council Committees. A clinical nurse specialist, for example, led the team responsible for developing and implementing the stroke project. The process for implementing the stroke protocol included developing staff education tools, offering "skills days," an e-mail newsletter, and "train-the-trainer" protocols.
Addition of New Services
As a result of the attention to patient safety, quality of care, and satisfaction, St. Mary's opened the only acute rehabilitation center in the region, with 20 beds. They also created a neuroscience unit, which recently earned the ranking of a Center of Excellence—"a specialty neuroscience hospital within a hospital"—by Neurosource. In 2002, the Diagnosis Related Group (DRG) assurance program was implemented. Staff in the case management department review patient records and work with physicians to ensure that comorbidities and complications are documented and coded accurately. For example, if hypoglycemia is documented, the case manager would work with the doctor to improve documentation to reflect the complete disease care process. The hospital is also very proud of its "One Call" service, in which registered nurses facilitate patient admissions. The One Call nurses ensure that incoming patients are admitted with the appropriate status, placed in the unit best suited to care for their needs, and generally coordinate patient care from the time of admission. The program has led to great improvements in physician and patient satisfaction as well as operational efficiency and has empowered nurses within the institution.
Interviewees noted that perhaps the biggest change that took place during the study period was the growth of the hospitalist program, whereby a staff physician becomes the physician-of-record for a patient, rapidly coordinating their care and quickly reacting to changes in their medical status. St. Mary's began their hospitalist program in 2002 and have since more than doubled the number of hospitalists (from three to seven)—greatly enhancing access to physicians and enabling 24-hour attention and clinical support. The interviewees believe that this expansion led to great improvements in quality of care. The hospitalists are active participants in quality initiatives and act as physician champions for quality and performance improvement teams.
In 2001, St. Mary's asked a dedicated neurologist and neurosurgeon to implement a stroke care protocol that reflected evidence-based medicine. As previously mentioned, the institution was certified as a stroke center by JCAHO in 2004, and certification was granted again in August 2006.
Empowerment of Bedside Nurses
In 2002, hospital leadership began a Shared Governance program designed to empower bedside nurses, believing that they could lead the charge in coordinating care and creating an environment in which multidisciplinary care protocols would thrive. To help achieve this vision, the hospital hired "top-notch" directors of nursing to ensure the program would have administrative support and leadership to bring it to fruition. Shared Governance provides the bedside nurse with the tools and avenues to shape and influence the provision of quality patient care. For example, the Practice Council reviews, approves, and/or revises nursing policies and procedures. The Performance Improvement (PI) Council looks collectively at unit-based performance improvement activities to see if there are hospital-wide trends or issues that need additional investigation. And through hospital-wide and unit-based Nursing Councils, nurses plan and shape policies and procedures as well as initiate and advocate performance improvement efforts. Via these programs, registered nurses work to improve patient care as well as improve their work lives and environment.
Recruitment of "Risk-Takers"
In early 2004, St. Mary's administration recognized the need to recruit and hire senior staff who were willing, and had the necessary experience, to take risks and come up with challenging and innovative programs. New staff positions were created, including vice president for managed care, director of quality and performance improvement, and director of case management. While these hires actually took place in 2005, after the study period, they stem directly from shifts in the culture and prioritization of quality and patient safety that took place between 2002 and 2004.
Incorporation of Technology
St. Mary's leadership learned the importance of investing in technology to increase the levels of quality care, patient safety, and patient, employee, and physician satisfaction. One of St. Mary's 2006 investments was a remote EKG system built into their ambulance fleet that can transmit information on a patient to the emergency department, and from there to a cardiologist. Interviewees noted that this system gives physicians access to EKG data before AMI patients even arrive at the hospital, making it more likely that they will receive appropriate care in the crucial first minutes. While this did not occur during the study period, it again grew out of the cultural shifts that took root between the years 2002 and 2004.
Another technology investment was the hospital's Pixis pharmaceutical dispensing system, implemented in 2003. This electronic dispensing apparatus tracks medications and has helped reduce the incidence of medication errors. Its implementation was accompanied by a more stringent review of medication error data by the pharmacy, patient safety committee, and department staff.
Monitoring Results
National Measures and Collaboratives
As described above, the Quality Council regularly reviews a variety of indicators, identifies areas in need of improvement, develops QI strategies, and reports to the board. In addition, the hospital relies on patient outcomes and identified community needs to guide its work. Recently it applied to JCAHO to be certified as a heart failure center of excellence and to the Commission on Accreditation of Rehab Facilities for acute rehab certification. As part of Catholic Health East, St. Mary's also participates in the IHI 100,000 lives program and benefits through collaboration with other CHE hospitals.
Local and Regional Benchmarking
St. Mary's relies mainly on local and regional data for benchmark comparisons. It used the Maryland Hospital Association for mortality and outcome data comparisons. Coverdale and Get with the Guidelines data are used by the stroke committee to monitor the effectiveness of the stroke project. The hospital participates in the Georgia Hospital Association's Partnership for Health and Accountability, which utilizes best practice process implementation and has developed a statewide quality index to measure the progress of Georgia hospitals in relation to patient safety. For 2005, the latest index score, St. Mary's scored 100 percent, a demonstration of the commitment to patient care by the organization. St. Mary's also benchmarks Core Measure, patient satisfaction, financial, and many other indicators against the 33 other acute care hospitals in the Catholic Health East system.
Challenges and Obstacles
Cultural Change Moves Slowly
In a relatively short period, St. Mary's implemented an array of programs and protocols that significantly raised its levels of quality and efficiency. Interviewees described how a number of physicians saw implementation of protocols based on the Core Measures as an imposition. They noted, however, that some physicians were "brought around" after becoming informed and involved in change initiatives. The hospital encourages physician input and provides support for physicians in learning how to integrate information technology in the delivery of care. In doing so, the administration tries to make implementation less onerous and more user-friendly.
Financial Implications
The investments made in quality improvement and patient safety have paid off for St. Mary's. Between 2004 and 2005 the hospital saw a 20 percent increase in admissions. That rate increased another 8 percent from 2005 to 2006. Improvements in services, such as a new neonatal intensive care unit that enables parents to spend the night with their infants, gave the hospital a 2 percent increase in market share for newborn specialty care.
Quality improvement and patient safety have been integrated into the fabric of St. Mary's, reflected in the fact that the chief financial officer is an ad hoc member of the Quality Council. There is a specific line item for quality improvement in the operating budget, and additional funds may be reallocated to that purpose when appropriate and available. At the same time, St. Mary's financial resources are always tight, and reimbursement rates for Medicaid and Medicare are potentially on the chopping block. The administration is concerned with how it will continue to implement potentially money-saving programs while at the same time fulfill its mission to take care of the poor and provide a consistent level of uncompensated care.
Lessons
Leaders, Not Managers
One lesson the staff at St. Mary's has learned is that change requires dedicated leaders. As reflected by their use of nurse and physician champions, and the fact that all staff members are empowered to identify problems and issues, they are working to create a culture in which anyone can become a leader and all are encouraged to do so.
Celebrate Successes, but Don't Get Complacent
St. Mary's recognized that, without commitment from staff, quality improvement and patient safety efforts would not get very far. Celebrating achievements in successfully implementing new strategies was crucial to staff involvement. These celebrations took the form of dinners, parties, and gifts of Wal-Mart shopping cards. The administration also created a recognition program in which patients can give points to their caregivers. The points can then be redeemed by staff at the hospital cafeteria and gift shop. Recently, they developed five annual nursing clinical excellence awards. Nominees are submitted by the clinical nursing staff, and recipients' photographs are placed on the "Wall of Strength" in recognition of their achievements.
At the same time, interviewees warned that it is important not to celebrate to the point where you become complacent about your successes. They noted that, as soon as they implement a new Core Measure protocol, another condition needs attention. They also noted that the evidence base is changing all the time, so even new Core Measure protocols can become outdated and require renewed attention and consideration. Thus, maintaining and building on achievements is an ongoing challenge.
Public Policy Can Help
Interviewees noted that one area in which public policy can help address the needs of hospitals seeking to improve quality and performance is regulation. They are concerned that the multitude of regulatory requirements—sometimes in opposition to each other—focuses organizational resources on federal and state regulatory compliance, thus reducing the resources available to provide safe and good-quality care to patients.
Anyone Can Initiate Quality Improvement
As described above, everyone at St. Mary's is empowered to identify quality issues and needs. As one interviewee noted, "quality flows up and down. It goes down from the board, and up from the clinicians." They advocate the development of an environment in which this type of discourse is welcomed and encouraged.
Acknowledgments
The authors would like to thank the following individuals at St. Mary's Health Care System who generously offered their time and insights for this case study: Brenda Dugger, senior vice president of patient care services; Jackie Ginter, director of quality and performance improvement; Jeff Frehse, director of risk management and compliance; and Avery McLean, director of marketing.
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.