The Key to a High-Performance Multihospital System

A high-quality multihospital system can be defined specifically by: (a) high patient satisfaction; (b) good use of performance measurements; (c) low readmission rates; (d) up-to-date health information technology; (e) availability of top-notch providers; (f) its large or small size in the healthcare marketplace; (g) all of the above; or (h) none of the above. So what's the right answer?

Give up? How about "i" for: "It just depends."

A new guide from the American Hospital Association's Health Research & Educational Trust (HRET) in Chicago, with support from the Commonwealth Fund, found that overall, it is difficult to link one specific element that ties together high-performing multihospital systems.

Multihospital health system leaders do have a significant impact on the quality of American healthcare, according to HRET's new guide. After all, the 200 largest hospital systems—with a hospital system being defined as having two or more general acute care hospitals—account for more than half of all hospital admissions.

Interviews with leaders of 45 multihospital health systems and analysis of publicly available quality data allowed the guide researchers to identify three major themes related to higher performing systems.

(1) No one system type was most associated with high performance. The researchers examined the relationships of various system characteristics—comparing them with composite measures of quality, as well as to more specific measures, such as the Health Quality Alliance (HQA) core measures, overall patient satisfaction, and combined, risk adjusted readmission rates and mortality rates.

Overall, the researchers said, it became quite evident that high-quality scores were achieved by a variety of different system type—large or small systems, regional or multi regional systems, and systems that were academic and non-academic.

So any type of system—regardless of size, geographic location, or financial situation—can achieve high quality care.

(2) No single factor produces high-quality care in a health system. Although the researchers examined more than 50 system factors that could distinguish between top-performing systems and those with lower quality scores, "no one factor clearly separated top systems from others," they found.

In each case, factors found in high-performing systems were found in at least some of the lower-performing systems. Moreover, no unanimity was found among top performing systems with respect to factors associated with high performance.

While simplistic solutions are appealing, the researchers noted, these solutions are often wrong. The goal of providing consistently high-quality care is achievable—but not through any one single change.

(3) Creating a culture of performance excellence, accountability for results, and leadership execution are the keys to success. The guide found that many lower-performing systems had many of the same processes, policies, and structures as those with very high-quality scores. However, in conversations with system leaders, certain distinctions became apparent.

In particular, lower-performing systems in some cases had made changes recently that were likely to enhance quality—but the changes hadn't taken yet. And in other cases, the processes and policies appeared to be in place on paper, but the passion and commitment from the organization toward them seemed lacking.

"Every single leader of a high-performing system who we interviewed was passionate about making their system one where each patient received safe, high-quality care in each encounter," the researchers noted. Many had been aiming for this goal for years, and were part of a system where this goal was encompassed by everyone. All did acknowledge quality and safety failures, but they could see the progress their organizations were making towards achieving their quality and safety goals.

Systems with a strong cultures related to quality and safety demonstrated the following:

• A shared, system wide commitment/focus on achieving the system's quality and patient safety goals. For example, "system management is as important in achieving quality goals as is physician compliance with evidence based guidelines." So complying with evidence based guidelines becomes not just a physician responsibility but a system responsibility as well.
• A system board that is very engaged in quality and safety, such as being directly involved in setting the system's strategic goals for quality and safety and in frequent monitoring (at least monthly) the hospitals' progress toward achieving these goals.
• Extensive opportunities and vehicles for hospitals to collaborate and share best practices for improving quality and safety.
• Transparency around reporting performance both internally and externally. Teamwork needs to be emphasized to improve quality and safety, along with shared accountability for good outcomes.
• Having a mindset of perfect care and dramatic increases or stretch goals as compared to incremental improvement.

With all this in mind, perhaps the answer to the question posted at the beginning is actually "j," as in recognizing that "joining together at all levels is important to meeting quality goals."