July 1, 2004
Todd Kutyla, Jack Meyer, Sharon Silow-Carroll
Hospital Quality: Ingredients for SuccessA Case Study of El Camino Hospital, Jack A. Meyer, Ph.D., Sharon Silow-Carroll, M.B.A., M.S.W., Todd Kutyla, M.L.A. et al., The Commonwealth Fund, July 2004
High quality and effective quality improvement (QI) at El Camino Hospital are primarily the result of an internal environment that constantly focuses on quality, combined with a set of practical tools that promote good quality outcomes and QI on a daily basis. Key aspects of this internal environment include the following:
- Institutional leadership's commitment to quality, as evidenced by the development of aggressive quality goals and a willingness to make significant investments in quality-enhancing systems to help reach those goals.
- A culture that embraces quality and innovation, and that has done so since the institution's founding more than 40 years ago.
- High-quality, liberally-staffed nurses who act as proactive partners of physicians in caring for patients.
- A high-quality medical staff that embraces, and actively supports, these nurses as they fulfill this role.
- Local (i.e., departmental or unit-based) autonomy and accountability for quality and QI.
Practical tools that promote high quality and QI on a daily basis include the following:
- A comprehensive QI process driven by sophisticated data analysis and performance monitoring systems, top-down and bottom-up goal setting and project identification, and permanent and ad hoc structures to facilitate problem identification and solving.
- Leading-edge information systems and other technologies that promote seamless information flow and that provide safeguards against mistakes, leading to better decisions and reduced risk of error.
- Heavy reliance on critical paths and protocols that serve to reduce variations in practice patterns for those aspects of care that are amenable to standardization around best practices.
- Care coordinators and case managers who focus on high-risk patients and ensure that these and other patients, to the extent possible, receive care that is consistent with the critical paths and protocols, including early rehabilitation and preparation for discharge.
The external environment serves as only a modest impetus for quality and QI at El Camino. The development of reimbursement systems that reward performance is in a nascent stage among local payers. Current payment systems, in some cases, act as a deterrent to investment in quality-enhancing programs. For example, the failure to provide reimbursement for outreach into the community for the chronically ill has made it difficult for El Camino to invest in case managers to perform these tasks. That said, the external environment does serve as a good source of information on benchmarking data and also helps to identify priority areas, such as medication errors or appropriate use of beta-blockers, that are in need of improvement and should be the focus of performance goals and targeted projects.
Key challenges facing El Camino in its efforts to produce high-quality care include the following: getting physicians to use IT in new ways and to accept standardized care, although El Camino has been quite successful in overcoming these challenges; developing compensation systems that reward quality and QI; finding useful benchmark data, as El Camino is a stand-alone institution; and investing in QI in a reimbursement environment that, at best, provides no financial incentives for such investments and, at worst, actually discourages them.
The El Camino case underscores the following lessons learned:
- There is no substitute for creating the type of organization where top-notch talent wants to work, and for creating a culture that values mutual respect and peer-type relations between physicians and nurses.
- Assertive, knowledgeable nurses can play a critical role in ensuring high quality on a day-to-day basis, provided they enjoy the respect of the medical staff.
- Physicians, nurses, and other caregivers can and should be liberated to take local ownership and accountability for QI. The role of leadership is to give these caregivers the motivation to take on these tasks and the tools to support their efforts.
- IT is one of the critical tools that facilitates high-quality and effective QI. Getting physicians to consistently accept and use IT is a challenging task, even in an environment that embraces innovation.
- Proactive case managers play crucial supporting roles in facilitating team-based approaches that get patients appropriate care in a timely manner.