governance From Boardroom to Bedside: How to Define and Measure Hospital Quality Michael Heenan, Haajra Khan and Dorothy Binkley Abstract Following the release of its strategic plan, in which patient safety and quality were highlighted as key directions, St. Joseph’s Healthcare Hamilton recognized the importance of engaging its board of trustees to achieve these goals. Following a collaborative retreat with senior management, medical staff leadership and professional practice leaders, the board enhanced its governance oversight on quality. By removing quality from the consent agenda, defining quality and selecting a series of “big dot” measures, the board has led the development of a culture of quality that cascades from the boardroom to the bedside. This article describes how the organization followed a systematic process to define quality and select big dot quality indicators. S t. Joseph’s Healthcare Hamilton (SJHH) is a publicly funded, 700-bed, three campus academic health sciences centre in Hamilton, Ontario. Serving a population of more than 1.3 million, the organization is the regional lead for chest, head and neck; kidney-urinary; mental health and addictions; and ophthalmology services. St. Joseph’s has over 4,000 employees and an annual operating budget of $500 million. Like most hospitals boards in Ontario, the SJHH board had a Quality Committee for years. Often unfocused, the Quality Committee was the last place volunteer board members wanted to serve. Management and medical staff often tried to illustrate for the board that the hospital was providing quality care by inviting clinical or corporate leaders to present on issues of the day using positive stories related to the hospital’s mission, a series of ratebased data and complex clinical acronyms that the lay board member rarely understood. The end result was a lack of focus that rarely raised discussion at the main board table or challenged executive and medical leaders to make a substantial change at the bedside. Fortunately, the renewed focus in healthcare – patient safety and quality – has also renewed the role of governance. Following the release of its strategic plan, St. Joseph’s recognized that achieving its commitment to become one of Canada’s safest hospitals would require strong leadership and engagement across the organization. To accomplish the hospital’s strategic directions related to clinical quality and patient safety, the organization began to re-emphasize the partnerships between the board, management and medical staff required for success. To engage the board, the organization educated itself on governance practices and innovated the way in which it governed quality at both the main board and Quality Committee. By removing quality from the consent agenda, defining quality and selecting a series of “big dot” measures, the board has led the way to a culture of quality that is cascading from the boardroom to the bedside. Healthcare Quarterly Vol.13 No.1 2010 55 From Boardroom to Bedside: How to Define and Measure Hospital Quality Michael Heenan et al. Governing Quality by Defining Quality To adequately govern and monitor quality, the board first had to understand what quality really means. Following advice provided by the Institute for Healthcare Improvement (IHI) and the Ontario Hospital Association (OHA), the board decided to begin by defining quality. In doing so, the organization realized that this was easier said than done. The first step was to analyze how peer organizations define quality. Following a review of various teaching hospitals in Canada, the United States, the United Kingdom and Australia, we found that few hospitals publicly publish a definition of quality. A number of organizations mention components of a framework or list a series of metrics, but few specifically mention a formal definition. Further reviews of both provider agencies and policy or think tank organizations such as the Institute of Medicine (IOM), IHI, OHA, the Ontario Health Quality Council, the Canadian Patient Safety Institute and the Quality Healthcare Network revealed that existing definitions of quality can be divided into two main categories: (1) system-level definitions – those that policy makers use to address population health issues; and (2) provider-level definitions – those reflective of care delivery organizations such as hospitals, long-term care or home care agencies. Most system-level definitions were based on the IOM’s Six Dimensions of Patient Expectations, namely, safe, timely, effective, efficient, equitable and patient centred. Some system definitions incorporated further dimensions such as capacity or appropriately resourced to acknowledge the differences in the American healthcare system (on which the IOM dimensions are based) and the public healthcare systems in the United Kingdom, Canada and Australia. Table 1 presents the matrix that was created to map the various definitions found along the dimensions mentioned in those definitions. The most commonly mentioned dimensions at the system level were safe, equitable and patient centred. A review by SJHH staff also showed that there are very few hospitals that have publicly published their definitions of quality. The definitions at the provider level were not based directly on the IOM’s Six Dimensions, but dimensions still generally encompassed the expectations of patients. Table 2 illustrates the dimensions found in a selection of provider-level definitions. The most common themes in the provider definitions we examined were safe and patient centred. SJHH discussed the possibility of framing the definition around the patient credo (Heal me, Don’t hurt me and Be nice to me and an additional dimension, Treat me quickly). In the end, however, it was decided that a formal definition was required to educate board members and the public on the minimum expectations all patients should have with regard to quality care. As a result, SJHH developed its own provider definition of quality as a teaching institution: “Quality care at SJHH is safe, kind, effective and timely and is provided in an environment of inquiry and learning.” Measuring and Cascading Quality with Big Dots As with most volunteer hospital boards, the challenge SJHH board members face is that despite spending only 75–100 hours a year in the organization, they are expected to understand a complex array of metrics and to make decisions impacting quality of care within a two-hour meeting. While SJHH’s scorecard system was proving valuable, the increased focus of the board on quality and safety required a more useful tool to enable it to govern more effectively and hold senior management accountable for the performance of these measures. With a definition of quality in place, SJHH decided it would follow Table 1. Dimensions of patient expectations mentioned in various healthcare systems’ definitions of quality Safe Timely Effective Efficient Equitable PatientCentred System 1 System 2 System 3 System 4 System 5 System 6 56 Healthcare Quarterly Vol.13 No.1 2010 Capacity Outcomes Value Appropriately Resourced Population Health Focus Michael Heenan et al. From Boardroom to Bedside: How to Define and Measure Hospital Quality Table 2. Dimensions of patient expectations mentioned in various providers’ definitions of quality Safe Timely Effective Efficient Equitable PatientCentred Hospital 1 Hospital 2 Hospital 3 Hospital 4 Capacity Outcomes Value At hospital 5, quality is not just a simple measure. Quality is a comprehensive look at all aspects of a patient's experience. Quality at hospital 5 involves the totality of a patient's experience – from the first phone call to the last appointment. Hospital 5 Figure 1. Big dot quality cascade pyramid BOARD Executive Team Re po rti ng M ea su res Big Dots Medical & Clinical Leadership Clinical and Corporate Programs the advice of IHI and select a number of big dot indicators: whole-system measures that address core processes or functions that patients expect the organization to perform in order to improve quality and safety. By monitoring big dot measures, the board is able ensure that the organization is performing well without getting involved in operational issues. Since big dots are whole-system measures that reflect the overall quality of the healthcare system, and all other smaller measures flow to and from the big dots, if the system is performing well at the highest level of aggregation, then it is likely performing well at the lower levels. SJHH realized that the key to using big dots for change is linking them to other measurable process and outcome indicators at the program or unit levels – little dots. At SJHH, we illustrated this by creating the big dot cascade pyramid, presented in Little Dots Figure 1. At the top of the pyramid is the board, which reviews the systemlevel measures or big dots. Moving down the pyramid, management and clinical leadership are responsible for overseeing the little dots and their associated improvement at the program or unit level. A good example is the issue of infection, where the big dot may be a certain infection rate or outcome, and this is connected to many little dots, including hand hygiene compliance, housekeeping practices and central line insertion compliance, among others. Illustrated in this manner, it is clear how the board’s role can improve care at the bedside. Selecting the Big Dots When first examining the literature on big dots, SJHH thought it had to select five to seven indicators on which the board could focus, versus the 25-plus it had on its balanced scorecard. After examining the current indicators, however, it was agreed that a short list of big dot indicators could not accurately reflect the complexity of the organization. An example of this dilemma is the hospital standardized mortality ratio (HSMR). It was decided that the HSMR could not be the only mortality indicator the board examines given that the HSMR accounts for only about 68% of the organization’s annual death count. The second example of this dilemma was finding a single infection metric, given that certain infection rates are calculated against denominators such as patient days and others are calculated against device days. Thus, it was decided that fewer metrics were needed but that Healthcare Quarterly Vol.13 No.1 2010 57 From Boardroom to Bedside: How to Define and Measure Hospital Quality Michael Heenan et al. they would have to be presented in newly created big dot categories. By selecting categories, the organization was able to frame indicators into a language that was easy to comprehend and had relevance to clinical practice at the bedside. While no single set of categories is currently recommended in the literature, three category types emerged for the board to consider. As shown in Figure 2, these categories included placing indicators around a safety or communication theme such as the patient credo, within categories that reflect clinical care or within categories reflective of the organization’s strategic directions. To illustrate how these categories function, consider the themed categories of the patient credo. A big dot indicator in the bucket Heal me may be outcome indicators such as readmission rates or functional improvement scores; indicators for Don’t hurt me, Be nice to me and Treat me quickly may include reported patient incidents, patient satisfaction and wait times, respectively. At SJHH, a decision to ensure the board’s work maintained relevance to clinical practice at the bedside led the board to elect to monitor big dots using the clinical categories of timely access, incidents, infection, mortality and satisfaction. Selecting Big Dot Indicators: The Criteria Once the big dot categories were selected, the board began to select individual indicators to be housed in each category. The major challenge facing the board, management and medical staff was distinguishing whole-system measures (big dots) from process indicators (little dots). In order to facilitate the selection of big dot indicators, the following criteria were developed and defined: the organization. It is not program, unit or disease specific. • Is outcome driven. As opposed to a process indicator, a big dot speaks to results or effects of the delivery of care. It is not reflective of compliance with a procedure or practice standard. • Connects to other little dots or processes (multifaceted). A big dot has a variety of little dots that flow from it; these are defined and measurable process indicators operating at the program or unit level. • Reflects the organization’s strategic priorities. A big dot should reflect the organization’s corporate priorities. • Reflects the organization’s definition of quality. The dimensions emphasized in the organization’s definition of quality should be reflected in the big dots. By agreeing on a set of criteria, the big dot working group evaluated the metrics it had on its current scorecard to help narrow the number of big dot metrics it would monitor. This also enabled the working group to identify areas where a previously monitored metric was perhaps not needed. Table 3, (http://www.longwoods.com/product.php?productid=21245) illustrates the big dot categories and indicators selected by SJHH. HSMR: A Real Big Dot Example As stated, the goals of governing big dot measures are not only to have the board examine system-wide measures but to probe management and medical leadership on quality and safety issues that may be of concern. A tangible example of how the board of SJHH changed practice at the bedside involved analyzing • Is institution wide. A big dot indicator is a whole-system our HSMR. measure that reflects the overall quality and performance of As illustrated in Figure 3, in 2007–2008, management presented the board with an HSMR value of 88 against a target of 76. In Figure 2. Types of big dot categories the ensuing discussion, a board member queried Themed Categories Clinical Categories Strategic Categories why the organization’s Patient Credo target was 76 when all the organization was required Access to do was meet the national Patient Safety Heal Me benchmark of 100. Management responded Incidents by indicating that the Patient Flow Don’t Hurt Me top quartile of Canadian Infection hospitals measuring HSMR began at 76, and Be Nice To Me Service Excellence if SJHH wished to be one Mortality of Canada’s safest hospitals, its HSMR should be Treat Me Quickly Financial Stewardship Satisfaction in the top quartile. The board member then asked 58 Healthcare Quarterly Vol.13 No.1 2010 Michael Heenan et al. From Boardroom to Bedside: How to Define and Measure Hospital Quality Figure 3. HSMR: board quality example HSMR Score of 88 to Board Jan 2008 Exec & MAC Discussions Mar 2008 • Question: Why is target 76 if benchmark is 100? • Answer: Top Quartile • Question: How do we get there? Internal Analysis MAC & Program Discussions Spring 2008 Fall 2008 Action: Sepsis Management Project in ER & ICU Jan 2009 • Mgmt examines data by death type, unit location, and researchers other peers across globe • Mgmt Findings: Sepsis & safety campaigns including infections & hand-washing key to lowering HSMR • Number 1 cause of death at SJHH: Sepsis ER = emergency room; ICU = intensive care unit; HSMR = hospital standardized mortality ratio; MAC = Medical Advisory Committe; QPPIP = Quality Planning and Performance Improvement Program; SJHH = St. Joseph’s Healthcare Hamilton. management and medical leadership how it planned to get from 88 to 76. Management and medical staff began to examine the literature on HSMR reduction and its own internal data. In addition to learning about the need to focus on infection prevention, hand washing and rapid response teams, the hospital’s data indicated an increasing number of deaths related to sepsis. Thus, as result of the board’s discussion, a sepsis management program was initiated. By asking two simple questions about a big dot and its target, the board required management and medical staff to discuss clinical practice, to further investigate the hospital’s data, to research best practice on sepsis management and to change practice at the bedside – a process that arguably would not have occurred without the board oversight of a big dot metric. Team Unity: Education with Management, Medical Staff and Professional Practice The board began its journey by hosting a retreat on governing quality and patient safety to which senior management, medical staff leadership and professional practice leads were invited. Outside experts advised of the board’s moral, ethical and legal role in quality. By involving all four partner groups at the outset, each group was able to identify its different perspectives and the common goals that would help drive quality to the bedside. Methodical Approach to Selecting Big Dot Categories and Indicators Success Factors A number of key success factors helped St. Joseph’s Healthcare in its quality governance journey: identifying board champions, promoting team unity, taking methodical and systematic approaches, resourcing the process and reviewing outcomes. A working group of board members, members of management, physicians and allied health professionals researched the different definitions of quality and the various categories of big dots, and it evaluated each of the big dots’ scorecard metrics against a set criteria. All participants agreed that by involving each stakeholder and methodically choosing categories and metrics, the process had credibility and the outcome was representative of the organizational strategy and focus on quality. Identification of Board Champions: Ownership Systematic Approach: Quarterly Review The process was driven and guided by the chair of the board and the chair of the Quality Committee. By involving two board members, the board owned the process and forced management and medical staff to think how the board could govern quality. In addition to the Quality Committee’s greater focus on data, the board dedicates strategic discussion every quarter to reviewing big dot data. By systematically adopting a stop and review point in the work plan, the board created an accountability mechanism for senior management and clinical leadership. Healthcare Quarterly Vol.13 No.1 2010 59 From Boardroom to Bedside: How to Define and Measure Hospital Quality Michael Heenan et al. Resourcing the Process: This Is a Journey Board members are community volunteers and spend only about 75 hours per year in the hospital. The work required to research definitions, summarize the literature and define big dot criteria cannot reasonably be expected from a volunteer or off the side of one’s desk. Assigning a management lead was crucial to ensuring that the goals of the board were met. Outcome: Showing That the Board Has Value Previous to this focus, the board often asked how its work was impacting care. Now, each quarter, the board is updated on key actions that result from their questions. The board sees how clinical outcomes result from its oversight, and it is more engaged than ever before. Conclusion Supported by the research of IHI and OHA, St. Joseph’s enhanced focus on patient safety is proving that hospital boards matter. Boards represent the people we serve – our patients and our communities. By designing a process that engages board members, clinical leadership and management, we have all parties working collaboratively toward a common goal. 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Retrieved May 8, 2009. <http://www.qhn.ca/events/OH_Patientsafety_CIHI. ppt>. About the Authors Michael Heenan, MBA, CPHQ, is now the director of quality performance and risk management at The Credit Valley Hospital in Mississauga, Ontario. Previously he was working at St. Joseph’s Healthcare Hamilton as the Director of the Quality Planning and Performance Improvement Program. Haajra Khan, MBA, CPHQ is a performance improvement consultant in the Quality Planning and Performance Improvement Program at St. Joseph’s Healthcare Hamilton. Dorothy Binkley, MBA, CPHQ, worked at St. Joseph’s Healthcare Hamilton as a co-op student. She recently completed her MBA at the DeGroote School of Business at McMaster University, in Hamilton, Ontario. For further information on this article you may contact Romeo Cercone, VP for quality and strategic planning, St. Joseph’s Healthcare Hamilton at 905-522-1155, ext. 33405, or by e-mail at [email protected] governance From Boardroom to Bedside: How to Define and Measure Hospital Quality Michael Heenan, Haajra Khan and Dorothy Binkley Table 3. SJHH big dot categories and associated indicators Timely Access Total time spent in ED – high acuity (CTAS I, II) Total time spent in ED – low acuity (CTAS III, IV, V) ED – left without being seen Mental health outpatient wait times Cancer surgery wait times Cataract surgery wait times MRI wait times CT scans wait times Readmission rate Number of ALC equivalent beds Incidents Number of serious incidents Number of never events Seclusion incidents (mental health) Infections Central line infection rates per 1,000 device days Infection rate – Clostridium difficile per 1,000 patient days Infection rate – MRSA per 1,000 patient days Infection rate – VRE per 1,000 patient days Surgical site infection prevention rate Ventilator-associated pneumonia rates per 1,000 ventilator days Mortality Hospital standardized mortality ratio Deaths in acute care Deaths in CCC, rehabilitation and mental health Healthcare Quarterly Vol.13 No1 2010 1 From Boardroom to Bedside: How to Define and Measure Hospital Quality Michael Heenan et al. Table 3. Continued. Satisfaction Patient satisfaction – acute care Patient satisfaction – emergency care Patient satisfaction – surgical care Patient satisfaction – mental health ALC = Alternative Level of Care; CCC = Complex Continuing Care; CT = Computed Tomography; CTAS = Canadian Triage and Acuity Scale; ED = Emergency Department; MRI = Magnetic Resonance Imaging; MRSA = Methicillinresistant Staphylococcus aureus; SJHH = St. Joseph’s Healthcare Hamilton; VRE = Vancomycin-Resistant Enterococci.
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