The full case studies of the four hospitals discussed in this overview report are available at:
- Beth Israel Deaconess Medical Center, Boston, MA
- El Camino Hospital, Mountain View, CA
- Mission Hospitals, Asheville, NC
- Jefferson Regional Medical Center, Pittsburgh, PA
Three related commentaries also are available:
- Invited Comments—Hospital Quality: Ingredients for Success
- Aspiration or Way Station?
- Physician–Hospital Alignment: The Elusive Ingredient
Hospitals across the country are searching for ways to improve quality of care and promote effective quality improvement (QI) strategies. The findings from this study offer guidance and action steps to help hospitals move in the right direction. To promote greater use of practices and policies that enhance quality and QI in hospitals, this research study identifies and describes the key ingredients that have contributed to the success of four high-performing hospitals. Through site visits and in-depth interviews with each of these top performers, we assessed specific internal factors and external pressures that drive quality. Additionally, we considered supportive tools and processes, challenges the hospitals face, and lessons they offer other hospitals. Based on our synthesis of these findings and the results of telephone interviews with additional hospitals, we have developed an overarching set of factors that strongly support high-quality care and successful QI programs in hospitals.
The key elements of a successful strategy can be organized into the following categories:
- developing the right culture for quality to flourish;
- attracting and retaining the right people to promote quality;
- devising and updating the right in-house processes for quality improvement; and
- giving staff the right tools to do the job.
Also at play are external influences, such as local market competition, and public or private health quality initiatives and standards. Further, there seems to be greater scrutiny of hospital quality and safety resulting from the Institute of Medicine's (IOM's) reports that have documented widespread problems in this area.
Instill a Supportive Culture and Policies
Top-performing hospitals have a striking degree of motivation and commitment to ensuring high-quality care and fulfilling the QI mission. They are not just going through the motions or conducting QI activities because they are under outside pressure to do so. This commitment is reflected in and nurtured by: active leadership and personal involvement on the part of the CEO, other top managers, and the Board of Trustees; an explicit quality-related mission and aggressive quality-related targets; standing and ad-hoc quality committees; regular reporting of performance indicators with accountability for improved results; and the promotion of a safe environment for reporting errors.
Manifestations of such commitment among the hospitals we examined include: administrators coming in on weekends to help out on patient floors; a CEO who stresses the importance of QI at every orientation for new employees; and performance indicators for every department with specific targets related to quality, service, people, and finances.
Attract and Retain the Right People
High-quality physicians, nurses, administrators, and ancillary staff are critical to producing high-quality outcomes and effective quality improvement. Top-performing hospitals stressed the need for selective hiring, credentialing, and re-credentialing. Successful recruitment and retention of nursing staff was tied to an absolute respect for and empowerment of nurses-who must be treated as full partners in patient care and given opportunities for advancement. All are expected to be good team players, able to participate in multi-disciplinary teams for both QI and patient care management.
Among the hospitals studied, examples of dedication to attracting and retaining the right people include: preservation of nurse-patient ratios even during layoffs and at the expense of revenues; a policy that results in loss of staffing privileges for physicians who do not show respect for nurses; and a QI residency elective to introduce medical residents to QI philosophy and techniques.
Develop Effective In-house Processes
The best hospitals not only collect data on outcomes and cost, but also pull apart the numbers on surgeries, tests, and other procedures to identify each step in the process where less-than-optimal medicine is practiced. QI departments are adequately staffed, have credibility with physicians, and are trained to facilitate the problem-solving process (e.g., two of the hospitals studied have QI departments headed by physicians; another hospital has seven QI consultants who are assigned to facilitate QI in specific service lines). Deficiencies in outcomes are not hidden or ignored, but instead are used to inspire an iterative process of discovery followed by corrective actions and accountability. Effective problem-solving leads to the development of evidence-based protocols and critical paths, and enhanced efficiencies such as reduced turn-around time for test results and reduced errors related to standardization of supplies and procedures.
Another important process involved team-based care management. A key to success involves making sure physicians and other caregivers accept the case manager's or team leader's role in coordinating and facilitating care. One hospital studied promotes such acceptance through a physician-based model where physicians are assigned case managers who works with all of their patients.
Provide the Right Tools to Do the Job
The best hospitals also give their physicians, nurses, and other staff the tools and support they need to practice high-quality medicine on a daily basis and to identify and investigate quality problems when they do surface. This includes investments in Information Technology (IT) as well as QI/Performance Improvement departments with qualified staff who abstract medical records, analyze data, and facilitate the QI process. It also includes access to guidelines and protocols, and support to physicians in developing a consensus around their own evidence-based best practices so they have tools they are actually willing to use. Other tools involve external training, peer networking, and conferences.
Information and data tools play a critical role. We found that successful IT strategies employed by the top-performing hospitals studied involves four main commitments: a willingness to invest in IT; working with physicians and others to customize an information system to meet specific needs and culture of the institution (e.g., some of the hospitals studied had IT directors who were physicians themselves as well as IT experts); nurturing and encouraging buy-in so that new systems will be utilized and their benefits realized; and devising IT systems that provide real-time feedback to providers (including access to patient history, test results, computerized reminders/alerts, etc.) as they are caring for patients.
Our research team has found that many hospitals around the country are taking up the challenge of improving quality of care and patient safety. Initiatives in these areas are not limited to the narrow domain of a few leaders. This means that the efforts of the IOM, leading hospitals and physicians, and a few purchasers to put quality on the radar screen of American hospitals are succeeding. What distinguishes the leading hospitals from the others is that these hospitals do not simply address the issue, but back up their words with concrete actions and dig more deeply beneath the surface to identify the root causes of quality problems, develop practical solutions, measure impact, and hold themselves accountable for improvement. Willingness to invest and focus on long-term change and comprehensive quality integration (e.g., into all service lines and from the top of the institution to the bottom) are essential.