Achieving Productivity and Quality: The Trustee’s Role
By Stephen Lothrop and Sarah Nickerson
Health care insurance premiums are increasing at an alarming rate, while at the same time, hospital productivity is decreasing.* The ability to maintain a competitive cost position is further compounded by the fact that hospitals have a portion of their Medicare reimbursement at risk because it is now based on quality outcomes. Trustees can play a leadership role in putting the organization on course to achieve improvements in both productivity and quality outcomes. To accomplish this successfully, trustees first need to understand the perspectives of multiple stakeholders and, secondly, recognize that a paradigm shift may be necessary in order to implement the processes and programs to help the organization achieve its goals.
California Healthcare Foundation Meeting Survey
During a recent conference sponsored by the California Healthcare Foundation in Oakland, attendees were asked to prioritize 24 practices that they believe contribute most significantly to their hospitals’ achievement of high quality patient care. Results were grouped according to each respondent’s profession or organizational role. When analyzing the results, it’s interesting to note the alignments of various groups (i.e., board members, physicians, nurses, senior managers) and the differences among them:
- Board members and nurses were aligned in placing the highest importance on evidence-based protocols and care guidelines.
- Physicians believed investments in information systems supporting medical error reduction would have the most significant impact on providing high quality patient care.
- Senior managers ranked interdepartmental cooperation as the most influential aspect of providing quality care.
Not only does this comparison indicate there is little agreement on how hospitals should approach delivering quality care, it dramatically underscores the need to understand the dynamics among evidence-based protocols, technology and interdepartmental cooperation. The foundation for driving and achieving improvements in productivity and quality outcomes is at the intersection of these three factors.
Evidence-Based Protocols and Care Guidelines
One objective of evidence-based protocols is to reduce variations and create a performance baseline. When developed and used correctly, the application of evidence-based protocols can improve quality and reduce costs simultaneously. This correlation stems from the premise that poor quality is the result of a performance glitch.
Since a poor outcome uses more resources than a good one, savvy boards will focus their search for quality improvements on those service lines that are costing more than corresponding services lines at other hospitals. Service line costs can be obtained by collecting detailed hospital clinical data from selected hospitals. In any facility, if a product or service is not delivering expected outcomes—indicated by excessive cost—there is an opportunity to improve quality. In this way, the quest for improved quality and enhanced productivity go hand-in-hand.
Another objective of evidence-based protocols is to create a baseline against which outcomes can be compared. Without a baseline, it’s difficult to determine exactly what causes variance from a norm. A baseline of care creates a platform from which to make adjustments to care methods and patterns. These minor adjustments provide evidence for modifying care and create a path for continuous quality improvement. Although many physicians have been working with evidence-based medicine in their own practices, breakthrough methods of collaboration are required to effect change throughout the health care system.
These platforms for collaboration among physicians are becoming increasingly important. As an example, LDS Hospital, in Salt Lake City, part of the Intermountain Health System, has successfully implemented guidelines for treating patients with community-acquired pneumonia. LDS’ success with evidence-based protocols, which has been 10 years in the making, began with active measures to demonstrate the need for change (see “Case Study”.
Since physicians respond best to data, resources that encourage them to look beyond the confines of their own hospital’s walls are very powerful tools for building acceptance to new pathways and protocols. Physicians and nurses are committed to providing the best care possible and will want to change any care process that is clearly ineffective. LDS Hospital discovered that displaying variances in quality of care generated enthusiasm for creating a pneumonia guideline.
Trustees can encourage the senior executive team to measure variation within and between hospitals, identifying the service lines most amenable to making improvements. From there, senior execs can create a business case for targeting those service lines that require the most improvement and are responsible for the greatest excess costs and then develop a corrective action plan. Trustees can ask for objective data that lead to the prioritization of quality projects. Without objective information, project prioritization can become subject to personal views and interests.
The Information Systems Objective
The objective of information technology is to support internal processes. But because investments in technology do not always yield increases in productivity, some hospitals have been reluctant to invest in computer technology to support the patient continuum of care. President Bush believes that innovations in electronic health records and the secure exchange of medical information will help transform health care in America. But the initiatives cited to tout this extraordinary investment in technology describe transmitting X-rays, electronic laboratory results and electronic prescriptions over the Internet. All of these technologies have been available for the last 10 years, and many hospitals are already using them. Yet there have been no significant increases in hospital productivity.
Like any information system implementation, processes need to change before the hardware and software are in place. Otherwise, institutions run the risk of either duplicating poor processes on their IT system or implementing a computer system where there are no standardized practices. In the first instance, poor processes get locked into place with computer codes. In the second instance, programmers have to try to code every conceivable contingency in the current system. Either way, the costs of implementing “technology first” systems quickly become expensive in the short run, and exorbitant in the long run. In other words, without positive changes in internal productivity, technology alone cannot deliver a return on investment.
Trustees can play a critical role in avoiding the pitfalls of “technology-first” systems by identifying the strategic gap between current technology and short- and long-term goals. Too often, hospitals choose strategies strictly based on current operating performance, an approach that limits capabilities to reveal the organization’s true potential. Trustees need to drive the hospital’s mandate to have sound processes that have been tested first, and then advocate for investments in technology initiatives to support those processes.
Stakeholder Perspectives: Nursing
Among hospital staff, nursing has perhaps the most to gain from implementing clinical protocols and pathways. One of the greatest advantages of managing patients according to care guidelines is that all care providers, throughout the continuum of care can plan their activities based on an expected path. Planning the patient’s expected hospital release date at the time of admission provides a set of expectations for the care team, a common goal that works to align key stakeholders within the organization.
Marc-Auriel Marial, a quality consultant who works closely with LDS physician Nathan Dean, M.D., on improving pneumonia care through successfully implementing pneumonia guidelines, points out that: “Among other things, simple guidelines, when based on best practices, help dictate expectations for nurses and aid in facilitating timely order completion. Protocols also allow nurses to be more independent. [Nurses] don’t have to make as many calls to doctors because the decision to provide the best care has already been made in the protocol.”
Setting expectations for the care team is especially useful for patients seen in the emergency department. Long ED wait times can be particularly damaging to a hospital’s reputation. Crowded waiting rooms, poor patient privacy, and inefficient administrative policies are just a few of the inconveniences that have become the norm in too many ED patient encounters.
When ED systems break down, it is typically because there are either too many patients waiting to be admitted or a large number of patients are being held in observation while the decision to admit is being made.
Aligning the care patients require with the area of the hospital best prepared to care for them goes a long way toward increasing patient and employee—especially nurses’—satisfaction. Patients inappropriately assigned to the ICU—the highest and most expensive level of care—end up occupying beds that would be better saved for more acute patients. And, referring patients who require ICU care to another floor means nurses must take care of sicker patients when they most likely have a full caseload.
This mismatch of patient requirements and nurse staffing is a breeding ground for increased medical errors. Since ensuring that every patient receives the optimum level of care is at the core of all hospitals’ missions, boards should encourage the use of care guidelines that support adherence to evidence-based standards of care. Further, given that care guidelines streamline communication among care providers and thereby increase nurse satisfaction at a time when the nursing workforce is at a premium, trustees need to focus on this critical issue.
Stakeholder Perspectives: Senior Management
Without strong leadership, internal politics will inevitably interfere with efforts to change core hospital processes. It’s not surprising that, in the California Healthcare Foundation survey, senior managers ranked having a culture that supports interdepartmental cooperation for clinical process improvements as the most significant factor influencing the hospital’s ability to provide quality care. Senior managers are acutely aware of the difficulty of managing IT investments in a way that allows the hospital to achieve gains in both quality and productivity.
In order to be effective, senior management needs to promote the quest for cost and quality as a single journey, not two separate pathways. In doing so, they set the stage for achieving gains in both areas. But they cannot rely on passive expectations for improvements; the most successful senior managers manage proactively. They should play an integral role in collecting data to pinpoint those procedures that have a large variation in cost or quantity of such items as supplies, drugs or lab tests. They must recognize that the status quo is unacceptable and sustain the improvement momentum by continually building staff awareness. Once protocols are developed, management needs to work with physicians and nurses to develop measures that show real-time evidence that a new system is working.
For their part, trustees should insist on reviewing an objective dashboard that allows them to quickly assess whether the organization is on course in meeting quality goals. Board members should also emphasize the value of learning from the experiences of other institutions that have gone through similar processes successfully.
Stakeholder Perspectives: Physicians
In the California Healthcare Foundation survey, physicians felt that a greater investment in technology, like computerized physician order entry systems (CPOE), would have the biggest impact on reducing paperwork and improving quality of care. But, historically, physicians have been reluctant to agree on evidence-based guidelines and protocols, which would go a long way toward ensuring successful CPOE implementation. It’s important to understand, however, why some physicians might be apprehensive about following prospective care guidelines, even when evidence suggests that using them in certain treatment plans has been successful. Understanding their perspective is critical. If physicians believe protocols are going to restrict their decision-making and create more paperwork, generating the momentum for change will be difficult.
Accordingly, it’s important to develop guidelines that are supported by the medical literature. Administrators must involve physicians in developing guidelines and create avenues for them to collaborate with their colleagues. Since change is never easy, it helps to elicit the support of a physician champion who can mobilize less-resistant colleagues to start following the protocol. Those physicians in the middle generally respond positively to the strong leadership of a physician champion.
Another reason that physicians are less likely to participate in quality initiatives is because evidence-based pathways are developed based on large data sets, without regard to patient demographics or preferences.
The physician’s experience, on the other hand, is usually drawn from a smaller subset of patients. The doctor’s opinion can be swayed by individual experiences and the likes and dislikes of his or her patients. That being said, physicians tend to react well to good data and information. They prefer not to be outliers in terms of patient outcomes, and if they are, are likely to change processes so their results are more in line with other physicians’ outcomes.
Physicians also want to work in a financially sound environment, one that reflects their own standards. Accordingly, hosptial trustees can play a critical role in educating the medical staff about hospital revenue and costs.
The Trustee’s Role
The board sets the culture for collaboration, and developing evidence-based guidelines requires two kinds of collaboration. First, there needs to be collaboration within the organization and a consistent platform for sharing outcome data. Developing regular internal measures creates a consistent set of goals and objectives. A well-constructed hospital dashboard, which includes meaningful measures—not just those that are most readily available—is perhaps the single most important step in aligning the organization.
Secondly, there needs to be a method for sharing information between hospitals. The primary source for evidence-based practices will most likely come from research conducted outside the organization. And the fastest way to jump-start improvement efforts is to learn from other organizations that have experienced the same challenges. Trustees can trigger meaningful research by simply asking other hospitals what they have done in similar circumstances.
Trustees can further encourage knowledge exchange by developing a dashboard that can be linked with other management tools, especially those that support collaboration within and between hospitals.
Boardroom discussions about quality of care often come as an adjunct consideration to financial discussions. However, strategic and quality discussions should not be viewed as opposite sides of the spectrum; in fact, it’s a bad way to organize the agenda.
There is a real opportunity for board members, who generally come from industries outside health care, to introduce different management strategies into the organization. Other industries understand the importance of managing quality and productivity simultaneously, and the health care industry needs to follow suit.
Since strategic goals need to come from the top, that message must be communicated from the boardroom throughout the organization. Placing patient care issues first, building the best evidence-based processes, and actively seeking primary caregivers’ input are strategic imperatives that drive productivity and quality advances, leading to the best possible care for the community at large.
Stephen Lothrop and Sarah Nickerson are consultants with The Healthcare Management Council Inc., a performance management firm based in Needham, Mass. They can be reached at (781) 449-5287 or go to www.HMC-benchmarks.com.
*Calculated by dividing total hospital employed hours by the total number of adjusted admissions.
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This article 1st appeared in the December 2099 issue of Trustee Magazine.
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