Committed to Quality

Among the integrated healthcare systems around the nation whose leaders have committed firmly and publicly to continuous quality transformation has been Methodist Le Bonheur Healthcare, a seven-hospital system based in Memphis. The system has received numerous recognitions for its quality of care, and has been a leader in receiving incentive payments from the Hospital Quality Incentive Demonstration (HQID) program, co-sponsored by the Center for Medicare and Medicaid Services and the Charlotte-based Premier Inc. health alliance. Among other strategic decisions, the senior leaders of the system have committed to public posting of their quality outcomes data across a broad range of key clinical areas, for a number of organizations (including The Leapfrog Group, the Joint Commission, Hospital Compare, and others), and in fact, a great deal of data has been made instantly available on the organization’s website.Recently, Jerry Maliot, M.D., senior vice president and chief quality officer for the health system, and Alastair MacGregor, M.D., senior vice president and CMIO, spoke with HCIEditor-in-Chief Mark Hagland regarding their organization’s journey around quality, clinical transformation, and transparency. Below are excerpts from the interviews.Transparency for Clinical Outcomes Healthcare Informatics: Please tell us about your very publicly stated commitment to transparency and accountability for the clinical outcomes of your integrated health system.Jerry Maliot, M.D.: It goes back to our mission, that we’ll partner with our medical staffs, families, to be a leader in providing high-quality, cost-effective, patient-centered care. That’s our mission. And if you accept that as a mission, then transparency is going to end up being a very significant part of that. And since I came into my role in 2007, and our board insists on it, and I insist on it, is a culture of transparency. Of course, we protect patient data security.Now, if you really decide that transparency is a way to transform ourselves, to push ourselves, to embody our values and mission, we have to look at our patients, families, and members of our business community who are purchasers, and if you look at the data, it’s all over the place. There’s evidence-based data. And there’s Hospital Compare [the Medicare program’s Hospital Compare program]. And if you want central line infections, you need to go to the state registry. And ventilator-acquired infections and hand hygiene have not yet hit the radar. And Leapfrog has its own measures. And this is exhausting for us, even though we do it every day.

AlastairMacGregor, M.D.: With all that Jerry’s doing with quality and feeding back information to the stakeholders—as leaders, we all have a balanced scorecard; and it’s not only his leadership in measurement, but what’s important is holding our operational leaders accountable. I also think that the development of our electronic medical record is getting to a very exciting point, indeed an inflection point, in my view.For example, as far as Cerner’s North American clients go, we’ve got one of the largest databases in terms of the number of applications we’ve got going on, in terms of the platforms live. And so I’ve been able to implement a lot more best practices. We’ve just completed our third hospital inpatient CPOE go-live. In January 2010, we had a very successful tertiary care ED and inpatient pediatric hospital go-live.These have been my proof points in having a much more structured approach to go-live, but also the effort required to supplemental training, post-go-live. And I see my role as transforming the culture to be data-driven. And if you are not doing 80 percent of CPOE, I want to understand why some people are achieving more than the target levels, but why some are not meeting those levels; because if I don’t have high levels of CPOE adoption, we can never really turn that inflection point into the cool stuff around care improvement. What percent of patients are having their allergy histories documented within 12 hours of admission, for example?

AlastairMacGregor, M.D.Data Driven Environment HCI: What has the journey of physicians becoming data-driven been like so far?MacGregor: It’s involved engaging them, creating carrots and soft sticks, because we have many community physicians, and there’s always the risk that they might go away; but from my past vendor consulting experience, I know that one of the points of risk is insufficient training. So we’ve gone to entirely online training, which is great, because I can share with my team daily reports of who’s been trained and not, and so on. We give them four sessions for CPOE training, and then a competency test. And so I can produce reports that go back to operational leaders at each of the hospitals, because my job is to provide data that they can use. So that’s been a huge help.I also have a small team of process engineers who work with not just the medical staff, but the entire clinical staff. And they go in six to eight months before go-live to work with the clinicians to prepare them. We have a very structured go-live plan, in tight partnership with each facility’s leadership. And we offer CME credits from the University of Tennessee to medical staff, for the training.And as of last week, our medical staff have passed a regulation saying that credentialing fees are waived if physicians do the CPOE training prior to go-live, and provide us with a current email address. It can be very hard to communicate with the community physicians in a blended academic/community setting, and having a current email address is very important in communicating with them. And last year, I instituted a monthly CMIO report in which I communicate to the physicians through the monthly medical executive committee.And it’s very important that we measure some form of level adoption—where are we with CPOE adoption; but also where are we with lab results, door-to-balloon time performance, and so on and so forth? We’ve got good data on process and quality before and after CPOE.HCI: Can you speak to a few of the key data points among your many reports available online?Maliot: If you look at our acute myocardial infarction results, we’re particularly proud of those. We use appropriate care scores and not composite scores. If you go to Hospital Compare, we show appropriate care scores, which is the number of patients who have AMI or pneumonia or whatever, and the appropriate care is the percent of patients who get all of the appropriate care measures. There’s aspirin at arrival and discharge, but there are six altogether; those are two. ACE inhibitor or ARB for LVSD, smoking cessation advice and counseling; beta blocker at discharge; and door-to-balloon—PCI (percutaneous intervention) received within 90 minutes of hospital. Our appropriate care score is in the 99.3 percent range, for the whole system. For the period of this report, we were at 100 percent for Germantown and University and North; and 97 percent for our small hospital, South.And we’ve got two facilities that have not had a falloff in the PCI in 36 months from 100 percent. And the nice thing is, if you go into the website and double-click on the 99 percent, which is where we are with our appropriate care score, you can see what has happened.HCI: You’re about to go live with an enterprise-wide data warehouse?MacGregor: Yes, and in the next five years, meaningful use will be a major consumer of resources and of quality reporting around that. Long-term, I really want to use the clinical data repository, in concert with Jerry, to use clinical intelligence to look at clinical outcomes enterprise-wide. That will include looking at CMS measures, as well as looking at financial measures. And increasingly, I want to use this to communicate progress to the community. And we’re taking a broader approach to just clinical outcomes; we now include are ED wait times on our website, for example.Lessons LearnedHCI:What have been the biggest lessons learned so far?MacGregor: It’s hard; and we’ve got to be data-driven. Tenacity in the face of adversity is a key element. You present the data—and the doctors challenge the data immediately. So we do a lot of data validation before we share it. And you eventually get to where there’s no escaping that the data is right. And medical and clinical professionals really want to do a good job of providing good care; but in the past, the only way to measure was paper-based chart abstraction. That’s changing now.What’s more, we’ve got large screens within our EDs, electronic white boards, tracking the average time to see a physician, what’s the throughput time, what’s the left-without-being-seen time. So it’s very much in real time, how we’re performing with our process management.HCI: What would your advice be to CIOs and CMIOs about this journey around quality, transparency, and clinical transformation?MacGregor: They’re living in the next five years of the most exciting and challenging time in U.S. healthcare. Meaningful use has given us the framework that I think many of us believe is not just about getting the funding, but about improving quality and process efficiency, and aligning our patients much more closely.