The Blue Ridge Academic Health Group Health Care Quality and Safety in the Academic Health Center Report 11 October 2007 Report 11 October 2007 Mission: The Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and The Blue Ridge Academic Health to identify recommendations for academic Group health centers (AHCs) to help create Health Care Quality and Safety greater value for society. The Blue Ridge in the Academic Health Center Group also recommends public policies to enable AHCs to accomplish these ends. Members and participants Contents Me m b e r s Report 11: Health Care Quality and Safety in the Academic Health Center Enriqueta C. Bond, PhD, President, John D. Stobo, M.D., President Burroughs Wellcome Fund University of Texas Medical Branch at Galveston Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Darryl Kirch, M.D. President, Steven A. Wartman, M.D., Ph.D. President Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Association of American Medical Colleges Association of Academic Health Centers What is Quality? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Haile T. Debas, MD, Executive Director, Invited Participants Global Health Sciences Institute Discussion of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 University of California, San Francisco William Bornstein, M.D., Ph.D. Chief Quality Officer Finding #1: Quality must be addressed as a system property . . . . . . . . . . . . . . . . . . . . . . . . . . 7 *Don E. Detmer, M.D., M.A. Emory Healthcare President and CEO, American Medical Emory University Finding #2: “Culture Eats Strategy For Lunch”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Informatics Association; Atlanta, GA Professor Emeritus and Professor of Medical Carolyn Clancy, M.D. Finding #3: Focus on one or a few “Big Hairy Audacious Goals” (BHAGs). . . . . . . . . . . . . . . . 13 Education, University of Virginia Director, Agency for Healthcare Research and Quality Finding #4: Leadership that practices “meaning management” is particularly effective . . . . 14 Arthur Garson, Jr. M.D., M.P.H. Vice President and Dean, Washington, D.C. Finding #5: Governing Boards must be actively involved and supportive of Leadership School of Medicine, University of Virginia Mark Keroack, M.D., M.P.H. Quality Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Michael A. Geheb, M.D., Division President Vice President and Director Clinical Practice Advancement Center inding #6: Incentives F help. Well-conceived incentives can motivate and facilitate desired Oakwood Hospital & Medical Center/Heritage Hospital University Healthsystem Consortium behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Oak Brook, IL Finding #7: Health Information Technology and Informatics, while not sufficient to improve *Michael M.E. Johns, M.D., Chancellor David B. Pryor, M.D. quality, are increasingly indispensable and are best developed and deployed Senior Vice President through staged introduction into clinical practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Emory University Ascension Health St. Louis, MO Conclusion: AHCs must step forward and bring new leadership to realizing highest quality health care Jeffrey Koplan, M.D., M.P.H. both in our own organizations and in the health care system more broadly . . . . . . . . . . . . . . . . . . . . 20 Vice President for Academic Health Affairs, Emory University Staff References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Janet Waidner, Executive Administrative Steven Lipstein, M.B.A. President and CEO, Assistant, Woodruff Health Sciences Center, BJC HealthCare, St. Louis Emory University Arthur Rubenstein, M.B.B.C.H. Editor Dean andExecutive Vice President, Jonathan Saxton, M.A., J.D. University of Pennsylvania School of Medicine Special Assistant for Health Policy Woodruff Health Sciences Center Fred Sanfilippo, M.D., Ph.D. Emory University Executive Vice President for Health Affairs; CEO, The Robert W. Woodruff Health Sciences Design Reproductions of this document may be made with written permission of The Robert W. Woodruff Health Sciences Center by contacting Anita Bray, Office Center, Emory University Peta Westmaas Design Inc. of the Chancellor, 201 Dowman Drive, Atlanta, GA 30322. Phone: 404-712-3500. Fax: 404-712-3511. E-mail: abray@emory.edu. Health Care Quality and Safety in the Academic Health Center is eleventh in a series of reports produced by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions *Co-Chairs of Emory University. This report is not intended to be relied on as a substitute for specific legal and business advice. Copyright 2006 by Emory University. The Blue Ridge Academic Health Group Report 11 “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.” –Cyril Chantler The Blue Ridge Academic Health Group (Blue Ridge Group) studies and reports on issues of fundamental importance to improving our health care system and enhancing the ability of the academic health center (AHC) to sustain optimal progress in health and health Introduction care through sound research—both basic and applied—and health professional education. In Evidence of significant problems in the quality of federal payors (for instance, Medicare) and through nine previous reports, the Blue Ridge Group has sought to provide guidance to AHCs that US health care accumulated and generated a genu- regulatory and enforcement measures. And while ine sense of urgency in the health sector over the AHCs now are involved in a number of quality ini- can enhance leadership and knowledge management capabilities; aid in the adoption and past two decades. Academic Health Centers (AHCs) tiatives offered by organizations like the Institute development of Internet-based capabilities; contribute to the development of a more rational, could have provided stronger leadership in address- for Healthcare Improvement (IHI) or the National comprehensive, and affordable health care system; improve management, including finan- ing these systemic quality and safety issues; but for Committee for Quality Assurance (NCQA), most cial performance; address the cultural and organizational barriers to professional, staff, and the most part, like most of the hospital industry, such efforts remain localized in departments or institutional success in a value-driven health system; improve the education of physicians and they focused on the credentials of individual pro- particular provider sites. The sharing of results and viders and not on systems of care and performance wider adoption of evolving best practices has been other health professionals, lead comprehensive health care reform, revive medical profession- per se. In 1999, the Institute of Medicine (IOM) slow and not systematic or system-wide among alism, and address the growing problem of Conflict of Interest particularly in the relationship report, To err is Human, firmly added the IOM’s AHCs. While one can point to perverse incentives between academic health professionals and institutions and their private sector partners and imprimatur to the case that there are widespread and legal barriers, there has been insufficient pres- sponsors (Blue Ridge Academic Health Group 1998a, 1998b, 2000a, 2000b, 2001a, 2001b, 2003, deficiencies in the safety and quality of health care sure from leaders at in the Unites States that result in many tens of the top and middle Even now, with the wide- 2004, 2005, 2006). thousands of preventable deaths and other adverse ranks of AHCs. spread evidence of qual- The Blue Ridge Group has been advocating for a “value-driven” health care system patient outcomes every year (IOM 1999). The IOM Certainly, prog- ity problems, AHCs, with for nearly a decade. A healthy population is a paramount social good. A value-driven health followed that report with a prescription for the ress towards quality system would achieve both individual and population health through cost-effective diagnosis, future U.S. healthcare system, Crossing the Quality and safety will remain some notable exceptions, Chasm: A New Health System for the 21st Century, difficult so long as have been slow to take treatment, prevention and preemption of disease and disability. We would have an effective which demonstrated fundamental, systemic oppor- there is no “concerted leadership in systemically health care system that promotes safety, quality and efficiency -- and the highest standards tunities for constructive change (IOM 2001). The national effort to con- addressing or promoting of professionalism and integrity in the pursuit of health and healing. Through competition IOM called for replacing current systems of care solidate health care and rewards, providers, payors, states, communities and individuals all would be motivated with new systems to assure that health care is safe, performance measure- health care quality. to attain and maintain good health. Universal and equitable access to evidence-based effective timely, efficient, effective, equitable and patient- ment and reporting centered. (IOM 2001, 6) These “STEEEP” aims have activities” (IOM 2006, 1); standardization of quality care would help ensure that population health, information, and data management strategies since been embraced by many, including AHCs, measures (Schoenbaum and Holmgren 2006); or, can be implemented. the Blue Ridge Group, and most other stakeholders adoption of national policies requiring all provid- throughout the health care system. ers to measure and report on quality (NCQA 2007). For more information, visit our web site: http://www.blueridgegroup.org. AHCs have long cultivated the development Progress towards these larger enabling measures of leaders and innovators in the biosciences and in will only come from broad leadership on these health care. But the vast majority of AHCs under- issues, backed by experience, evidence-based proto- stood health care quality to be the province of cols, and ultimately computer-based decision sup- highly-trained individual practitioners, rather than a port at the point of care for clinicians and patients. system property requiring institutional and system- The goal of creating a high quality health care The Blue Ridge Group has been advocating wide leadership and change. (IOM 2001) Even now, system has become a manifest national goal of for a “value-driven” health care system with the widespread evidence of quality problems, health policy leaders, embraced by public and pri- AHCs, with some notable exceptions, have been vate organizations and stakeholders. The Blue Ridge for nearly a decade. A healthy population slow to take leadership in systemically addressing or Group believes it is time for AHCs to engage in is a paramount social good. promoting health care quality (Keroack et al 2008). systemic efforts to contribute to work redesign, edu- For the most part, attention to quality has been cation, and changes to the infrastructure that will be imposed from without: through hospital accredit- needed to realize highest quality health care both in ing organizations (like The Joint Commission), and our own organizations and in the health care system more broadly. This major recommendation of our ing quality and safety through collaborative and What is Quality? departments each year (NQF 2004). The task of report will be developed in the material that follows continuous learning and improvement. The IOM has adopted the following definition of improving quality and patient safety in these and with examples and ideas for how AHCs can proceed. The change management challenges directly quality, which is now employed broadly. Quality is: other ambulatory settings has only just begun to be Experience shows that this necessarily involves relate to both personal and system behavior at all “The degree to which health services for individuals understood and addressed. embracing new ideas and changing our orga- levels of our enterprise. By its nature, this will be and populations increase the likelihood of desired For organizations large and small, jump-start- nizations. It begins with addressing barriers to disruptive and at times will be resisted. As value- health outcomes and are consistent with current pro- ing the quality and safety-improvement process is understanding and achieving quality goals in our driven, personalized health care continues to fessional knowledge” (Lohr K.N. (ed.). 1990). a critical goal. The following discussion of the Blue organizational, academic, and professional cultures, unfold, emphasis will shift to greater standardiza- Patient safety is defined as a patient’s “freedom Ridge Group findings is a distillation of key aspects and in our practice patterns, information systems, tion with computer-based protocol management of from accidental injury” when interacting in any way of current knowledge and experience in creating management structures and governance practices. It chronic conditions and much greater emphasis on with the healthcare system, (IOM 1999, 4) The rela- robust efforts in quality and safety. It is designed to succeeds and is perpetuated with the establishment reviews of practices and performance. This will put tionship between patient safety and quality is nicely aid AHCs and other organizations that are strug- of a culture that engages all stakeholders in achiev- the patient truly at the center of our operations. captured by the Agency for Health Care Research gling to move forward on system-wide quality and and Quality (AHRQ) as policies and practices that: safety programs and to help jump-start this process. It is time for AHCs to engage in systemic efforts to contribute to work redesign, “Reduce the risk of harm by promoting delivery of education, and changes to the infrastructure that will be needed to realize highest quality the best possible health care” (AHRQ 2007). health care both in our own organizations and in the health care system more broadly. On the basis of these foundational definitions, Discussion of Findings there are many agencies, organizations and efforts Finding #1: Quality and safety must be addressed to improve our understanding of Quality and Safety. as system properties. High-risk industries and Key Findings: There are now literally hundreds of widely accepted organizations, like those in health care, must 1. uality must be addressed as a system property. Health care is complex and involves a Q (evidence-based) quality metrics by which health adopt system-wide “ultrasafe” and “high–reli- number of high risk decisions and operations that require adoption of system-wide “ultra- care professionals, provider organizations, and ability” policies and practices. safe” and “high–performance” policies and practices. health plans can record, benchmark, measure and report on their performance. Virtually none of these There is an extensive literature on the properties 2. Culture Eats Strategy For Lunch.” It is not enough to plan and/or to engineer organization- “ has been transformed today into scalable decision- of “ultrasafe” and high-reliability” organizations al changes. Unless and until the goal and practice of quality becomes part of professional and support aides for computer-based health records. (e.g., Weick & Sutcliff 2001; Amalberti 2002). Much organizational culture, quality initiatives are not likely to be successfully sustained. But there is a growing interest in this approach of what we understand about creating safe and 3. ocus on one or a few “Big Hairy Audacious Goals” (BHAGs). The sheer volume of Quality F (Osheroff et al 2007). The efforts of these organiza- highly-reliable operations comes from the expe- and Safety initiatives and measures development can be overwhelming and contribute to tions and others are contributing to both aware- rience of both the nuclear power industry (e.g., institutional inertia or minor, piecemeal efforts. The focus on a few BHAGs is often the best ness of and important gains in quality and safety in Apostolakis & Barach 2003) and the airline industry way to establish a culture of quality and to achieve measurable and meaningful improvements health care throughout the United States. (e.g., Amalberti 2001; Abbott et al 1996). Research in safety and outcomes. However, despite these efforts, quality and and experience in these and other industries have 4. eadership that practices “meaning management” is particularly effective. The right L safety of care is not improving for millions of people taught us that achieving quality and safety in certain leadership style been shown to be important in attaining organizational buy-in and initiative (NCQA 2007). Perhaps in part because of the myri- high-risk and high complexity organizations and that leads to achieving quality goals. ad separate efforts and the proliferation of hundreds operations begins with the adoption of standardized 5. overning Boards must be actively involved and supportive of Leadership Quality G of quality and safety guidelines and measures, many guidelines and processes (assuming an organiza- efforts. Leadership in quality efforts must be broadly dispersed throughout the system and organizations have found it difficult to gain traction tional commitment to quality, service and/or safety must be properly supported and informed by governing boards and bodies. for quality and safety initiatives. Are 439 measures excellence) combined with limits on aspects of tra- too many? Are four too few? Debates continue ditional individual discretion and autonomy. 6. ncentives help. Well-conceived incentives can motivate and facilitate desired behaviors. I about defining quality so that it is operationally Risk management science has shown that 7. ealth Information Technology and Informatics, while not sufficient to improve quality, H useful for substantial improvements in care. Also vast gains in safety and quality are achieved in are increasingly indispensable and are best developed and deployed through staged unsettled are the measures that can appropriately many situations where relatively high tolerance for introduction into clinical practice. AHCs must champion the staged adoption and advance- capture and quantify quality and safety outcomes. individual discretion is transitioned to a reliable ment of appropriate information and communications tools that support health care, educa- How should measures and efforts be prioritized? standard of excellence that is shared by broadly tion and research processes that are addressing quality and safety as system properties. Equally important, the majority of physicians equivalent actors. (Amalberti et al 2005, 759). Risk- This report summarizes issues in each of these key findings and offers examples of successful practice solo or in small groups of four or less. management programs create and enforce robust strategies and practices that can result in significant gains in patient safety and in high quality There are more than a billion visits to physician safety-focused protocols around a “reliable standard health care. offices, hospital outpatient facilities, and emergency of excellent care” (Ibid). Standardized guidelines and Risk management science has sion prioritization is provided residents commence their training, to the month less predictable and safe and hence can achieve a processes transition key person- shown that vast gains in safety by Emory University’s Woodruff of December, when these new learners have gained very high degree of safety and quality but at the nel, whether pilots, engineers, or health Sciences Center. There, an experience. However, such variation in the quality somewhat lower standard of “high-reliability.” and quality are achieved in many physicians, from a craftsmanship intensive internal strategy pro- and safety of care must be acknowledged as unac- Put another way, for the domains of medi- approach (centered on the primacy situations where relatively high cess resulted in the ratification of ceptable. This is a clear case where foundational cine that are less stable and fraught with more of the heroic or otherwise excep- tolerance for individual discretion three co-equal missions of health standards and systems must be employed and uncertainties, complexity and other factors tional individual) to an approach is transitioned to a reliable stan- care, education and research, enforced to carefully supervise and limit the discre- (uncertainties in specialty service demand, that values “equivalent actors”. By but at the same time established tion of early learners. highly unusual or complex cases, worker short- dard of excellence that is shared this process of standardization that the core end-purpose of this Balancing the need for learning experiences ages), more deference must be given to “flexible around reliable standards of excel- by broadly equivalent actors. tripartite activity is, “Making with the needs for safety is not easy. But studies risk arbitration and adaptation rather than strict lence, both the practices of pilot- People Healthy”. The acknowl- suggest that new approaches to training and super- limits” (Amalberti 2005; Weick, et al 2001). In ing in commercial aviation and of edgement of this ultimate purpose vision, involving teamwork and standards develop- such domains, Q&S is designed for and charac- anaesthesiology in health care have become two of in making people healthy serves to catalyze the ment relating to such basic factors as addressing terized by “high-reliability”. In domains where the nation’s most consumer-safe services (Ibid.). subsequent development of a system-wide quality, fatigue with adequate sleep, can significantly limited complexity of tasks enables the maximum The hard lesson for the AHC is that highly-reli- safety and service program (Bornstein 2006). increase safety and improve development and utilization of able, evidence-based care of the highest quality and learning (Philibert & Barach While many AHCs differentiate rules, procedures and equivalent safety for patients, whether those with relatively sim- n The traditions of significant autonomy of aca- 2002). Even more fundamen- actors, safety trumps productiv- themselves by virtue of their ple or with multiple and complex medical problems, demic faculty, departments, and professionals, tally, training must refocus ity and the organization can will not happen through superior intelligence, ency- combined with lack of experience with high- on learning to work in teams capabilities in managing highly aspire to “ultrasafe” standards clopedic knowledge, good intent, and/or vigilance reliability systems, may also contribute to an where each individual takes complex patients, the vast majority and systems (Amalberti 2002). on the part of particular individuals. Achieving this AHC disadvantage in achieving highest quality. responsibility for elevating of clinical care provided in AHCs Q&S processes can be cus- goal requires organizing a reliable standard of excel- A common refrain heard in response to efforts performance of the team to the is of average complexity. Progress tomized to fit these different lent care at the system level, employing appropriate to create a standard baseline of excellent care highest standards of clinical domains. information, communications, decision support and is, “I didn’t go to med school to practice cook- in enhancing Q&S in both routine excellence. These typologies are derived outcomes evaluation systems, and the organization book medicine.” Yet, risk-management research and complex care are of equal from experience in risk manage- of appropriate, responsible and accountable groups and experience has taught that “unconstrained” n The challenge of managing importance for the AHC. ment in various industries. In and teams composed, as far as possible, of equiva- human performance (guided by personal discre- high complexity patients and the nuclear power and commer- lent actors. tion, only) results in accident rates worse than services is another AHC Q&S challenge. There cial aviation industries, public policy demands AHCs have no inherent advantages in the 10-2. Constrained human performance can reach can be tension between delivering routine services ultrasafe systems and tolerates tradeoffs in the endeavor to create ultrasafe or highly-reliable systems 10-2 to 10-3 (Amalberti et al 2005). As part of the and delivering complex, individually tailored care form of occasional inconvenience (e.g., airline of care. In fact, university-based AHCs may have systemic processes that have been developed, lead- for esoteric clinical problems and diseases. While flight cancellations due to weather or mechanical significant disadvantages compared to community- ing to an extraordinary record of safety achieved many AHCs differentiate themselves by virtue issues). In the military and chemical production based provider organizations. These likely include: in airline travel, a fundamental and indispensable of their capabilities in managing highly complex industries, public policy endorses high-reliability safety measure developed by and for airline pilots patients, the vast majority of clinical care provided systems that rely more on, or demand, far more n he commitment to multiple missions (often T involves completing a pre-flight checklist. This in AHCs is of average complexity. Progress in operational discretion and higher risk-tolerance. expressed as “co-equal” misssions) that can dilute recipe from the professional piloting “cookbook” enhancing Q&S in both routine and complex care These two typologies deserve far greater develop- focus on patient care quality and safety. Although is understood as absolutely essential to the quality are of equal importance for the AHC. ment within health care organizations and should this is difficult for many in AHCs to reconcile, and safety mission of the professionals and crew A promising approach to Q&S challenges be the subject of extensive research and modeling. evidence is growing that achieving institutional involved in every flight. As equivalent measures within the AHC is suggested by Amalberti and focus and reform centered on quality and safety are incorporated into medical practice, studies colleagues. They suggest a two-tiered approach n he challenge of managing patient handoffs T requires of all health care organizations that they show marked improvement in safety (Cook & to quality and safety, corresponding to two types represents another unique AHC Q&S challenge. effectively make patient care quality and safety Woods 1996). of medical “domains”. Some medical domains In the AHC teaching environment, one result of the primary mission of the organization. Without (anesthesiology, blood transfusions, radiotherapy) the adoption of limitations on resident physician such prioritization of quality and safety in patient n The challenge of managing young learners so as are stable enough (relatively less complex and work hours is that “hand-offs” of hospitalized care, it becomes difficult as a matter of policy to achieve consistent year-round performance is more routine) to achieve criteria for ultra-safety. patients occur more frequently, increasing the and practice, to effect the changes in culture and another potential AHC Q&S hurdle. It is common Whereas, some medical domains (emergency risks of information and communications errors behavior that are necessary knowledge that quality and safety of care can vary medicine, intensive care, surgery) must deal with and resulting incidents or even a cascade of clini- An example of an effective approach to mis- significantly from the month of July, when new more unstable conditions and will inevitably be cal errors. The increasing utilization of hospitalists helps to mitigate this problem because hand-offs as is periodically the case in a dynamic economy, focused on reducing the autonomy of pilots, train- culture change had to come from within the is a core competency of such specialists. The society, or organization, it is often the established ing all aviation professionals and workers to func- organization. The Blue Ridge Group believes that hand-offs issue implicates a broader set of orga- organizational culture (way of doing things) that tion on the equivalent actor model in teams, and this is an essential insight: The exact formula for nizational imperatives related to developing and either inhibits or prevents change. As one study on the development and implementation of com- effecting culture change likely will vary with each institutionalizing appropriate care management describes it, “When competent people craft good prehensive risk-management and process improve- organization. What is most important is that there systems and teams. strategies that they continually fail to execute, the ment programs (Amalberti, et al 2005). is an explicit decision to achieve Q&S transforma- problem lies not in the strategies but in understand- Culture change in a highly tion within the organization. These factors, and possibly others, are intrinsic ing what it is in the culture that causes the failures” regulated and relatively consoli- Ascension’s approach to Ascension started with a retreat and somewhat unique to AHCs and can present (Pryor et al 2006, 301). dated industry like aviation or that included 120 leaders who understanding and achieving culture especially tough issues for developing organization- The culture of health care organizations is dom- nuclear power is not simple to defined a consensus vision: al capacity in quality and safety. However, the fact inated by professional and academic “ways of doing effect, but might appear a cake- change within the health care “Health care that works, health- of special challenges cannot be an excuse for not things” that have been described many times and walk compared to the challenge organization provides a wealth of care that is safe, and healthcare undertaking systemic improvement in quality and that are characterized earlier in this report as the of changing culture throughout insight for others to model and adapt that leaves no one behind”. safety. Significant Q&S improvements require, at a traditions of relative autonomy, status and authority our decentralized and balkan- within their own organizations. Once this vision and minimum, significant organizational commitment, of physicians and medical faculty (see page 8). As ized health care industry. But explicit Q&S goals were adopt- planning and execution. Both the missions of the health care has begun to transition from a decentral- nothing short of this sort of ed, the formula for culture AHC (we exist in part to tackle the hard cases!) and ized artisan or craft model of medical practice to a comprehensive approach is required in health care. change evolved out of its internal process. What the moral and ethical foundations of health care modern, knowledge-worker model, health profes- In light of the significant changes that must be emerged was a process to change “the way we do professions and practice (e.g., “First, do no harm”) sionals, learners, managers and staff are increasingly accomplished in health care, the Blue Ridge Group things around here” based on, ”The Five C’s of require our leadership in Q&S. facing the need to develop a culture of teamwork, believes that there is much to learn from and emu- Culture Change”. These are identified as: shared responsibility and adherence to acknowl- late examples of systems where large-scale cultural edged Q&S controls. This is no trivial task. transformation has been successfully undertaken. n Comprehension: Understanding the problem. To take the aviation example again, commer- Ascension Health presents a compelling example This first element is perhaps the most important. Finding #2: “Culture Eats Strategy For Lunch”. cial pilots are not simply required to perform at of such initiative. The progress at Ascension in Comprehension of the need for change of culture It is not enough to plan and/or to engineer the highest levels of technical expertise in flying an addressing Q&S issues has been well documented must become a common, shared perspective. organizational changes. Unless the goal and aircraft, but are responsible for the safe operation of in a series of published studies that should be Ascension reports that critical to this compre- practice of quality becomes part of the orga- the aircraft and the overall safety and flying experi- required reading for everyone interested in hension has been coming to the understanding nizational culture, quality initiatives are not ence of the passengers. Pilots must work closely improving Q&S in health care. Highlights of their that safety is a system characteristic: errors and likely to succeed. with other professionals and crew to achieve these experience in achieving culture change include: other quality problems are not about blaming goals. For a physician, the analogy is that he or she individuals but about creating better systems. The culture of our organizations is perhaps the must not simply see their role as being in charge n ngaging the entire leadership team in formulat- E Addressing the issue in this way is critical to biggest impediment to under- of the patient and the episode ing a vision for safe health care, setting a clinical minimizing defensiveness of caregivers and standing and addressing quality Just as a pilot is not only responsible of care, but being responsible transformation agenda, identifying challenges to providing a motivation for broad-based and safety issues in health care. for the operation of the aircraft for the experience and safety of this agenda, and establishing measurements of participation and initiative in changing the There are extensive sociological care for the patient. Physicians progress way things are done. but for the overall safety and flying and business management liter- must work closely with other atures on the culture of organi- experience of the passengers, the professionals and staff to n A ddressing the cultural challenges explicitly, with n Compassion: Spirituality and commitment. zations and how to understand physician must not simply see their achieve these goals. Put another constructive, positive initiatives that involved This element has been important to Ascension the role that culture plays. But role as being in charge of the patient way, physicians must change professionals and staff in understanding and as a religiously-sponsored (catholic) health care culture can be relatively simply and the episode of care, but being their perspective from, “it is the defining how the environment could and should system. Considerations of spirituality and understood as, “The way we do decisions I make that determine change in light of the goals and vision and what commitment relate to the importance of the responsible for the experience and things around here” (Schneider outcomes” to “I am responsible, investments had to be made in people, infra- meaning and purpose of the work and the types 1994). Every organization has safety of the patient. at least in part, for creating a structure and systems to enable and support the of relationships with colleagues, patients and a culture; some contain a core safe health care environment new environment. (Pryor et al 2006) families essential to it. Mutual respect and a culture with a number of distinct sub-cultures. for my patients and for my team members” (Pryor caring orientation towards colleagues as well Culture tends to be relatively stable and grows more et al 2006). Ascension decided not to try to take on a pre-for- as patients and families is systematically culti- “entrenched” as an organization ages and achieves In aviation, this change to a culture of safety mulated “six sigma” or other “branded” approach. vated as a hallmark of this organization and success. (Ibid). When significant change is required, and quality has evolved over more than 30 years, There was a strong sense that the approach to its people. 10 11 n Collaboration: Teaming between subcultures tural change schema denotes the emphasis on A great deal of progress can be Finding #3: for end of life care, Ascension was able to target an and providers. Collaboration at Ascension means engendering change through engagement rather made in establishing a culture of quality and overall 25% reduction in mortality rate. something more than simply cooperation as than by edict. Researchers at Ascension report in improving safety and outcomes by focusing Many of adverse events that appeared to be proxi- might traditionally exist among caregivers, staff, that, in many cases, best practices are effectuated on one or a few “Big Hairy Audacious Goals” mate causes of preventable mortality were those leadership and other stakeholders. Collaboration and rolled out through a “viral” process of will- (BHAGs). identified as “Priorities for Action”. For each prior- here refers to what is now commonly referred to ful adoption spurred both by examples of internal ity, one or more alpha sites were chosen to pilot as teamwork. It embraces the concept of individu- success and the initiative of localized caregivers After review of many efforts of health systems and new approaches to mitigate these risks. In each site, als coming together as “equivalent actors” in the and staff. Convergence among disparate parts of practices to improve Q&S, the Blue Ridge Group is leadership and staff teamed-up to conduct compre- ways described earlier in this report (see page 8). the organization on the goals for clinical Q&S convinced that significant and meaningful improve- hensive studies of risk factors and new approaches Especially important to generating shared under- doesn’t rely on the naïve notion that caregivers ments -- and in some cases transformations of the to mitigation. standing of the difference between traditional and staff would or should simply spontaneously health care environment -- can occur where the The Borgess Medical Center (Kalamazoo, cooperation and the new type collaboration being change out of the goodness of their hearts. Instead, target is one or a few key goals or outcomes. “Big Michigan) became the alpha site to address the elimi- targeted were surveys of caregivers and staff that convergence is achieved by deliberate and always Hairy Audacious Goals” (BHAGs), as they are nation of preventable deaths. A comprehensive effort have shown very significant differences in percep- collaborative efforts to structure all activity to sometimes called, can go a long way towards estab- included the introduction of intensivists and hospi- tion of the extent and effectiveness of cooperation achieve quality and safety as well as fiscal and lishing an orientation towards change in systems talists and the employment of four new strategies in between physicians and other caregivers and staff. operational success at every level of the organiza- and behavior throughout a health system. critical care and two outside critical care. A study of Sharing such data, as well as other important tion. Innovative incentive, reward and recognition There are a number of prominent examples of the results of one critical care strategy—tight glyce- perspectives on teamwork and collaboration, has programs are important in establishing norms and the successful pursuit of BHAGs. The Institute mic control with insulin drips—and one non–critical been critical in effecting needed changes in com- accountability for quality and safety and “the way for Healthcare Improvement’s 5 Million Lives care strategy—deploying rapid response teams to res- munication and behavior by and among all team things are done around here” (Ibid). Campaign, in particular, has been a catalyst for cue patients before cardiopulmonary arrest outside of members many ambitious Q&S programs focused on prevent- critical care – reports that over the three year period To measure and ensure feedback on the effort to able mortality and avoidable injuries that have cap- from April 1, 2003–March 31, 2006, observed mor- n Coordination: System processes, infrastruc- change culture, Ascension employs a system-wide tured the imagination of whole health systems. tality decreased by 19.2%. This result was considered ture, and ideation. Addressing coordination at culture survey of front-line workers. Such measure- In this regard, Ascension Health again provides a tremendous quality and safety achievement in a Ascension refers primarily to the need for all ment enables Ascension to gather data on front-line examples that are well documented. Ascension has relatively short span of time, representing the preven- caregivers and staff to understand and become workers’ perceptions and experience of everyday reported achieving what is described as clinical and tion of hundreds of deaths (Tolchin et al 2007). proactive in establishing standards, protocols, and issues and encounters. This data reinforces connec- cultural “transformation” through the adoption of Similar results have been reported in the other systems inter-operability especially in the areas tivity of leadership with the broad spectrum of care eight BHAG “priorities for action” in hospitals and Priorities for Action areas (Ibid). Important to all of of clinical terminology, clinical pathways, cod- processes and front-line workers that is often lost care groups throughout its system. Based on the these achievements has been choosing the best sites ing, care plans, staffing, and other fundamentals. in the course of change or process implementation. overall goal of providing “health care that is safe” to pilot and develop such innovative approaches to The focus is on identifying those fundamental The survey assesses safety and teamwork across all the Ascension priorities for action or BHAGs have Q&S. Through a careful vetting process, investing processes, resources and information sets that can clinical areas and is used to discover best practices included: in the sites where success is most likely enables the be standardized to a high level of operational and and track progress in improving performance. 1. Joint Commission National Patient Safety roll-out of this process to other parts of the system. clinical excellence. Ascension’s approach to understanding and Goals and core measures The teams dealing with eliminating pressure ulcers achieving culture change within the health care 2. Preventable mortality found that the solution required replacing many n Convergence: Leadership of local culture with organization provides a wealth of insight for others 3. Adverse drug events surfaces used in patient care and transport. A “busi- spread and dissemination of new norms in a to model and adapt within their own organizations. 4. Falls ness case” became an important enabler for the rapid way. Convergence within Ascension’s cul- 5. Pressure ulcers substantial investment required to achieve this goal. 6. Surgical complications Identifying the right, motivated development team 7. Nosocomial infections and making the business case is something that Ascension employs a system-wide culture survey of front-line workers. Such mea- 8. Perinatal safety other industries have found to be critical to estab- lishing a new practice or product and then raising surement enables Ascension to gather data on front-line workers’ perceptions and A key catalyzing BHAG for Ascension was the the bar for others. This is something that is not yet experience of everyday issues and encounters. adoption, in 2002, of the goal of eliminating pre- well done in health care, where well-entrenched ventable injuries and mortality from its system by local cultures and procedures often trump the intro- July of 2008. Through a systematic process of analy- duction of even well-tested alternatives developed in sis and evaluation of deaths of patients not admitted other settings. 12 13 Finding #4: Leadership that practices “mean- cal chairs and faculty physicians. In turn, chairs Governing Boards must be actively Finding #5: board of the health sciences center became aware of ing management” is particularly effective in demonstrate ownership of the quality and safety involved and supportive of Leadership Quality an issue having to do with the re-credentialing of a attaining organizational buy-in and initiative agenda. Information related to that agenda is shared efforts. physician who had what seemed to be an increased that leads to achieving quality goals. regularly throughout all levels of the organization frequency of a certain type of adverse event. Issues of (Keroack et al 2007) Governance is an issue that emerged strongly from quality and accountability were raised. In an unprec- Not surprisingly, leadership is an absolutely criti- The UHC calls this leadership style “meaning the Blue Ridge Group’s consideration of success fac- edented step, the board asked the chair of the depart- cal factor in the success of culture change and the management”, in which the values of the importance tors in achieving a focus on quality and safety. In ment to appear before the board to address the issue adoption of quality and safety as primary health of excellence in patient care are communicated particular, there was broad agreement that many and explain the reasons for the particular creden- system characteristics. The importance of leadership personally by the senior leader of the organization. institutions may not currently have a board gover- tialing decision. While the situation was quickly has long been assumed, but a recent study by the A key indicator of leadership impact in all three of nance structure sufficient to devote the time and cleared-up in that encounter, the impact of that University Health System Consortium (UHC) has the centers where leadership excelled was that staff attention necessary to support quality and safety as action by the board has reverberated throughout the added vital new insight into specific attributes of would recount stories about the hands-on actions a primary institutional focus or to provide sufficient institution. It put everyone on notice that the board leaders who appear to be most effective in achieving of the CEOs. Often, these stories involved first hand oversight and accountability for measurement and is “owning” the issue of quality and safety with a new culture change (Keroack et al 2007). experience of the CEO engaging in a front-line reward of quality and safety achievement. attentiveness. Leaders will be held accountable. It is a UHC set out to identify the organizational and activity or issue and effecting immediate results or In 2005, The National Quality Forum issued a lesson well given and well learned. cultural characteristics of high performing Q&S orga- changes focused on patient care and safety. guidance letter to Hospital Boards concerning their Recognizing this critical issue, the Institute for nizations. Broad-based measures of safety, mortality, Another important characteristic was that responsibility for overseeing the quality of care Healthcare Improvement has recently developed effectiveness, and equity were developed and applied successful leaders insisted on the adoption and delivered in their institutions. The NQF’s guidance a program called, “From the Top: The Role of the to data obtained from UHC member institutions development of objective measures and the use of presents four principles for hospital boards to fol- Board in Quality and Safety”, as part of its 5 Million in 2003-2004. Each hospital was ranked according benchmarking and external comparisons. They low, with specific strategies for each principle. The Lives Campaign, designed to improve the capabil- to an overall score. Three top performing and three were unafraid of finding areas where performance principles are that hospital boards should: ity of an organization’s board to oversee quality and middle-performing institutions were chosen for fell short and were committed to understanding and safety endeavors (IHI 2007). The IHI has developed intensive site visits that involved extensive interviews achieving best practices. 1.Take concrete steps to fulfill their role in a set of six critical guidances for governing boards. with leaders, clinicians and front-line workers, and In contradistinction to this type of leadership, ensuring quality; These include: reviews of key documents from committees charged the UHC found that leadership characteristic of 2.Enable effective evaluation of their own role in with quality and safety. Case studies of the top per- average institutions failed to display this sort of enhancing quality; n Aims: Make an explicit, public commitment to Set formers present a fascinating and valuable study of engaged, committed behavior or priority setting. 3.Develop “quality literacy” regarding patient measurable improvement. how an organization can set Leaders of these organiza- safety, clinical care, and healthcare outcomes; and carry-out a Q&S agenda The bottom line for the high- tions treated quality and safety and n Seek Data and Personal Stories: Audit at least 20 through an exciting and trans- more as an abstract concept or 4. versee and be accountable for their insti- O randomly chosen patient charts for all types and performing organizations is that, “By formative process. Case studies regulatory requirement, rather tutions’ participation and performance in levels of injury, and conduct a “deep dive” investi- of each of these examples can be focusing on patient care continually than a personal passion. There national quality measurement efforts and gation of one major incident, including interview- accessed by UHC member orga- and repeatedly, CEOs have instilled was often tension or conflict subsequent quality improvement activities. ing the affected patient, family, and staff. nizations on the UHC website: an organization-wide stewardship of between the missions of clini- (http://216.122.138.39/pdf/news/call2responsi- http://www.uhc.edu/results_list. service, quality, and safety” cal care, teaching and research. bility3-16-05.pdf). (Kurtzman and Page-Lopez n Establish and Monitor System-Level Measures: asp?folder=WEB/IE/BenchNew/ Department Chairs were often 2004) Track organization-wide progress by installing and all/PerfImp. allowed to opt out of quality overseeing crucial system-level metrics of clinical On the basis of its interview and case review and safety initiatives, and the atmosphere was one The NQF guidance makes clear that hospital quality, such as medical harm per 1,000 patient process, the UHC found that CEOs of top-perform- of “every department for itself.” trustees have responsibility for ensuring the qual- days or risk-adjusted mortality rates over time. ing organizations are passionate about quality, and The bottom line for the high-performing ity of clinical care provided in their institutions. It safety and have an authentic, hands-on style. They organizations is that by focusing on patient care suggests that responsibility cannot be delegated to a n Change the Environment, Policies, and Culture: often use a focus on service as a way of catalyzing continually and repeatedly, CEOs have instilled an quality committee of the board or to the executive Require respect, communication, disclosure, trans- commitment to patient care. Everyday events are organization-wide stewardship of service, quality, leadership or to medical staff. parency, resolution, and all the elements of an connected to the higher purpose of patient care and safety. An example of the power of Board involvement organization fully committed to quality and safety. through stories and highly visible actions. The chief comes from one of our member organizations. In medical officers also play a critical role in perfor- this example (in which the institution will not be n Encourage Learning, Starting with Yourself: mance improvement and serve as mentors for clini- identified in order to protect privacy), the governing Identify the capabilities and achievements of the 14 15 best hospital boards and apply that standard to Finding #6:Incentives can help. Well-conceived for-performance have been Providers must assume that P4P is A report by the Robert yourself and all staff. incentives can motivate and facilitate desired published to date. The evidence here to stay. P4P and other such Wood Johnson Foundation in behaviors. for efficacy is promising but not 2005 discussed the ambiguous initiatives are not all about “show n Establish Accountability: Set the agenda for conclusive. Ascension Health results and implications of the improvement by linking executive performance There are well-worn, business-tested approaches to reports significant success in me the money”. They can and should Rewarding Results initiative, and compensation. (see http://www.ihi.org/IHI/ both incentivize and discourage certain behaviors tying everyone to incentives, play a key role in the transition to a national initiative under- Topics/LeadingSystemImprovement/Leadership/ and outcomes among employees and other stake- including CEOs (Pryor 2006). patient-centered practice. taken by the Leapfrog Group, ImprovementStories/FSThePowerofHavingtheBoa holders, including monetary incentives and profes- But the results overall are still the Robert Wood Johnson rdonBoard.htm) sional rewards in the form of awards, promotions, inconclusive. In a recent study Foundation, the California and recognition of all sorts. of the effects of new Medicare incentive payments, Healthcare Foundation and the Commonwealth The Blue Ridge Group fully endorses these recom- Pay for Performance (P4P) has been controver- results showed a mere 2.9% gain in participating Fund to help pilot the use of incentives for high- mendations. The adoption of such policies and prac- sial within the health care industry since it was hospitals over a control group of non participa- quality health care. The ten lessons learned and tices would go a long way towards catalyzing institu- introduced. But it was introduced because provider tors (Lindenauer et al. 2007). Only modest gains reported represent a very good summary of the tion-wide transition to a quality and safety focus. organizations and payors both have experienced in performance improvement have been found in many issues in pay for performance that require Beyond the board level, governance through- difficulties in effecting changes in medical practices most studies of their implementation (Rosenthal & ongoing investigation. These include: out an AHC or other provider organization should and processes. The drivers of P4P include: Dudley 2007) be informed and infused by policies and prac- There are many limiting factors in developing and 1. inancial incentives F tices that catalyze a Q&S focus. The UHC, for • Large gaps in quality and safety testing incentive and reward programs. Most studies do motivate change. Vitally important is instance, found that a quality and safety-focused • Rapid rise of health care costs focus on one element or aspect of care, while most But they need to be that the leadership AHC is characterized by “governance structures • Perverse incentives in payment systems P4P initiatives use multiple indicators. There are large enough to make of AHCs adopt as and practices (that) minimize conflict between •Huge budget problems in the private an significant limitations in the existing knowledge and a difference. Bridges to public sector research base for performance measures. Providers a priority agenda missions”; and “is led as an alliance between the Excellence for example executive leadership team and the Chairs” (Keroack •Payers who want to use market forces to often are not convinced that P4P measures pro- suggests that at a mini- research into P4P et al 2007). This entails accountability for quality move the needle on quality, cost or both mulgated by payors are more than dressed-up mum the incentive be set and the efficacy of and safety being equally shared among depart- (Clancy 2006) cost-cutting schemes. Administering and track- at $5,000 per physician incentives in changing ments, divisions and clinical unit leaders. As in the ing performance requires new resources and time. to affect quality improve- P4P has been championed especially by payers behavior and Ascension model, and in those of the top perform- There is the potential for unintended consequences. ment; others suggest that ers in the UHC study, Q&S improvement must flow who see P4P as a way to accelerate the pace of qual- Measures and their implementation can distort or they need to be struc- improving Q&S. in a continuous loop from the central administra- ity improvement. And while many providers have distract a medical practice from other important tured to account for at tion to the entire institution and back. While mea- resisted developments in P4P, as one senior official clinical activities. Performance and measurement least 10 percent of a physician’s annual income. sures and priorities can be set initially by leader- has said, “The train has left the station” (Ibid). In can be “gamed”, providing a false overall outcomes The seven Rewarding Results sites are offering ship, the specifics of localized implementation must June of 2005, CMS Administrator Mark McClellan and practice picture. Many performance measures incentives at a variety of levels. be cultivated and catalyzed locally. This should announced CMS plans “to implement a pay-for- require the implementation of new and expensive result in a continuous loop of feedback, measure- performance system for Medicare providers”, along health information technologies that for many phy- 2. on-financial incentives also can make a dif- N ment, implementation and innovation – and a new with plans to pilot the use of claims data to measure sician groups, especially small groups, is a limiting ference. Just providing support for additional “way of doing things around here”. physicians’ use of health care services to compare factor. For instance, site visits to 12 nationally rep- staffing to make a physician’s job easier or sup- physicians’ performance (http://www.medicalnews- resentative communities discovered only two had porting infrastructure to supplement technology today.com/medicalnews.php?newsid=26769). There significant pay-for-performance programs (Center can motivate physicians to hit quality targets. are already over 100 private pay-for-performance for Studying Health System Change 2005). Simply adopting electronic or programs nationwide, covering 40 million patients In the face of these and many other concerns, it 3. ngaging physicians is a critical activity. E digital information and decision (Clancy 2006). More than half of commercial health is absolutely essential that providers become fully maintenance organizations are using pay-for-per- All seven projects have worked hard to engage support systems to existing care engaged partners in the process of creating and formance (Rosenthal & Dudley2007) physicians, with varying degrees of success. implementing incentive and rewards programs. P4P practices does not necessarily Providers must assume that P4P is here to stay. If physicians are not brought into the process and other such initiatives are not all about “show me It is no longer a question of incentives versus no early as collaborators to ensure that goals are lead to improved quality, the money”. They can and should play a key role in clinically meaningful, they will not adopt and incentives, but “How do we develop incentives the transition to patient-centered practice, including safety or outcomes. aligned with what we want from health care?” sustain the change. better and consumer-friendly performance and out- Only nine randomized controlled trials of pay- comes assessment tools, transparency, and feedback. 16 17 4. here is no clear picture yet of return on T 9. xperience with managed care matters. E n involved with purchasers as early as possible Get Finding #7:Health Information Technology and investment. Estimating the return on invest- Markets where managed care has more of a in the design, implementation and evaluation of Informatics are increasingly indispensable and ment of P4P is essential but few projects foothold seem to have an easier time with P4P P4P programs are best developed and deployed through staged nationally are conducting rigorous research on because physicians and the general public are introduction into clinical practice. AHCs must this topic. There are still questions about who more comfortable with issues related to quality n Understand that incentives work best as a source champion the staged adoption and advance- should benefit from cost savings and over what improvement such as transparency, accountabil- of funding for investment in quality improvement ment of appropriate information and commu- time span the return on investment should be ity, and performance comparisons. tools and infrastructure nications tools that support health care, educa- calculated. tion and research processes that are addressing 10. 4P is not a magic bullet. It is one of a number P n Focus on the quality of care measures so we’re not quality and safety as system properties. 5. ublic reporting is a strong catalyst for pro- P of activities underway by the public and private just “scoring”, but healing viders to improve care. However, providers sectors to improve quality and change incentives The growth of health information technology (HIT) need adequate tools and data to keep improving. in the way health care is delivered and financed. n Continue migration to health information tech- and informatics combined with applied research To maximize improvement, providers also need If it’s implemented well and aligned with other nology to enable full utility of P4P programs in quality measurement and safety has been key to to be rewarded for installing and using health incentives including performance feedback, enabling the new focus on quality and safety in the information technology and building infrastruc- public reporting, and support for systems n Understand the incentives and what must be done environment for health education, research and care. ture to track and compare performance. improvement, it appears that it can be a useful to qualify for them Yet there is still much to be done. Understanding tool. (http://www.rwjf.org/files/newsroom/ and addressing Q&S as system properties requires 6. roviders need feedback on their perfor- P RewardingResulstsLessons_110705.pdf?gsa=1) n Perceive the value of the incentives to be worth appropriate system infrastructure and capabilities. mance. Frequent, clear and actionable feedback The current consensus is that many strategic ques- their time and efforts Many of the shortcomings in health care identified to providers is essential. Many of the Rewarding tions remain to be addressed, including: in the IOM Errors report, and in other studies, are Results projects issue public report cards to help n Believe the incentives will be good for their patients the result of non-existent, poor or inaccessible data physicians compare their performance to others n ill P4P primarily reward providers who are W or information, and the lack of capacity to easily and and make their performance more transparent already doing well, or can it also stimulate lower n Have sufficient control over the clinical activities efficiently share information. to consumers. Physicians need to understand performers to improve quality? required to achieve the targets Improving health in our nation requires not what aspect of their performance will be evalu- n here should incentives be directed – to indi- W only the deployment of local electronic medical ated; how performance will be measured; and viduals, groups, hospitals, or a mix? n assured incentives are administered fairly Be records systems, but a national health information how performance and incentives are related. n ow do we integrate process and efficiency mea- H (Clancy 2006) infrastructure (NHII) that can provide connectiv- They also need to be given tools and guidance sures with quality and outcomes measures? ity, decision support, and knowledge management on how they can improve. n hile outcomes are what really matter, how do we W Vitally important is that the leadership of AHCs across national boundaries (Detmer 2003). This deal with imperfect risk adjustment methodolo- adopt as a priority agenda research into P4P and has been recommended by the National Committee 7. roviders need to be better educated about P gies and long-term follow-up needed to meaning- the efficacy of incentives in changing behavior and on Vital and Health Statistics and the President’s P4P. Physicians are deluged with clinical and fully measure and compare outcomes? improving Q&S. There is a science to the testing and Information Technology Advisory Committee reimbursement information. For any payer, n ow do we standaradize the measures sufficiently H evaluation of performance measures and incentives (PITAC), among many other organizations and even those with a large share of the market, it to lower the overhead costs for data collection? that has not yet been broadly accepted as the type of thought leaders (PITAC 2004). can be challenging to attract provider attention. n hat is the role of incentives in areas such as W challenge to engage the hearts and minds of AHC Further, experience is showing that simply But they need to find effective communication chronic disease management, and prevention and faculty—nor has it been prioritized, recognized and adopting electronic or digital information and deci- tools to raise awareness about P4P; if they don’t, wellness programs? rewarded. Importantly, while monetary payments or sion support systems does not necessarily lead to physicians will ignore quality improvement n How can P4P programs work in small group prac- withholds are relatively new additions to the incen- improved quality, safety or outcomes. At its best, demands or as in one case, inadvertently throw tices, the settings where the majority of Americans tives and rewards arsenal in AHCs, in the environ- information technology improves Q&S “ . . .by sup- bonus checks in the trash because they aren’t receive care? ment of health care and academic medicine, there plying information when and where it is needed to aware of the program. is intimate familiarity with the use and utility of help people make better decisions, by eliminating A report from IOM on P4P strongly recommends incentives and rewards. AHCs and professional soci- communication and process errors, and by analyz- 8. ata integrity is important. Most health care D that a single playbook is needed to make P4P work eties have long employed a broad array of traditional ing information about the patient in combination providers are deluged with quality measures and calls on Congress to authorize National Quality incentives and rewards, including academic promo- with biomedical knowledge to make patient-specific from a variety of payers. They are more likely to Coordination Board to facilitate the development of tion, professional recognition, named chairs and recommendations.” (Stead 2007, 14.3) However participate and embrace P4P if they view mea- common national standards (IOM 2005). other prestigious rewards, and tenure, and so forth. there is evidence that many applications of informa- sures as valid and scientifically based. Quality In the meantime, with P4P and similar programs All of these can be leveraged and applied to the goal tion technology in practice do not accomplish these targets also need to be clinically relevant. here to stay, providers must work to: of building a culture of quality and service. goals and in fact can lead to quality and safety issues 18 19 of their own. (Han et al, 2006) It is likely that such practice. The approach is to match particular tech- References sequences of computerized physician order entry. problems arise where information technologies are nologies to particular tasks in the clinical process, Stud Health Technol Inform. 2007;129:198-202. simply applied to manage health care processes and understanding that there is a learning curve associ- Abbott K, Slotte S, Stimson D. 1996. The existing cultures and organizations where quality ated with any such changes, including a feedback Interfaces between Flight Crews and Modern Flight Baker DP, Gustafson S, Beaubien JM, Salas E, and safety have not been adequately addressed as loop for revising both the clinical and technology Deck Systems. Washington, DC: Federal Aviation Barach P. 2003. Medical Teamwork and Patient system properties. In such cases, new technologies, processes. A similar staging of the introduction of Administration; 1996. Safety: The Evidence-Based Relation. Washington, including electronic health records (EHRs) may health IT to the patient is suggested. (Stead 2007) DC: Am Institute for Research; 2003. codify outdated practices and The public and private sectors need to collabo- Abelson R. 2005. Medicare says bonuses can Simply adopting roles or only add new layers of rate to build and implement robust health informa- improve hospital care. The New York Times, Nov. 15, Blue Ridge Academic Health Group. 1998a. electronic or digital complexity for providers and/ tion systems. Overall leadership for this requires 2005, page C3. Academic Health Centers: Getting Down to Business. information and or patients without enabling nation-wide buy-in and can be helped significantly Report 1. Washington DC: Cap Gemini Ernst & decision support measurable improvements in by federal incentives or mandates. AHCs collabora- Agency for Health research and Quality (AHRQ) Young US, LLC. quality, safety or outcomes. tion in understanding and implementing model 2007. AHRQ Focus and Strategic Goals, avail- systems to existing (Ash, et al. 2004, 2007) health IT systems could be pivotal in catalyzing the able at: http://www.ahrq.gov/about/ataglance.htm Blue Ridge Academic Health Group. 1998b. care practices does Ascension Health has best approaches to HIT adoption. Accessed October 9, 2007. Promoting Value and Expanded Coverage: Good not necessarily lead approached the introduction Health Is Good Business. Report 2. Washington, DC: to improved quality, of new information technolo- Altman DE, Clancy C, Blendon RJ. 2004. Cap Gemini Ernst & Young US, LLC. safety or outcomes. gies through a process where Conclusion Improving patient safety: Five years after the IOM newly re-designed processes of The goal of creating a high quality health care sys- report. N Engl J Med 351:2041–2043, Nov. 11, 2004. Blue Ridge Academic Health Group. 2000a. care drive the IT systems that are introduced to bet- tem has become a manifest national priority. This Into the21st Century: Academic Health Centers as ter enable those clinical processes. In describing the goal has been explicitly adopted by health policy Amalberti R. 2002. Revisiting safety and human Knowledge Leaders. Report 3. Washington, DC: clinical transformation of Ascension Health, princi- leaders, embraced by public and private organiza- factors paradigms to meet the safety challenges Gemini & US, LLC. pals involved in both conceiving and implementing tions and stakeholders and remains at the heart of of ultra complex and safe systems. In: Willpert B, this transformation describe the supportive role for all health professional norms and values. Despite Falhbruch B, eds. System Safety: Challenges and Blue Ridge Academic Health Group. 2000b. IT in this way: the initiation of multiple efforts across the nation, Pitfalls of Interventions. Amsterdam: Elsevier; In Pursuit of Greater Value: Stronger Leadership the recently published HealthGrades Fourth Annual 2002:265-76. in and by Academic Health Centers. Report 4 “Ultimately, however, redesigned systems must Patient Safety in American Hospitals Study reports Washington, DC: Cap Gemini Ernst & Young US, be supported by substantial infrastructure invest- that progress is slow in American hospitals in pre- Amalberti R, Auroy Y, Berwick D, Barach P. 2005. LLC. ments, which can be grouped as follows: . . . venting medical errors that injure or kill patients. Five system barriers to achieving ultrasafe health Though hospitals have improved in some areas, care. Ann Intern Med. 142(9):756-64. May 3, 2005. Blue Ridge Academic Health Group. 2001a. “System knowledge infrastructure, which entails overall, the study found a 3% increase in the rate of e-health and the Academic Health Center in a Value- creation of a systemwide information base and the medical errors in hospitals between 2003 and 2005 Andrews LB, et al. 1997. An alternative strategy driven Health Care System. Report 5. 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New York: DC: Cap Gemini Ernst & Young US, LLC. ment systems.” (Pryor et al. 2006, 301) goal and practice of Q&S an indispensable element Aspen; 2003: 205-25. of professional and organizational culture. This can Blue Ridge Academic Health Group. 2003. This approach to IT infrastructure, where the often best be catalyzed by the adoption of a few Ash JS, Berg M, Coiera E. 2004. Some unintended Reforming Medical Education: Urgent Priority for the “knowledge infrastructure” is designed to support a BHAGs, which are championed by an engaged lead- consequences of information technology in health Academic Health Center in the New Century. Report redesigned clinical care process, likely provides the ership supported by governing boards and bodies, care: the nature of patient care information system- 7. Atlanta, GA: Emory University. best opportunity to employ health IT in support of where everyone in the organization is incentivized related errors. J Am Med Inform Assoc. 2004 Mar- Q&S improvements. and appropriately rewarded for the achievement of Apr;11(2):104-12. Blue Ridge Academic Health Group. 2004. William W. Stead, at Vanderbilt University, has desired behaviors and outcomes. The development Converging on Consensus? Planning the Future of developed a model for staged, stepped introduc- of a national health information infrastructure will Ash JS, Sittig DF, Dykstra R, Campbell E, Health and Health Care. Report 8. Atlanta, GA: tion of health information technologies into clinical be essential to making quality and safety job one. Guappone K. 2007. Exploring the unintended con- Emory University. 20 21 Blue Ridge Academic Health Group. 2005. Getting Donchin Y, et al. 1995. A look into the nature and 2006. Available online at: http://www.iom.edu/ Lohr KN. (ed.). 1990. Medicare: A Strategy for the Physician Right: Exceptional Professionalism for causes of human errors in the intensive care unit. 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Improving communica- sive care units: Does good management make a dif- tion in the ICU using daily goals. J Crit Care 18:71– ference? Med Care 32:508–525, May 1994. 75, Jun. 2003. Stead WW. 2007. Rethinking Electronic Health Pryor DB, et al. 2006. The Clinical Transformation Records to Better Achieve Quality and Safety Goals. of Ascension Health: Eliminating all Preventable Annu. Rev. Med. 58:14.1–14.13. 2007. Injuries and Deaths. Jt Comm J Qual Pat Saf 32:299–308, Jun. 2006. Thomas EJ, Sexton JB, Helmreich RL. 2003. Discrepant attitudes about teamwork among critical Blue Ridge Academic Health Group Report Ordering Information Reason JT. 1997. Managing the Risks of care nurses and physicians. Crit Care Med 31:956– If you would like to order copies of this publication—or any of the others listed below—please contact Organizational Accidents. Brookfield, VT: Ashgate 959, Mar. 2003. Publishing, 1997. Anita Bray Tolchin S., et al. 2007. Eliminating Preventable Office of the Chancellor Rose JS, et al. 2006. A Leadership Framework for Deaths at Ascension Health. Jt Comm J Qual Pat Saf 201 Dowman Drive Culture Change in Health Care. Jt Comm J Qual Pat 33:145-154. March 2007. Atlanta, GA 30322 Saf 32:433-442, Aug. 2006. Phone: 404-712-3500 Wachter RM. 2004. The end of the beginning: Fax: 404-712-3511 Rosenthal MB, Dudley, RA. 2007. Pay-for- Patient safety five years after “To Err Is Human.” E-mail: abray@emory.edu. Performance: Will the Latest Payment Trend Improve Health Aff (Millwood) Suppl. Web Exclusives: W4- Care? JAMA Voll. 297, No. 7. February 21, 2007. 534–W4-545, Jul.–Dec. 2004. When requesting publications, please refer to the report number and title and provide your full name, organization name, business address, city, state, zip, telephone, and email. Schmidek JM, Weeks WB. 2005. What do we know Weeks WB, Bajian JP. 2003. Making the business Report 11: Health Care Quality and Safety in the Academic Center about financial returns on investments in patient case for patient safety. Jt Comm J Qual Patient Saf Report 10: Managing Conflict of Interest in AHCs to Assure Healthy Industrial and safety? A literature review. Jt Comm J 29:51–54, Jan. 2003. Societal Relationships Qual Patient Saf 31:690–699, Dec. 2005. Report 9: Getting the Physician Right: Exceptional Health Professionalism for a New Era Weick KE, Sutcliffe KM. 2001. Managing the Schneider WE. 1994. The Reengineering Alternative: Unexpected. San Francisco: Jossey-Bass, 2001. Report 8: Converging on Consensus? Planning the Future of Health and Health Care A Plan for Making Your Current Culture Work. Burr Report 7: Reforming Medical Education: Urgent Priority for the Academic Health Center Ridge, IL: Irwin Professional Publishing, 1994. Zwarenstein J, Reeves S. 2002. Working together in the New Century but apart: Barriers and routes to nurse-physician Report 6: Creating a Value-driven Culture and Organization in the Academic Health Center Schoenbaum SC, Holmgren AL. 2006. The collaboration. Jt Comm J Qual Improv National Committee for Quality Assurance’s 28:242–247, May 2002. Report 5: e-Health and the Academic Health Center in a Value-driven Health Care System The State of Health Care Quality 2006, The Report 4: In Pursuit of Great Value: Stronger Leadership in and by Academic Health Centers Commonwealth Fund, November 2006. Report 3: Into the 21st Century: Academic Health Centers as Knowledge Leaders Report 2: Promoting Value and Expanded Coverage: Good Health Is Good Business Sexton JB, Thomas EJ, Helmreich RL. 2000. Error, Report 1: Academic Health Centers: Getting Down to Business stress, and teamwork in medicine and aviation: Cross sectional surveys. BMJ 320:745–749, Mar. 18, 2000. 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