Moun­tain States’ qual­ity ap­proach

Pa­tient-cen­tered ap­proach earns Ten­nessee sys­tem an­nual na­tional qual­ity award

Modern Healthcare - - FRONT PAGE - For a list of this year's award judges and pre­vi­ous win­ners, please visit mod­ern­health­care.com/nqf

In­pa­tients at Moun­tain States Health Al­liance have forms at­tached to their beds. In­stead of doc­u­ment­ing their blood pres­sure or tem­per­a­ture, these par­tic­u­lar forms have in­for­ma­tion on their fa­vorite foods, spe­cial mem­o­ries, pets and other small de­tails of their lives. Fill­ing in the forms helps calm them down, and the tid­bits give their care­givers both in­sight and fod­der for con­ver­sa­tion, says Tracy Bol­ing, the health sys­tem’s cor­po­rate man­ager of pa­tient-cen­tered care.

“We re­ally try to place an em­pha­sis on the de­vel­op­ment of re­la­tion­ships,” she says. One staff mem­ber may sing to pa­tients while trans­port­ing them to ra­di­ol­ogy; an­other may hold their hands dur­ing a pro­ce­dure. Nurses have been known to spend their days off cook­ing a meal for a pa­tient’s fam­ily.

All new em­ploy­ees spend a full day of train­ing on the prin­ci­ples of pa­tient-cen­tered care, and those new hires are se­lected partly for their abil­i­ties to re­late to peo­ple, Bol­ing says. Some of them have been in­spired to ap­ply for jobs at Moun­tain States be­cause of their ex­pe­ri­ences there as pa­tients. Ev­ery em­ployee’s job is framed in terms of how it af­fects pa­tients, even when the em­ployee rarely in­ter­acts with them di­rectly—for ex­am­ple, the per­son re­spon­si­ble for clean­ing a floor is do­ing it so pa­tients have a smooth, dry sur­face and can walk with­out trip­ping. “All team mem­bers are con­sid­ered care­givers,” Bol­ing says.

The sys­temic em­pha­sis on pa­tient-cen­tered care is part of an over­all cul­ture of qual­ity that earned the John­son City, Tenn.-based sys­tem the Na­tional Qual­ity Forum’s 2012 Na­tional Qual­ity Health­care Award, pre­sented an­nu­ally since 1993. The re­cip­i­ent is se­lected through a blinded re­view by a panel of judges rep­re­sent­ing pur­chasers, gov­ern­ment, health sys­tems, clin­i­cians and con­sumers.

A first for Ten­nessee

Laura Miller, the NQF’s in­terim pres­i­dent and CEO, as well as chief oper­at­ing of­fi­cer, says Moun­tain States is the first award-win­ner to be based in Ten­nessee. Moun­tain States’ ser­vice area cov­ers sparsely pop­u­lated parts of four states.

“We were pleased that we could rec­og­nize an or­ga­ni­za­tion that pro­vides care in dif­fi­cult ar­eas,” Miller says.

Moun­tain States’ com­pre­hen­sive plan­ning strat­egy im­pressed the judges, as well as the way its guid­ing prin­ci­ples trans­lated into con­crete ac­tions at all lev­els of the or­ga­ni­za­tion.

One of the judges, Dr. Tom James, med­i­cal di­rec­tor for na­tional net­work op­er­a­tions at Hu­mana, Louisville, Ky., cited the “sys­tem­ness” of Moun­tain States’ ap­proach as a key fac­tor. “It’s not just ad­her­ing to mea­sures,” he says. “We looked at pri­or­ity-set­ting, dash­boards, trans­parency, the pro­cesses they had in place for im­prove­ment of care, their (ac­count­able care or­ga­ni­za­tion) readi­ness and pub­lic re­port­ing ca­pac­ity. It’s about be­ing blan­keted in qual­ity.”

An­other judge, Bill Cor­ley, a con­sul­tant with Health­care Per­for­mance Im­prove­ment, Vir-

ginia Beach, Va., says some of the judges were sur­prised when the win­ner was cho­sen and the names of the can­di­dates were fi­nally re­vealed.

“MSHA isn’t out there broad­cast­ing the won­der­ful things they’re do­ing,” he says. He praised the or­ga­ni­za­tion’s plan­ning process, dash­board de­sign, use of bench­marks and in­clu­sion of pa­tients and their fam­i­lies on ad­vi­sory coun­cils.

“We re­viewed the min­utes from some of those meet­ings, and you could see that they were im­ple­ment­ing some of the coun­cils’ sug­ges­tions and then giv­ing them feed­back,” he says. “They were clos­ing the loop.”

Blow­ing up the qual­ity process

It took a fig­u­ra­tive cat­a­clysm to start the de­vel­op­ment of Moun­tain States’ qual­ity process in the late 1990s, when Pres­i­dent and CEO Den­nis Von­der­fecht de­cided to “blow up” his qual­ity depart­ment. He fired ev­ery­one in the small depart­ment and hired all new em­ploy­ees—ones who were will­ing to join him on a sys­temic search for qual­ity. Von­der­fecht has been with the or­ga­ni­za­tion since 1990, orig­i­nally as CEO of flag­ship 501-bed John­son City (Tenn.) Med­i­cal Cen­ter.

“Qual­ity wasn’t poor, but we just didn’t have a de­fined process for it,” he says. He had made sev­eral at­tempts to change that sit­u­a­tion, but it was the cri­te­ria for the Mal­colm Baldrige Na­tional Qual­ity Award that fi­nally in­spired him to take dras­tic ac­tion. Af­ter in­stalling a new team, he set the or­ga­ni­za­tion on a Baldrigestyle course in 2003.

The first step was to make sure the or­ga­ni­za­tion’s lead­er­ship un­der­stood the process, and to that end, Von­der­fecht di­vided up the cri­te­ria and had the ex­ec­u­tive team share the process of writ­ing the first award ap­pli­ca­tion. Moun­tain States ap­plied first to the Ten­nessee Cen­ter for Per­for­mance Ex­cel­lence, the state-level Baldrige award pro­gram, and then to the na­tional one.

“We had noth­ing to lose and ev­ery­thing to gain by ap­ply­ing for the high­est recog­ni­tion from day one,” Von­der­fecht says, cit­ing the ex­ten­sive feed­back that award ap­pli­cants get at both the state and na­tional lev­els.

By 2005, Moun­tain States had achieved the high­est level of recog­ni­tion in Ten­nessee, which it re­ceived again in 2009 (the ear­li­est it was al­lowed to reap­ply af­ter win­ning the first time). It has also won state recog­ni­tion in Vir­ginia and has im­proved its na­tional scores ev­ery year.

Tight fo­cus has been one of the keys to suc­cess, says Tam­era Par­sons, vice pres­i­dent of qual­ity and pa­tient safety. “You can’t be suc­cess­ful with 30 or 40 pri­or­i­ties,” she says.

Mak­ing pa­tients the cen­ter of ev­ery process sounds sim­ple and ob­vi­ous, but was a ma­jor trans­for­ma­tion for many em­ploy­ees who rarely saw pa­tients and were ac­cus­tomed to fo­cus­ing on their im­me­di­ate task.

“We have had em­ploy­ees who didn’t buy in, and they were ter­mi­nated be­cause it was that crit­i­cal,” Par­sons says.

Moun­tain States mea­sures of­ten and cel­e­brates each mile­stone, she says. “If we had waited 10 years to see if we had got­ten good enough to win the (Na­tional Qual­ity Health­care Award), we wouldn’t have made it. The mile­stones fur­ther ev­ery­one’s en­gage­ment and mo­ti­va­tion.” Each em­ployee cre­ates goals—a “per­sonal blue­print”—that con­trib­ute to­ward the achieve­ment of over­all or­ga­ni­za­tional goals. Not only are they eval­u­ated on achiev­ing those goals, but they lit­er­ally wear them next to their hearts, in a plas­tic pouch be­hind their name badges.

Mov­ing to ac­count­able care

Von­der­fecht says that form­ing an ac­count­able care or­ga­ni­za­tion is a nat­u­ral out­growth of the pa­tient-cen­tered phi­los­o­phy, and his sys­tem’s new ACO, the A new Care Col­lab­o­ra­tive, is well-po­si­tioned for value-based re­im­burse­ment (See re­lated story be­low).

A new Care CEO Dr. Tom Lundquist says the new or­ga­ni­za­tion will cre­ate a dis­rup­tive force that changes the eco­nom­ics of care for physi­cians.

“Physi­cians do all the work and rarely see the sav­ings,” he says. “This ve­hi­cle will al­low them to ben­e­fit in real time from mak­ing changes, and will cre­ate pres­sure on us to make sure we’re the best value for the physi­cian.”

Lundquist es­ti­mates that physi­cians usu­ally get only 5% to 15% of the to­tal cost of car­ing for a pa­tient, with an out­sized por­tion go­ing to mak­ers of drugs or im­plants. With the de­tailed in­for­ma­tion that Moun­tain States col­lects as part of its qual­ity dash­board, physi­cians will be able to see which ser­vices im­prove care and which sim­ply drive up costs—and will re­ceive a larger share when they change their care pat­terns.

Here are some ways Moun­tain States met cri­te­ria for the Na­tional Qual­ity Health­care Award:

Pri­or­i­ties for per­for­mance im­prove­ment: The “MSHA House of Qual­ity” is built on four “pil­lars of ex­cel­lence”—clin­i­cal, op­er­a­tional, stake­holder safety and ser­vice. It also has 10 guid­ing prin­ci­ples for pa­tient-cen­tered care: All team mem­bers are con­sid­ered care­givers. Care is based on con­tin­u­ous heal­ing. Care is cus­tom­ized and re­flects pa­tient needs, val­ues and choices.

In­for­ma­tion is freely shared with pa­tient-care

part­ners, physi­cians and other care­givers.

Pa­tient fam­i­lies and friends are con­sid­ered an es­sen­tial part of the care team. Pa­tient is a source of con­trol for his or her care. Trans­parency is the rule in care of the pa­tient. Pa­tient safety is a vis­i­ble pri­or­ity. All care­givers co­op­er­ate with one an­other through a com­mon fo­cus on the best in­ter­ests and per­sonal goals of the pa­tient.

Care is pro­vided in a heal­ing en­vi­ron­ment for com­fort, peace and sup­port. Per­for­mance dash­board:

Moun­tain States has cre­ated a blue­print based on the four pil­lars of ex­cel­lence. For each pil­lar, the blue­print com­bines a num­ber of mea­sures into over­all scores that are com­pared against an­nual tar­gets.

For ex­am­ple, the “clin­i­cal ex­cel­lence” pil­lar in­cludes over­all scores on mor­tal­ity and ap­pro­pri­ate in­pa­tient and out­pa­tient care; the “op­er­a­tional ex­cel­lence” pil­lar in­cludes oper­at­ing ex­pense per ad­justed ad­mis­sion, days’ cash on hand, and cost of care com­pared with a bench­mark set by the Premier health­care al­liance. Moun­tain States is a Premier owner or­ga­ni­za­tion.

The blue­print is updated monthly, and lead­ers across the or­ga­ni­za­tion re­view their re­sults with the em­ploy­ees who re­port to them. Charts pro­vided on the Moun­tain States in­tranet make it easy to com­pare each re­sult with base­line, his­tor­i­cal, tar­get and bench­mark re­sults. Com­mit­ment to trans­parency:

The ex­ec­u­tive team en­cour­ages self-re­port­ing of pa­tient con­cerns, com­pli­ance is­sues and er­rors. The Moun­tain States web­site pro­vides wait times for each of its hos­pi­tals’ emer­gency de­part­ments, and pa­tients can ac­cess that in­for­ma­tion via smart­phone along with direc­tions to the near­est ED.

The web­site also con­tains hospi­tal-level, state and na­tional com­par­a­tive per­for­mance mea­sures for many in­di­ca­tors, such as heart at­tack, heart fail­ure, pneu­mo­nia, read­mis­sion rates, joint re­place­ments, chil­dren’s asthma and pa­tient ex­pe­ri­ence. Data-driven im­prove­ment:

Moun­tain States reg­u­larly re­views mea­sures re­lated to its four pil­lars of ex­cel­lence and es­tab­lishes im­prove­ment teams to take cor­rec­tive ac­tion when mea­sures fall short of goals. Best prac­tices are shared with all em­ploy­ees, and the or­ga­ni­za­tion presents in­ter­nal qual­ity awards that are judged by rep­re­sen­ta­tives from ex­ter­nal or­ga­ni­za­tions that have ex­pe­ri­ence judg­ing Baldrige, Joint Com­mis­sion and other qual­ity pro­grams. Readi­ness for ac­count­able care:

The es­tab­lish­ment of a for­mal­ized ac­count­able care or­ga­ni­za­tion is the pri­mary fo­cus of Moun­tain States’ cur­rent strate­gic plan, and A new Care is the or­ga­ni­za­tion es­tab­lished to unite an in­fra­struc­ture of providers, in­clud­ing hos­pi­tals, pri­ma­rycare physi­cians, spe­cial­ists, post-acute-care providers, be­hav­ioral-health providers, home health agen­cies, hospice providers, phar­ma­cies and well­ness cen­ters. Med­i­cal home mod­els will be es­tab­lished in all pri­mary-care of­fices.

“Ac­count­able care is scary be­cause we’re tak­ing on more risk than we had in the past, but with risk comes re­ward,” Von­der­fecht says. “We are still on a jour­ney, and there’s more im­prove­ment to be made.” TAKE­AWAY: A sharply fo­cused qual­ity process, em­braced by all staffers and data-driven, pro­vides a strong for­mula for per­for­mance im­prove­ment.

Bol­ing

Von­der­fecht

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