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Everybody loves a comeback story. At AHMC Anaheim (Calif.) Regional Medical Center, a team of quality services staff, clinicians and managers, with support from administrators and trustees, turned around a downward trend in performance on clinical quality measures. ARMC's experience highlights the crucial role of hospital board members in identifying areas that need improvement, putting the right people in place and demonstrating that quality is a priority.

Three Years in Limbo

A 223-bed hospital situated 25 miles southeast of Los Angeles, ARMC was somewhat immobilized for three years while it was for sale. "It was difficult to operate in that kind of unsure environment," says John Seymour, a 15-year ARMC board member. During those three years, key physicians, nurses and staff left, including the quality director, and the hospital was operating with a "bare-bones administrative structure," he says. Along with staff attrition, the hospital experienced a falloff in performance efforts in clinical quality. For example, compliance with Surgical Care Improvement Project core measures dipped dramatically.

Quality 'Dream Team'

In July 2009, the hospital was bought by AHMC, a for-profit hospital corporation based in California. Once new ownership was established, the hospital hired a new executive director of quality services, Marie Trembath, who put together a multidisciplinary performance improvement team chaired by the medical staff department chair for surgery.

The PI team includes anesthesiologists, nursing directors from surgery and inpatient units, directors from case management, infection control, pharmacy services and quality services, as well as front-line staff. Trembath recruited a program manager to abstract most core measures and complete a strategy grid for identifying each fallout (or missed process measure) and a clinical analyst to develop dashboards for reporting data. "We gave [Trembath] freedom to build her dream team in quality," Seymour says.

Educating staff and emphasizing the shared accountability for patients are key. SCIP measures are communicated via inservice training, fliers, shift huddles, posters and other visual cues on units. In addition, when a surgeon misses a process measure, the department of surgery chair sends an advisory letter and a relevant journal article about the surgery and the specific core measure to educate the surgeon about evidence-based practices.

Trembath shares information from dashboards and reports with the hospital's medical executive committee and the ARMC board. Seymour estimates the entire board spends 10 to 30 minutes during its one-and-a-half-hour monthly meetings discussing quality, including "things we did well and things we didn't do well." Though the board does not have a quality committee, one or two trustees attend every performance improvement/patient safety committee meeting to ensure the group has the resources it needs to drive improvements.

Sustaining Improvements

In one year, ARMC's compliance on SCIP measures increased from 53.9 to 85.6 percent. Donald Lorack, ARMC's CEO, marvels at "how fast it was to show significant improvement." The board's oversight of the improvement initiative "helped add great strength and credibility to the process itself," Lorack says. ARMC's next challenge will be sustaining the work and using it to spread improvement in other areas of the hospital.

"Having worked in corporate America, [I know] quality is everything," Seymour says. He advises hospitals to demonstrate that quality is important and will be a priority. After that, changing the culture of how the hospital operates may be required.

"Having a strong quality effort does not cost a lot of money," he notes. Creating an effective program takes the right people leading the effort and the right people participating. He adds, "There is no additional cost but a small support staff. The real cost savings come in efficiency and effectiveness."

For more information on this quality initiative and others, visit

Cynthia Hedges Greising ( is a communications specialist for the Health Research& Educational Trust, Chicago.