Mountain States’ quality approach
Patient-centered approach earns Tennessee system annual national quality award
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.