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Measuring Quality: Being Small Has Its Advantages

By Carrie Vaughan for HealthLeaders News, July 11, 2007
One of the top priorities at any community hospital is to deliver high quality healthcare. But simply listing quality as one of your organization's goals is not good enough in today's healthcare market. The emergence of consumer-driven care combined with hospital transparency, quality improvement and pay-for-performance programs has made accurately measuring quality even more important. By measuring performance and tracking quality indicators, community hospitals can see what their facility does well and identify areas that need improvement. And as Fairview Northland Medical Center in Princeton, MN, and Aurora Medical Center in Kenosha, WI, discovered, being smaller can have its advantages.

On the fast track
When Fairview Northland began gathering data and measuring its performance in 2004, the hospital found itself near the bottom of Premier Inc.'s best hospitals list. The 40-staffed-bed hospital quickly identified the processes needed to deliver the best outcomes and established an infrastructure to track and sustain that level of quality, says President Mike Youso. "We had a goal to go from worst to first."

Fairview Northland, part of seven-hospital Fairview Health Services in Minneapolis, didn't have to wait long to achieve its goal. It won the Premier Award for Quality in heart failure and acute myocardial infarction in 2006 and then again in 2007.

Fairview Northland made two key changes to standardize processes and ensure compliance, says Marti Bollman, RN, vice president of patient care. First, the hospital established order sets to make sure requirements would always get done. It customized pre-existing order sets to meet its specific requirements--a process that took about six to nine months, Bollman says. "A lot of discussion had to go on before we were able to come to an agreement that this is the order set." The biggest challenge was reconciling individual practice styles and getting a common level of understanding among all the caregivers of what the requirements were, she adds.

Second, Fairview Northland created core measure checklists that nurse clinicians would examine prior to the patient being discharged, Bollman says. For congestive heart failure, for example, the checklist includes making sure patients being discharged receive written instructions for medications, activity, diet and weight, as well as what to do if symptoms worsen.

Out of the red
Every employee, patient and provider at Aurora Health Care understands that the organization’s No. 1 priority is quality, says Candace Hennessy, PhD, regional vice president of nursing and clinical integration for the 12-hospital system based in Milwaukee. "Every single meeting you go to--be it a board meeting or a regional management meeting--it is on every agenda," she says. That dedication appears to be paying off; the system won eight Premier Awards for Quality in 2007.

Aurora developed what is commonly referred to as "Bingo scorecards" that provide a quick snapshot of its hospitals' quality rankings on a quarterly basis. The hospitals get a color-coded score based on their performance in each category such as obstetrics or pneumonia, explains Hennessy. For example, the lowest performer is red and ranked fourth, while the best performer is teal and ranked first.

The first time Christine Olson saw the scorecard was not a pleasant experience. "My facility had the most red boxes, which is not a good thing. Besides being embarrassed, it did spark a competitive spirit in me," says the administrator and nurse executive at Aurora Medical Center in Kenosha.

The 73-staffed-bed hospital worked on getting more real-time data to the staff, so people could intervene if needed, says Olson. The facility now gets daily reports that summarize all of the measures and what the hospital still needs to do. The hospital also dedicated time for staff to collaborate with other departments across the system. In addition, it introduced neonatal nurse practitioners to act as the first responder when a baby is born. "There is somebody highly skilled whose whole attention is on that baby to prevent complications," she says.

Nobody wants to think of themselves as giving bad care, says Olson. "I am very proud to say that we have no more red in the scorecard."

Smaller is sometimes better
Bollman says one of the mistakes Fairview Northland made was complaining about the measurement criteria--and thinking that the hospital's size and limited patient volumes meant they could not achieve top scores. Leaders worried that missing something on one patient would drop them to the 50th percentile because they have such a small sample size. "We had to finally decide that we were going to stop moaning about the criteria and just get it done," she says.

Now that Fairview Northland has reached the top decile, it plans to stay there, Youso says. The key, he adds, is accountability. "The measurements on quality are catching up to all of the measurements that we have had on economic performance in healthcare over the years. Without measurements and data and processes identified, it is hard to manage something. We have physicians and nursing leadership that are identified as accountable for this particular process."

Small hospitals have some advantages, as well. Fostering a common expectation among every person who has contact with the patient is often easier in smaller facilities, says Bollman. In addition, employees in smaller hospitals can have a better sense of the big picture because they often have multiple jobs, says Olson. "I think it gives them a greater sense of ownership and seeing that what they do actually has an impact. They see it through to the end--not just that one little cog."

Carrie Vaughan is editor of HealthLeaders Media Community and Rural Hospital Weekly. She can be reached at cvaughan@healthleadersmedia.com