CommonSpirit Health Making Gains in Quality and Patient Safety

Harnessing data is essential to improve quality and patient safety, the chief medical and quality officer of CommonSpirit Health says.

CommonSpirit Health has been making a concerted effort to improve its performance on quality and patient safety.

Quality and patient safety are top concerns for CMOs at health systems and hospitals. CommonSpirit Health has been posting impressive results for quality and patient safety in recent years. For example:

• The health system has achieved performance in the 72^th percentile for stoke care, which is an 18 percentile gain over its baseline.
   
• In fiscal year 2025, the health system focused on reducing hospital adverse events and has achieved 59^th percentile performance, which is a 7 percentile improvement over baseline.
   
• The health system has achieved national 71^th percentile performance in the hospital-acquired infection metric, which is a 7 percentile improvement over baseline.
   
• The health system has avoided about 3,200 hospital-acquired Infections since 2020 and more than 1,000 in fiscal year 2025.
   
• The health system has targeted increasing annual wellness visits as a primary strategy to improve quality performance, with a baseline at the 65^th percentile and a goal to reach the 73^rd percentile by the end of this fiscal year.

Harnessing data is crucial to boosting quality and patient safety scores, according to Phillip Chang, MD, MBA, CommonSpirit Health's chief medical and quality officer.

"We want to get data at the local level as well as at the market, regional, and national level," Chang says. "We use this data to ensure our staff members understand our goals and work in a consistent fashion."

The health system tracks several data points to support care quality improvement efforts.

"We look at data that shows reduction of hospital harm such as hospital-acquired infections," Chang says. "We look at mortality rates. We look at the end-of-life experiences of our patients. We look at patient experience measures."

Multiple elements of patient experience contribute to care quality, according to Chang.

"We want to explain care plans to patients in a way that they understand," Chang says. "We want patients to be treated with respect. We want to deliver care in a timely fashion, which is part of being respectful. We want the environment of care to be appealing to patients—it must be clean, quiet, restful, and humane."

CommonSpirit Health follows a wide range of patient safety indicators, but the health system focuses on one every year, Chang explains.

"Every year, we pick a specific patient safety goal based on data that indicates we have an opportunity to perform better," Chang says.

This year, the health system focused on venous thromboembolism. This effort has touched several areas, including the supply chain, where department leaders made sure facilities had the right compression stockings and sequential compression devices.

Phillip Chang, MD, MBA, is chief medical and quality officer of CommonSpirit Health. Photo courtesy of CommonSpirit Health.

Reducing hospital-acquired infections

A focal point of CommonSpirit Health's efforts to improve quality and patient safety has been decreasing hospital-acquired infections.

"We have looked at national trends and resources such as new technology, new tools, and new advances in infection prevention," Chang says. "We have infection prevention experts at the national and regional levels who have looked at the best practices for infection prevention."

Reducing hospital-acquired infections starts with eliminating unnecessary use of central lines, urinary catheters, and other invasive devices, according to Chang.

"We have standardized this kind of care at the national level, but we have also given local leaders the ability for self-governance on how to get this work done," Chang says.

For example, to avoid central line-associated bloodstream infections, CommonSpirit Health has established best practices such as hand hygiene and sterile procedures, as well as setting a goal to achieve timely removal of central lines.

"We have set these standards nationally; but at the same time, we have given local leaders some leeway on how to implement these national standards," Chang says. "We give them measures and toolkits, but we give them the ability to execute best practices in a way that makes sense for them. Then we track the outcomes."

Managing chronic diseases

An area where CommonSpirit Health has sought to improve quality is chronic disease management.

"Chronic disease is challenging in terms of our ability to reach out to patients in the ambulatory setting," Chang says. "In the acute-care setting, we have patients as a captive audience, so it is relatively easy to control their chronic diseases. Once patients are home, we must rely on our primary care and ambulatory network to improve the health of our chronic disease patients."

One strategy the health system is pursuing is to ensure that they get annual wellness visits.

"We have set this as a goal for our organization across our entire footprint," Chang says. "Once you get a patient to their annual visit, we have full confidence that chronic disease patients will get the care they need such as care for hypertension and diabetes."

A crucial component of successful annual wellness visits is for clinicians to have unhurried conversations with patients, Chang explains.

"As part of an unhurried conversation, we want our care providers to get to know at least one thing about their patients that is not necessarily related to their medical condition such as what they do as an occupation," Chang says. "This helps caregivers develop trust and rapport with their patients. In addition, it can provide insights into patients' medical conditions."