Opportunities Aimed at Improving Quality and Value Abound

Finding focus and avoiding burn out

Partnership for Patients, Million Hearts, RARE, Home Health Quality Improvement National Campaign—the campaigns, initiatives, and other efforts aimed at improving health care quality and value abound. With the changes flowing from health reform, ever more improvement offerings are being made available. That leaves health care organizations to sort through numerous invitations to participate and to be cautious of engendering quality improvement burnout among staff.

The Centers for Medicare & Medicaid Services (CMS) is working toward large-scale change in America's health care system. And, campaigns and initiatives hold promise for facilitating great impact. Well-developed campaigns and initiatives, based on evidence and best practice, that can be adapted to fit an organization's culture and practice are most likely to succeed. A recent Journal for Healthcare Quality article noted that the literature widely supports the value of continuous learning networks to maximize workforce improvement capability and of social networks to generate motivation and increase energy for improvement.1

Campaigns can shorten the performance improvement process by pulling together evidence-based practices and measurement strategies, and offering interventions along with technical assistance and support. "By participating in campaigns, our wish list of initiatives become actual projects," said Marilyn Grafstrom, director of quality and risk management at LifeCare Medical Center, a 25-bed hospital with two nursing homes and a home health agency.

For some organizations, participating in campaigns can change how they view quality. Cokato Manor Home Health participated in the Home Health Quality Improvement National Campaign through Stratis Health's home health collaborative from 2005 to 2008. Its staff now looks at trends for the year and conducts one to two initiatives where they have identified opportunities. "This laid the groundwork for how we approach quality improvement," said Nancy Deiter, director of nursing.

Unifying the calls for quality

Recognizing the sea of seemingly disconnected campaigns and initiatives, some quality leaders are working to unify efforts. Nationally, CMS is leading change in health quality by using all of the levers within its means to facilitate large-scale improvement. The agency is mobilizing people across the country to improve care by aligning incentives, measurement systems, regulations, and its quality improvement initiatives—through its Quality Improvement Organizations (QIO) like Stratis Health, Partnership for Patients, and Million Hearts. These all flow from the Department of Health and Human Services' National Quality Strategy for better care, healthy people and communities, and affordable care.

"All of these initiatives are coming from the same place, from the new broad vision," said Kelly Anderson, lead for the CMS Office of Clinical Standards and Quality Communications Team. "The CMS quality initiatives are all intended to ignite a spark, to have the key influencers and trusted voices spreading outwards to patients."

Stratis Health's work on reducing patient risk factors for cardiac disease aligns with Million Hearts. Our work in healthcare associated infections; pressure ulcers, physical restraints, and other nursing home concerns; and care transitions aligns with Partnership for Patients.

Locally, many organizations are working together to support the national priorities. Stratis Health as Minnesota's QIO, the Minnesota Hospital Association, and the Institute for Clinical Systems Improvement have joined forces to lead RARE (Reducing Avoidable Readmissions Effectively), a statewide campaign to prevent 4,000 avoidable hospital readmissions across Minnesota between July 1, 2011, and December 31, 2012. The three operating partners are using evidence-based best practices from the leading initiatives. They are mobilizing a broad base of stakeholders across the care continuum to address the readmissions challenges that stem from fragmentation in health care. Over 70 individual hospitals and six health systems have signed on to achieve the campaign goals.

"RARE has felt coordinated," said Eva Gallagher, Park Nicollet Health Services senior director, nursing quality, research and care innovation. "It pulls the best practices from other readmissions focused initiatives so that participants do not have to sift through them all and decide what we should participate in."

Selecting initiatives

Health care organizations have developed different strategies for how they evaluate the many quality improvement offerings. Some larger organizations have quality committees that evaluate initiatives brought before them. Some quality leads use cost-benefit analysis spreadsheets to compare opportunities.

Criteria used to evaluate whether to participate in an initiative include effectiveness, cost, compatibility with goals, ease of use, and ability to modify interventions to fit the organization—including being able to integrate with ongoing continuous quality improvement efforts.

"When presenting new initiatives to staff, we need to be careful not to be presenting the flavor of the month," said Gallagher.

For smaller organizations unable to have dedicated quality staff and with fewer staff overall to test changes, evaluating and integrating external efforts is a greater challenge. "In a small hospital, we can only focus on one big project at a time, while doing other smaller projects," said Susan Swan, performance improvement and risk management director at Sanford Tracy Medical Center. The 25-bed hospital set a three-year plan to participate in the American Stroke Association's Get with the Guidelines, to ensure they did the work well.

Many organizations, especially rural and smaller providers, turn to outside trusted advisors and colleagues for guidance on an initiative's ability to provide value. "If Stratis Health and the state association are aware of and supporting an initiative, that lends more weight," commented Deiter.

"For us, the question is where are we putting our patients at risk," said Linell Santella, director of infection prevention and control service, Park Nicollet Health Services. "When I select a campaign or initiative to participate in, I always look for it to align with decreasing risk and with improved patient safety."

1. Rocco J. Perla, Elizabeth Bradbury, Christina Gunther-Murphy. Large-Scale Improvement Initiatives in Healthcare: A Scan of the Literature, Journal for Healthcare Quality, 2011.