The Top Five Essentials For Outcomes Improvement

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EXECUTIVE REPORTThe Top Five Essentials for Outcomes ImprovementGiven the complicated nature of outcomes improvement and thenumerous requirements for building and maintaining an effective,continuous quality improvement program with sustainedoutcomes, it’s no surprise health systems feel overwhelmed.Successfully sustaining quality improvement in healthcare is atall order to fill—consider this partial list of success factors andrequirements for effective quality improvement programs(explained later in this executive report):Adaptive leadership, culture, and governanceTOP FIVE QUALITYIMPROVEMENT ESSENTIALSAdaptive leadership, culture,and governanceAnalyticsEvidence- and consensusbased best practicesEvidence- and consensus-based best practicesHealthcare analyticsAdoptionFinancial alignmentValue-based systems of careClearly defined goal and aimsAdoptionDefined measures and validated baselinesFinancial alignmentQuality improvement teams, tools, and methodologiesKEY COMPONENTS TO QUALITYIMPROVEMENT PROGRAMSUnderstand the problemTarget improvementCreate Aim statementMeasure improvementFortunately, as healthcare organizations strive to improve carequality and affordability, they’re beginning to understand thequality improvement essentials—critical elements successfulquality improvement programs have in common. This executivereport defines quality improvement in healthcare, describes criticalquality improvement considerations, components, and tools, andidentifies the top five quality improvement essentials:1. Adaptive leadership, culture, and governance2. Analytics3. Evidence- and consensus-based best practices4. Adoption5. Financial alignmentCopyright 2017 Health Catalyst1

Before health systemscan implementsuccessful qualityimprovement programs,they need useful,pragmatic definitions toguide their efforts.THE BEST DEFINITIONS OF QUALITY IMPROVEMENT INHEALTHCARETo further complicate an already complex topic, there are dozens ofquality improvement definitions. Before health systems canimplement successful quality improvement programs, they needuseful, pragmatic definitions to guide their efforts. Focusing on threeof the most useful definitions from the Robert Wood JohnsonFoundation, CDC, and Institute of Medicine (IOM) will help guidesystems’ quality improvement efforts.Robert Wood Johnson Foundation’s DefinitionThe Robert Wood Johnson Foundation defines quality improvementas, “The process-based, data-driven approach to improving thequality of a product or service. It operates under the belief that thereis always room for improving operations, processes, and activitiesto increase quality.”CDC’s DefinitionCDC’s definition focuses on activities that improve populationhealth, ensure healthcare’s affordability, and deliver the best patientexperience. These three dimensions mirror The Institute forHealthcare Improvement (IHI) Triple Aim; the framework all qualityimprovement in healthcare ties back to:1. Improve the health of populations.2. Reduce the per capita cost of healthcare.3. Improve the patient experience.The Triple Aim is a framework for optimizing health systemperformance. And the primary goal of quality improvement is toimprove outcomes. CDC also describes quality improvement asone component of the performance management system, whichhas three defining characteristics: It uses data for decisions toimprove policies, programs, and outcomes. It manages change.And it creates a learning organization.IOM’s DefinitionIOM's definition adds even more clarity to CDC’s definition with itssix aims for improvement:1. Safe: avoid harm to patients from the care that is intended tohelp them.Copyright 2017 Health Catalyst2

Success Story on Safety: How to Reduce PreventableHealthcare Associated Conditions in Children Using BestPractice Bundles and Analytics2. Effective: provide services based on scientific knowledge toall who could benefit and refrain from providing services tothose not likely to benefit (avoid underuse and misuse,respectively).Success Story on Effectiveness: Dedication to QualityImprovement Delivers on the Triple Aim3. Patient-centered: provide care that is respectful of andresponsive to individual patient preferences, needs, andvalues and ensure that patient values guide all clinicaldecisions.Success Story on Patient-Centered Care: Quality Improvementin Healthcare: An ACO Palliative Care Case Study4. Timely: reduce waits and sometimes harmful delays for thosewho receive and give care.Success Story on Timeliness: Streamlining RadiologyOperations and Care Delivery through Analytics5. Efficient: Avoid waste, including waste of equipment,supplies, ideas, and energy.Success Story on Efficiency: How an IDS Improves OutcomesUsing a Clinical Collaborative Structure6. Equitable: Provide care that does not vary in quality becauseof personal characteristics such as gender, ethnicity,geographic location, and socioeconomic status.HOW SERVICE DELIVERY MODELS IMPACT OUTCOMESIMPROVEMENTBefore delving into the success factors and characteristics ofeffective quality improvement initiatives, it’s important tounderstand the impact service delivery approaches have onquality improvement.ACOAccording to CMS, ACOs are groups of doctors, hospitals, andCopyright 2017 Health Catalyst3

other healthcare providers who voluntarily come together to providecoordinated, high-quality care to Medicare patients to ensure theyreceive the right care at the right time (while avoiding unnecessaryduplication of services and preventing medical errors). ACOs aredesigned to incentivize providers to deliver high quality of care atthe lowest possible cost.Patient-Centered Medical Home (PCMH)Integrated care models, such as PCMHs focus on providing highquality care across the continuum. For example, Allina Health’sCourage Kenny Rehabilitation Institute (CKRI) implemented aPCHM for rehabilitation care that focuses on the whole person; onethat looks beyond the medical to address vocational, social, andemotional needs. This collaborative model enables comprehensiveand integrated care across the continuum.CKRI is a great example of a targeted quality improvement initiativewith the goal of delivering the best care across the continuum byachieving measurable improvements in length of stay (LOS) andemergency department (ED) visits. CKRI knows that when patientshave medical issues, getting them same-day or next-dayappointments significantly reduces LOS and ED visits.TelemedicineTelemedicine influences quality by allowing for faster responsetimes. Telemedicine’s cost savings—for patients and health systems—explains its recent growth. A University of Florida—Gainesvillestudy demonstrated telemedicine’s cost saving potential when usedto treat diabetes. According to the study, “Even when line chargesand equipment costs of 18,826 were included, the program saved 27,860 per year. The reduction in hospital days saved amounted to 44,419 per year and the reduction in ED visits amounted to 2,267per year.” Patients also saved money by not having to travel to thediabetes clinic (the Medicaid transportation cost for one family to thediabetes clinic was 262).Quality Improvement Organizations (QIOs) and QualityImprovement Networks (QINs)CMS’s Quality Improvement Organizations (QIOs) are “private,mostly not-for-profit organizations staffed with doctors and otherhealthcare professionals trained to review medical care and helpbeneficiaries with complaints about the quality of care.”Quality Innovation Network (QIN)-QIOs work with providers andcommunities across the country on data-driven quality improvementCopyright 2017 Health Catalyst4

initiatives using a variety of strategies:Quality improvementstarts with a healthcareorganization’s underlyingsystems of care. Whatultimately determinesquality improvement is thesystem’s design; not theskills and abilities of thepeople working in it.Instead of saying, “Theprovider operated on thewrong area” healthsystems should ask, “Whatsystem allowed thismedical mistake to occur?”Provide technical assistance.Convene learning and action networks for sharing bestpractices.Collect and analyze data for improvement.Health systems that embrace service delivery approaches focusedon quality are particularly incentivized to drive sustained qualityimprovement.EFFECTIVE QUALITY IMPROVEMENT STARTS WITH SYSTEMSOF CAREQuality improvement starts with a healthcare organization’sunderlying systems of care. What ultimately determines qualityimprovement is the system’s design; not the skills and abilities of thepeople working in it. Instead of saying, “The provider operated onthe wrong area” health systems should ask, “What system allowedthis medical mistake to occur?”For example, the World Health Organization’s Safe Surgery SavesLives initiative promotes surgical improvement programs to“minimize the most common and avoidable risks endangering thelives and well-being of surgical patients.” The initiative promotes theuse of a Safe Surgery Checklist that identifies three critical phases ofan operation:1. Sign in before the induction of anesthesia.2. Time out before the incision of the skin.3. Sign out before the patient leaves the operationroom.The checklist encourages surgical teams to ask, “Are weperforming the right procedure on the right patient in the rightarea?” The ultimate goal is to design a system that ensures patientsafety; that doesn’t allow for the introduction of errors.ALL QUALITY IMPROVEMENT SHOULD BE CONTINUOUSQuality improvement can’t happen without constantmeasurement and evaluation. Although it is possible toimplement the quality improvement cycle once, single cycleimprovement isn’t quality improvement in the purest sense; iteliminates the critical “study” step in the “plan, do, study, andact” sequence; the evaluative step that’s so critical forsuccessful quality improvements.Copyright 2017 Health Catalyst5

Continuous qualityimprovement is aboutsustaining and hardwiringthe right behaviors. Forexample, if a healthsystem reduces its heartfailure readmission rate, itshouldn’t just check thatitem off the “to do list”and move on tosomething else within itscardiovascular program. Itstill needs to dedicatevaluable resources to thereadmissions initiative toensure outcomes aresustained; to make surethe interventionscontinue to be effective.Healthcare professionals are challenged to constantly improveoutcomes, so how do systems continue to push for improvementwhen it seems like every improvement increment is harder to attain?Healthcare leaders need to put their combined clinical, operational,and business hat on and ask, “What quality improvement initiativesdo we prioritize based on the healthcare data we have?” They needto work with their finance teams and do a cost-benefit analysis todetermine if it makes more sense to pursue a small, incrementalpercent reduction in heart failure readmissions (if already betterthan national benchmarking measures) or do something else with abigger impact on patient outcomes and costs.Continuous quality improvement is about sustaining and hardwiringthe right behaviors. For example, if a health system reduces itsheart failure readmission rate, it shouldn’t just check that item off the“to do list” and move on to something else within its cardiovascularprogram. It still needs to dedicate valuable resources to thereadmissions initiative to ensure outcomes are sustained; to makesure the interventions continue to be effective. A great example ofsustainable quality improvement comes from Thibodaux RegionalMedical Center, with a sepsis mortality rate that is half the nationalaverage. Even though Thibodaux achieved its quality improvementgoal, it’s constantly measuring and ensuring it sustains or improvesits outcomes.QUALITY IMPROVEMENT PROGRAMS: FOUR KEYCOMPONENTSAll successful quality improvement programs include four keycomponents: the problem, goal, aim, and measures.#1: The ProblemAll successful quality improvement programs start with an in-depthunderstanding of the problem. But what’s equally important issystem-wide buy-in for the quality improvement initiative and theproblem it targets.#2: The GoalDetermining the appropriate quality improvement goal can be adaunting challenge for most health systems. While it’s oftentempting to pursue incremental improvement gains in the samefocus areas, healthcare leaders need to target improvements basedon a return on investment (ROI) and cost-benefit analyses. Healthsystems should ask several key questions when defining theirquality improvement goals:Copyright 2017 Health Catalyst6

How does this tie into our organization’s strategicimprovement objectives?Analytics make it possiblefor health systems toassess quality of care,cost, and patientexperience. Qualityimprovement can only beeffective if it marriesquality improvementteams andmethodologies withanalytics, but manyhealth systems are in aneither/or situation.What will have the biggest impact on patients?What areas have the largest variation?What will have the biggest impact on costs?#3: The AimAims break up the work of achieving the goal into manageablepieces.#4: The MeasuresThere’s a big difference between a quality improvement initiativewith a result and one with an improvement; a distinction that canonly be made by measuring baselines and actuals. Measuringbaselines is so critical because it enables health systems todetermine if there is an improvement; and if and how theimprovement is correlated to intervention.THE CRITICAL ROLE OF ANALYTICS IN QUALITY IMPROVEMENTIn the confusing world of quality improvement, analytics serve as thecompass pointing in the right direction. Analytics make it possible forhealth systems to assess quality of care, cost, and patientexperience. Quality improvement can only be effective if it marriesquality improvement teams and methodologies with analytics, butmany health systems are in an either/or situation.Either health systems have quality improvement teams but collectand integrate data manually or they have analytics platforms buttheir quality improvement teams aren’t aligned with the qualityimprovement initiatives (an abundance of data but no clearunderstanding of the quality improvement goal methodologies).Health systems need analytics to enable valid measurement, theability to correlate interventions and improvement, and external datasharing and benchmarking.Valid MeasurementAnalytics are necessary for efficiently establishing valid baselinesand measuring improvements.Correlating Interventions and ImprovementsHealth systems rely on analytics to test interventions—to determineif the selected intervention is positively impacting outcomes. Forexample, one large medical center had an improvement programfocused on reducing their heart failure readmission rate. AfterCopyright 2017 Health Catalyst7

implementing a typical bundle of follow-up appointments, dischargemedication reconciliation, and follow-up phone calls, it didn’tachieve its improvement goal. After an in-depth analysis of its data,the program pursued another intervention: teach-backinterventions. The teach-back intervention (combined with the firstthree interventions) achieved the program’s 30-day readmissiongoal. If initial interventions don’t work, don’t give up; analyze thedata and determine additional aims to achieve the goal.External Data SharingExternal data sharing is based on the premise of collaboration andpopulation health management. It provides valuable insights aboutwhat systems are doing; sharing this information creates the bestpractices learning culture that’s so important in qualityimprovement. In an industry that attracts professionals passionateabout helping people, benchmarking is another tool that helpsprovide the best care to patients.THE TOP FIVE ESSENTIALS FOR SUCCESSFUL QUALITYIMPROVEMENT IN HEALTHCAREHealth systems want to improve the quality of the care they deliver.But, according to Becker’s Hospital Review, approximately 60 to 80percent of strategic initiatives fail. Successful quality improvementis challenging, but it’s becoming less elusive as systems learn fromeach other’s efforts. As a result of conducting an integratedliterature review of healthcare quality improvement efforts over thelast five years, the top five broad categories of success emerged todrive and sustain quality improvement:Essential #1: Adaptive Leadership, Culture, and GovernanceIndividuals or teams within a health system may have the aptitudeand dedication required to make continuous improvements, butindividual efforts alone won’t result in prioritized, sustained qualityimprovement. Successful quality improvement initiatives requiresenior leadership support and an adaptive learning culturecommitted to data-driven quality improvement.Essential #2: AnalyticsAnalytics is an essential ingredient for sustained qualityimprovement and plays an important role in each phase of thequality improvement lifecycle (plan, do, study, and act), frommeasuring a baseline and understanding the problem, todetermining if the resulting change was an actual improvement.Some healthcare organizations mistakenly think they have analyticsCopyright 2017 Health Catalyst8

because they have measurements, which is often not the case.Essential #3: Evidence- and Consensus-Based Best PracticesEvidence- and consensus-based best practices are thefoundation upon which successful quality improvementinitiatives are built. Developing and integrating evidence- andconsensus-based best practices isn’t enough; healthcareorganizations also need to have automated ways to measurehow consistently the best practices are being used and theirimpact on outcomes.Essential #4: AdoptionHealth systems with the necessary adaptive leadership,analytics, and best practices won’t have successful qualityimprovement programs unless they dedicate resources toimplement outcomes initiatives. From training to performanceevaluations and organizational incentives tied to qualityimprovement goals, prioritizing widespread adoption meanssaying three things:“Here’s why we want you to use this best practice.”“We’re going to measure your use of this best practice.”“We’re going to share the correlation of this best practice tooutcomes with you so we can learn together andcontinuously deliver quality, affordable care.”Essential #5: Financial AlignmentHealth system financial incentives and payment models have toalign with its quality improvement initiatives. If it’s paying providersone way but measuring them another way, then its financialpayment approach doesn’t properly align with its qualityimprovement goals. For example, hospitals organized as asystem—managed and budgeted as departments and units withinseparate hospitals—frequently find that hospital/departmentstrategic priorities are not in alignment with overall systempriorities. This misalignment frequently leads to well-intentioneddecisions that inadvertently result in overall waste, unnecessaryclinical variation, and operational inefficiencies.THE MOST EFFECTIVE QUALITY IMPROVEMENT TOOLSThe Health Care Data Guide: Learning from Data forImprovement by Lloyd Provost and Sandra Murray is anextremely valuable quality improvement resource for healthsystems feeling overwhelmed by quality improvement goals.Copyright 2017 Health Catalyst9

By working together asan industry to sharequality improvementsuccess stories,strategies, and lessonslearned, we cansignificantly turn that 60to 80 percent strategicinitiative failure rate intoa success rate. We canturn qualityimprovement’s tall orderinto a manageable,achievable, continuous,and sustained reality.Designed to help professionals “build a skill set specific to usingdata for improvement of healthcare processes and systems” thebook is a practical, step-by-step guide with strategies andmethods for continuous improvement. The book outlines themost effective tools, assigned to one of six categories:1. Systems and processes (e.g., flow diagrams).2. Gathering information (e.g., forms for collecting data).3. Organizing information (e.g., cause and effect diagrams).4. Understanding variation (e.g., run charts to determine ifvariation is special cause or common cause).5. Understanding relationships (e.g., scatter plots).6. Project management (e.g., Gantt charts).Systems can’t reap the benefits of these tools without skilledresources (people who know how to use the tools), training, anda framework for establishing, approving, maintaining, andupdating evidence-based practices.QUALITY IMPORVEMENT WILL TRANSFORM HELATHCAREAlthough successful, sustained, continuous quality improvementin healthcare is a tall order to fill, health systems guided bypragmatic definitions, armed with the most effective tools, andwilling to integrate the five essentials—adaptive leadership,culture, and governance, best practices, analytics, adoption, andfinancial alignment—are more likely to achieve their goals andcontribute to the industry wide effort to transform healthcare. Byworking together as an industry to share quality improvementsuccess stories, strategies, and lessons learned, we cansignificantly turn that 60 to 80 percent strategic initiative failurerate into a success rate. We can turn quality improvement’s tallorder into a manageable, achievable, continuous, and sustainedreality.Healthcare professionals go into healthcare because we careabout people; we truly want to improve patient health andexperiences, and help make care affordable. So we need toconstantly keep the end goal in mind: the Triple Aim. We need tomake sure every quality improvement goal ties back toimproving the health of populations, reducing the per capita costof healthcare, and improving the patient experience. By focusingCopyright 2017 Health Catalyst10

on collaboration, sustainability, and the Triple Aim, healthsystems will do more than provide better care—they willtransform the industry into one unequivocally dedicated toquality.ABOUT THE AUTHORSLeslie Falk joined Health Catalyst in 2012 as both anExecutive Engagement Manager and in various marketingroles. Prior to joining Health Catalyst , Leslie worked forHewlett-Packard in sales, support, and marketing roles. Shealso worked for Kaiser Permanente as their first BiomedicalEngineer in the Northern Region and helped launch the firstPediatric ICU in the state of Nevada. Leslie holds a Masters inBusiness Administration,Masters in Community Counseling, and a Bachelor of Science Degree inEngineering. Leslie has also earned certifications as a Project ManagementProfessional (PMP), Green Belt Lean, and Information Privacy Professional(CIPP, CIPP/IT). She is also a Registered Nurse.Ann Tinker joined Health Catalyst 2012 as a Vice Presidentfor Customer Engagements. Prior to coming to HealthCatalyst , she worked for GE Healthcare IT on the GE/Intermountain Healthcare partnership product calledQualibria as a Product Manager and Customer liaison. Annworked PRN (on-call) for LDS Hospital in the PostAnesthesia Care Unit (PACU) as a staff RN for the past 6 years. Before GE Ann was employedat 3M HIS business based in Salt Lake City working in a variety of positionsfrom sales support, implementation, development, marketing and productmanagement for both US and International products and prior to then workedfor Intermountain Healthcare for 10 years in Critical Care and NursingAdministration. Ann has a bachelor’s degree in nursing from Brigham YoungUniversity and a Masters from University of Washington.Copyright 2017 Health Catalyst

quality improvement essentials—critical elements successful quality improvement programs have in common. This executive report defines quality improvement in healthcare, describes critical quality improvement considerations, components, and tools, and identifies the top five quality improvement essentials: 1.

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