Case Study High-Performing Health Care Organization • March 2009 October 2009 Ridgeview Medical Center: Service Line Structure Lays Groundwork for Surgical Care Improvement By Aimee Lashbrook, J.D., M.H.S.A., and Jennifer N. Edwards, Dr.P.H. H ealth M anagement A ssociates The mission of The Commonwealth Vital Signs Fund is to promote a high performance Location: Waconia, Minn. health care system. The Fund carries out this mandate by supporting Type: Private, nonprofit hospital independent research on health care Beds: 109 issues and making grants to improve health care practice and policy. Support Distinction: Top 3 percent in a composite of five surgical care improvement process-of-care for this research was provided by measures, among more than 2,300 hospitals (more than half of U.S. acute-care hospitals) eligible The Commonwealth Fund. The views for the analysis. presented here are those of the authors Timeframe: April 2007 through March 2008. See Appendix for full methodology. and not necessarily those of The This case study describes the strategies and factors that appear to contribute to high performance Commonwealth Fund or its directors, on surgical care improvement measures at Ridgeview Medical Center. It is based on information officers, or staff. obtained from interviews with key hospital personnel, publicly available information, and materials provided by the hospital during May 2009 through June 2009.1      For more information about this study, Summary please contact: Ridgeview Medical Center is one of the top performers in the country on pro- Aimee Lashbrook, J.D., M.H.S.A. cess-of-care, or “core,” measures for surgical care reported by hospitals to the Health Management Associates alashbrook@healthmanagement.com Centers for Medicare and Medicaid Services. The core measures, developed by the Hospital Quality Alliance (HQA), relate to achievement of recommended treatment in four clinical areas: heart attack, heart failure, pneumonia, and surgi- cal care. Ridgeview performs well across all of the core measures, scoring in the top 10th percentile. Leaders at Ridgeview attribute achievements in surgical care to the hospi- To download this publication and learn about others as they become tal’s organizational culture and service line structure. Referred to as “The available, visit us online at Ridgeview Way,” the hospital’s systems, structures, and processes are designed www.commonwealthfund.org and register to receive Fund e-Alerts. to provide evidence-based care and enhance patients’ experiences. The hospital Commonwealth Fund pub. 1323 also collaborates with quality improvement organizations at the state and national Vol. 29 levels. For a small, independent organization such as Ridgeview, these 2T he  C ommonwealth F und Exhibit 1. Ridgeview Service Line Model Source: Ridgeview Medical Center, 2009 partnerships provide valuable access to quality Hospital-Wide Strategies improvement resources and opportunities to work Service Line Structure with peers. In the early 2000s, Ridgeview moved from a tradi- tional medical staff model, in which a physician Organization department chair serves as the senior leader, to a ser- Ridgeview Medical Center, located in the Minneapolis/ vice line structure, in which physicians and adminis- St. Paul suburbs, is a private, nonprofit hospital with trators work together. Ridgeview now has eight service 109 licensed beds. Ridgeview and its associated pri- lines: women and children, oncology, cardiovascular, mary and specialty care clinics serve more than surgical, orthopedics, medical specialties, emergency 300,000 people each year, including more than 20,000 services, and Ridgeview clinics. Each service line is emergency department visits, 100,000 outpatient visits, comanaged by at least one physician and one adminis- and 7,000 surgeries. In addition to the hospital, which trator, both of whom are charged with improving ser- has been expanded many times since it opened in vice, improving health care outcomes, and enriching 1963, Ridgeview has a regional network of clinics, a patients’ experiences. home care and hospice program, a home medical Leaders credit the service line structure with equipment business, and an ambulatory center. laying the groundwork for successful implementation Ridgeview operated as a public (community- of its surgical care improvement initiatives. They also owned) hospital until January 2000, when it became feel that moving to a service line structure has changed an independent private entity. Ridgeview does not relationships within the organization, engaged physi- belong to a larger health care system, and its indepen- cians in quality-improvement efforts, and provided a dence is a factor as its leaders approach quality forum for pursuing quality-improvement activities. As improvement. According to Sarah Urtel, R.H.I.A., illustrated in Exhibit 1, physician engagement is a B.A.S., director of organizational effectiveness, requirement of doing the multifaceted work under way Ridgeview is able to “chart our own destiny” without a in each service line (i.e., the five building blocks at the large corporation influencing decision-making. bottom). Improvement initiatives are reinforced through business planning, the use of a scorecard to track performance, and widespread use of improve- ment methods. R idgeview M edical C enter : S ervice L ine S tructure L ays G roundwork for S urgical C are I mprovement 3 Ridgeview compensates clinic-based physicians worked one-on-one with this surgeon, who eventually for their work on quality-improvement initiatives and changed his behavior. Such early successes created the management of the service lines. Hospital leaders feel momentum needed to address more complex measures. it is important to compensate physicians for this work, Monitoring performance is a shared effort even though the stipend is small in comparison with throughout Ridgeview. In the surgical area, account- reimbursable patient care. Recognition of the compet- ability for measurement is spread among the circulator ing demands placed on physicians helps engage them (the operating room nurse present during surgery and in quality-improvement efforts and strengthens their responsible for coordinating all nursing care), quality- relationships with administrators. improvement specialist, certified registered nurse In addition to clinic-based physicians, anesthetist (CRNAs), and nurses. Electronic charting Ridgeview has a hospitalist program with five full- captures surgical data, but performance reports shared time internists who cover the hospital around the clock with each service line are created manually. and help lead improvement initiatives. Quality initiatives are tested in project Ridgeview organizes its strategic planning improvement teams, which vary in size and include around seven priorities: clinical excellence and patient clinical leaders, administrative leaders, and other key safety, patient-centered experience, best workforce, staff. When a team is ready to implement a new care community connectedness, operational efficiency, phy- process, they will first test it over a short period with sician engagement, and being the preferred choice in one patient (“rapid cycle test”) and then meet to the region. Hospital leaders believe these priorities discuss the results. Process changes that show positive have contributed to improvements in surgical care. In results will be tested on a larger population (“extended their three-year strategic plan, hospital leaders set spe- cycle test”) and, if successful, rolled out across the cific measures and goals. For example, Ridgeview is hospital (“spread the change”). When process changes committed to total implementation and use of an elec- fail to show positive results, the team starts over— tronic health record system by 2011. It is also commit- revising the process and monitoring the results at the ted to investment in its service lines and engagement rapid cycle level until it is ready to be tested at the of the medical staff in leadership development and next level. An extended cycle test typically involves quality improvement. three to five patients and lasts one to three days. After a successful extended cycle test, the change is spread Project Improvement Teams throughout the organization through staff education, Ridgeview staff follow the Plan-Do-Study-Act model updates to policies and procedures, and other activities. of quality improvement. Urtel believes the benefits of Many improvement initiatives take place simul- this model include its reliability and capacity to initiate taneously. To help staff understand what projects are rapid change. When pursuing improvements in a par- under way, team leaders—together with their team ticular area, staff initially target low-hanging fruit. For members and other staff involved in testing the example, one HQA surgical-care measure monitors the change—fill out a communication sheet describing the method of hair removal prior to surgery; use of clip- project and the reasons for undertaking it, outlining the pers, rather than razors, has been shown to reduce roles of various staff, and providing the name of a per- infection rates. To ensure compliance with this mea- son to contact with questions. The communication sure, all razors were removed from the operating sheets are posted in areas such as nursing stations and room. According to B. J. Buckland, R.N., M.S., direc- break rooms and made available on the hospital’s tor of surgical services, physicians “can’t use a razor if intranet. The sheets are color-coded to indicate the they don’t have one.” The new clipping practice was stage of the change process. If applicable, an order set adopted by all but one surgeon. Hospital staff then or other form will be attached (Exhibit 2). 4T he  C ommonwealth F und Exhibit 2. Communication Sheets: Three Stages of Process Improvement Source: Ridgeview Medical Center, 2009 Transparent Reporting During service line meetings, Buckland reports Ridgeview’s leaders believe in transparency in report- performance results and engages staff in discussions ing the results of quality-improvement efforts. All hos- about them. He posts progress reports and other qual- pital employees can view the results of any improve- ity-related announcements in well-trafficked and sur- ment initiative via the hospital’s intranet. Quality indi- prising locations, such as employee restrooms—adding cators are also built into the management dashboards. a touch of humor to the improvement process. A bath- “It is important to keep quality improvement in the room may also be a less threatening location for post- forefront,” Buckland says, “otherwise it becomes ‘out ing individual results than a public hallway. of sight, out of mind’.” Daily and weekly “huddles” are also part of the Each service line receives regular reports outlin- communication process. During the 20- to 30-minute ing performance at the group and individual physician huddles, project-improvement teams gather to review levels. At minimum, the reports include core measure the results of rapid cycles completed in the past week performance; in some cases they also include other and determine next steps for the upcoming week. statistics of interest to service line staff. The reports incorporate data from departments such as pharmacy Regional and National Initiatives and laboratory to illustrate how different units in the As an independent hospital, Ridgeview looks outside hospital work together. its walls to benchmark and share best practices. The A dashboard outlining the surgical service line’s hospital regularly participates in state and national ini- performance is created monthly for managers and tiatives and partners with leading quality organizations other service line staff. Individual physician results, to further its own activities. It has taken part in collab- identified by name, are reported at surgeons’ meetings oratives and training programs sponsored by the that occur eight times a year. When a problem is iden- Institute for Healthcare Improvement (IHI), the tified, the quality improvement coordinator for surgical Institute for Clinical Systems Improvement, the Joint services, Chris Vos, R.N., B.S., works with physicians Commission, and the Minnesota Hospital Association.2 to resolve it by answering questions and providing Ridgeview is a charter member of IHI’s IMPACT clinical evidence supporting new practices. Leadership Community, which aims to improve R idgeview M edical C enter : S ervice L ine S tructure L ays G roundwork for S urgical C are I mprovement 5 leadership capabilities for quality-improvement in Surgical Care Improvement Strategies health care organizations. The hospital also partici- Facilitating Dialogue and Sharing Evidence pates in IHI’s 5 Million Lives campaign, which pro- Achieving physicians’ buy-in and support is important motes adoption of patient safety interventions. to Ridgeview’s surgical-care improvement strategy. Partnerships such as these provide access to quality Quality-improvement staff engage physicians and improvement resources and opportunities to work other clinicians in discussions about proposed initia- with peers. tives and seek consensus before moving forward. To For example, working with IHI, Ridgeview cre- promote understanding, they share the clinical evi- ated a set of order bundles for suspected pneumonia dence demonstrating the links between best practices patients. An order bundle is a designated grouping of and better patient outcomes. Buckland also relies on clinical orders that are evidence-based and vary clinicians from other specialties, such as pharmacists, according to a patient’s risk factors. to help garner support from surgical staff for a particu- Ridgeview’s leaders believe the Minnesota lar initiative. Hospital Association (MHA) has played a critical role For example, to improve compliance with the in improving quality and patient safety in the state. core measure recommending administration of antibi- MHA leads a variety of statewide campaigns, or “Calls otic prophylaxis more than one hour prior to surgical to Action,” which provide tools and a forum through incision, Beth Schnabel, R.N., nurse manager, surgical which hospitals can collaborate and share best prac- services, met with the CRNAs as a group and provided tices. Current campaigns include prevention of wrong- education and clinical evidence regarding the efficacy site surgeries, prevention of patient falls, and elimina- of prophylactic antibiotic timing. Their compliance tion of serious pressure ulcers. with this measure improved by the next measurement According to Urtel, the MHA campaigns “rein- month. To secure buy-in from surgeons about discon- forced the hospital’s internal decisions and provided a tinuing antibiotics within 24 hours of surgery, roadmap for best practices and an opportunity to learn Schnabel and her team distributed clinical evidence from colleagues.” Standardization of care practices supporting the change and invited the director of across the state spares hospitals from “reinventing the pharmacy to speak with surgeons about the efficacy of wheel” each time they roll out a new initiative. In this practice. addition, the state’s physicians benefit, in that similar processes are used at the different institutions at which Standardizing Operating Room Procedures they practice. Standardization of care processes through preprinted A joint effort between MHA, the Minnesota order sets has helped improve the hospital’s perfor- Medical Association, and the Minnesota Department mance on certain measures, such as preoperative anti- of Health has further contributed to a culture of quality biotic selection. With preprinted order sets, the best and transparency in hospitals across the state. practices became the default standard, thereby reduc- Minnesota was the first state in the country to require ing the opportunity for human error. There are pre- hospital reporting of the 28 adverse events identified printed order sets for both preoperative and postopera- by the National Quality Forum, commonly referred to tive activities, varying by type of surgery (Exhibit 3). as “never events.” The Minnesota Department of Health publishes an annual report of hospital-specific Team Building in the Operating Room data on the incidence of never events. Ridgeview has worked to facilitate open communica- tion and teamwork in the operating room. In 2000, its operating room staff participated in a series of 6T he  C ommonwealth F und Exhibit 3. Colon Surgery Pre-Op Preprinted Order Set Source: Ridgeview Medical Center, 2009 R idgeview M edical C enter : S ervice L ine S tructure L ays G roundwork for S urgical C are I mprovement 7 team-building exercises that led to the development of manager spoke with the surgeon. He acknowledged his a conflict resolution process that is still used today. tendency to swear and subsequently improved his “The team training resulted in marked improve- behavior. ments in communication and teamwork because the teams learned that there are only four choices when it Results comes to handling a problem in the operating room,” Ridgeview exceeds state and national averages on all Buckland says. The four choices are: initiate one-on- of the surgical process-of-care measures. Exhibit 5 dis- one discussions with the other parties, rely on a third- plays the most recent year of data for Ridgeview on party resource to resolve the conflict, escalate the issue these measures. Exhibit 6 shows the trends over time to management, or do nothing. This conflict resolution for selected surgical measures. Ridgeview’s perfor- process offers a roadmap to improve the working envi- mance in the antibiotic selection and discontinuation ronment by opening lines of communication and measures shows significant improvement from 2007 to reducing unproductive gossip. Operating room staff 2008. The hospital’s performance on the measure understand that, once they choose how to resolve a gauging antibiotic administration within one hour fluc- conflict, they should not spend additional time think- tuates from year to year—indicating an opportunity for ing about it (Figure 4). improvement. After a dip in 2007, the data indicate One issue resolved through this process solid performance in the venous thromboembolism involved a surgeon who used inappropriate language prophylaxis measures. when he was frustrated, making some operating room In Minnesota, some payers promote quality staff uncomfortable. After staff shared their concerns improvement by increasing reimbursement for positive with managers, the department director and nurse clinical outcomes. In addition, local newspapers report Exhibit 4. Ridgeview Operating Room Dispute Resolution Process How Do I or Can I Approach Someone Identify Need Write Approach Do Request 3rd up One to One Nothing Person Done/ Done/ Satisfied Satisfied No Gossip No Gossip Meet Meet One to One One to One Done/ Done/ Done/ Satisfied Satisfied Satisfied No Gossip No Gossip No Gossip Involve 3rd Involve 3 rd Involve 3rd Person Person Person Done/ Done/ Satisfied Done/ Satisfied No Gossip Satisfied No Gossip No Gossip Clarify issue Clarify issue Clarify issue Identify next steps Identify next steps Identify next steps Document if Document if Document if leadership involved leadership involved leadership involved Set review date Set review date Set review date Source: Ridgeview Medical Center, 2009 8T he  C ommonwealth F und on hospitals’ performance on the core measures. These • Engage physicians and secure their buy-in incentives provide motivation for Ridgeview to main- before implementing new care processes. tain its high performance. In the future, Ridgeview • Collaborate with the departments that work staff in the quality and finance departments would like with the surgical staff, such as the emergency to quantify the cost savings associated with high per- department and pharmacy. formance in order to better understand the value of the hospital’s quality-improvement efforts. • Rely on a team approach in the operating room and other clinical units. Lessons Learned • Use preprinted order sets and order bundles to Hospitals looking to improve their performance in sur- help standardize practices and reduce the gical care might take the following lessons from opportunity for human error. Ridgeview’s experience: • Create a strategic plan dedicated to quality and For More Information backed up with specific measures and goals. For further information, contact B. J. Buckland, R.N., M.S., director of surgical services, • A service line model focused on improving b.j.buckland@ridgeviewmedical.org. patients’ experiences creates a team environ- ment and lays the groundwork for change. Exhibit 5. Ridgeview Medical Center Scores on Surgical Care Improvement Core Measures Compared with State and National Averages National Minnesota Ridgeview Surgical Care Improvement Indicator Average Average Medical Center Percent of surgery patients who were given an antibiotic at the right 86% 86% 96% of 291 patients time (within one hour before surgery) to help prevent infection Percent of surgery patients who were given the right kind of 92% 93% 96% of 292 patients antibiotic to help prevent infection Percent of surgery patients whose preventative antibiotics were 84% 89% 99% of 289 patients stopped at the right time (within 24 hours after surgery) Percent of all heart surgery patients whose blood glucose is kept 85% 85% 0 patients under good control in the days right after surgery Percent of surgery patients needing hair removal from the surgical 100% of 210 area before surgery, who had hair removed using a safe method 95% 92% patients (electric clippers or hair removal cream, not razor) Percent of surgery patients whose doctors ordered treatments to 84% 87% 99% of 354 patients prevent blood clots after certain types of surgeries Percent of surgery patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood 81% 84% 99% of 354 patients clots after certain types of surgery Source: www.hospitalcompare.hhs.gov. Data are from April 2007 through March 2008. R idgeview M edical C enter : S ervice L ine S tructure L ays G roundwork for S urgical C are I mprovement 9 Exhibit 6. Performance on Selected Surgical Care Improvement Core Measures, 2007–08 2007–Q1 2007–Q2 2007–Q3 2007–Q4 2008–Q1 2008–Q2 2008–Q3 2008–Q4 Antibiotic within one 95.0% 93.9% 98.8% 94.6% 98.7% 92.1% 94.4% 93.2% hour – All Antibiotic selection – All 92.5% 93.9% 93.8% 93.2% 98.7% 98.4% 95.7% 98.6% Antibiotic discontinuation 90.9% 96.9% 98.8% 98.6% 98.6% 100.0% 100.0% 100.0% within 24 hours – All VTE prophylaxis 99.0% 95.6% 97.7% 100.0% 100.0% 99.0% 100.0% 100.0% ordered* – All VTE prophylaxis timing* 99.0% 95.6% 96.6% 100.0% 98.8% 99.0% 100.0% 100.0% – All *VTE= venous thromboembolism. Source: Ridgeview Medical Center, 2009. N otes 2 Institute for Clinical Systems Improvement is a nonprofit organization that promotes patient- 1 This study was based on publicly available informa- centered and value-driven care. It is sponsored by a tion and self-reported data provided by the case- group of health plans in Minnesota and Wisconsin. study institution(s). The aim of Fund-sponsored case See http://www.icsi.org/. studies of this type is to identify institutions that have achieved results indicating high performance 3 Two additional surgical care improvement measures in a particular area, have undertaken innovations were added in 2007 but were not included in the designed to reach higher performance, or exemplify composite score for selection purposes because data attributes that can foster high performance. The were not available for four quarters. studies are intended to enable other institutions to draw lessons from the studied organizations’ experi- ences 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-study series is not an endorsement by the Fund for receipt of health care from the institution. 10T he  C ommonwealth F und Appendix. Selection Methodology Selection of high-performing hospitals in process-of-care measures for this series of case studies is based on data submitted by hospitals to the Centers for Medicare and Medicaid Services. We use five measures that are publicly available on the U.S. Department of Health and Human Services’ Hospital Compare Web site, (www.hospitalcompare.hhs.gov). The measures, developed by the Hospital Quality Alliance, relate to practices in surgical care. Surgical Care Improvement Process-of-Care Measures 1. Percent of surgery patients who received preventative antibiotic(s) one hour before incision 2. Percent of surgery patients who received the appropriate preventative antibiotic(s) for their surgery 3. Percent of surgery patients whose preventative antibiotic(s) are stopped within 24 hours after surgery 4. Percent of surgery patients whose doctors ordered treatments to prevent blood clots (venous thromboembolism) for certain types of surgeries 5. Percent of surgery patients who received treatment to prevent blood clots within 24 hours before or after selected surgeries The analysis uses all-payer data from April 2007 through March 2008. To be included, a hospital must have submitted data for all five measures (even if data submitted were based on zero cases), with a minimum of 30 cases for at least one measure, over four quarters.3 Approximately 2,360 facilities—more than half of acute care hospi- tals—were eligible for the analysis. No explicit weighting was incorporated, but higher-occurring cases give weight to that measure in the aver- age. Since these are process measures (versus outcome measures), no risk adjustment was applied. Exclusion criteria and other specifications are available at http://www.qualitynet.org/dcs/ContentServer?cid=1141662756099&pagena me=QnetPublic%2FPage%2FQnetTier2&c=Page). While high score on a composite of surgical care improvement process-of-care measures was the primary cri- teria for selection in this series, the hospitals also had to meet the following criteria: not a government-owned hospi- tal, at least 50 beds, not a specialty hospital, ranked within the top half of hospitals in the U.S. in the percentage of patients who gave a rating of 9 or 10 out of 10 when asked how they rate the hospital overall (measured by Hospital Consumer Assessment of Healthcare Providers and Systems, HCAHPS), full accreditation by the Joint Commission; not an outlier in heart attack and/or heart failure mortality; no major recent violations or sanctions; and geographic diversity. R idgeview M edical C enter : S ervice L ine S tructure L ays G roundwork for S urgical C are I mprovement 11 A bout the A uthors Aimee Lashbrook, J.D., M.H.S.A., is a senior consultant in Health Management Associates’ Lansing, Mich., office. Ms. Lashbrook has six years of experience working in the health care industry with hospitals, managed care organizations, and state Medicaid programs. She provides ongoing technical assistance to state Medicaid programs, and has played a key role in the development and implementation of new programs and initiatives. Since joining HMA in 2006, she has conducted research on a variety of health care topics. Aimee earned a juris doctor degree at Loyola University Chicago School of Law and a master of health services administration degree at the University of Michigan. Jennifer N. Edwards, Dr.P.H., M.H.S., is a principal with Health Management Associates’ New York City office. Jennifer has worked for 20 years as a researcher and policy analyst at the state and national levels to design, evaluate, and improve health care coverage programs for vulnerable populations. She worked for four years as senior program officer at The Commonwealth Fund, directing the State Innovations program and the Health Care in New York City program. She has also worked in quality and patient safety at Memorial Sloan-Kettering Cancer Center, where she was instrumental in launching the hospital’s patient safety program. Jennifer earned a doctor of public health degree at the University of Michigan and a master of health science degree at Johns Hopkins University. A cknowledgments We wish to thank B. J. Buckland, R.N., M.S., director of surgical services, Sarah Urtel, R.H.I.A., B.A.S., director of organizational effectiveness, Pat Michaelson, R.N., M.B.A., vice president of patient care/chief nursing officer, Beth Schnabel, R.N., manager, surgical services, and Chris Vos, R.N., B.S., quality improvement coordinator/surgical services, for generously sharing their time, knowledge, and materials with us. Editorial support was provided by Martha Hostetter. This study was based on publicly available information and self-reported data provided by the case study institution(s). 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. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, 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 institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.