Transcript: Identifying Your Improvement Priorities
Speaker: Julie Cerese, Vice President for Performance Improvement, University Healthsystem Consortium (UHC)
Interviewer: Donna Farley
Date: April 2012
Audio format: Identifying Your Improvement Priorities (MP3 audio file; 11 min., 55 sec.)
Interviewer: On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to a series of interviews designed to orient and educate users of the AHRQ Quality Indicators Toolkit for Hospitals. This toolkit was designed to support hospitals seeking to improve their performance on the AHRQ Inpatient Quality Indicators and the Patient Safety Indicators.
Subject: Today's topic is how you can go about setting priorities regarding which quality indicators are most important for your hospital to improve performance. You can find a tool that addresses priority setting on the AHRQ Web site at http://www.ahrq.gov/qual/qitoolkit. To get to this tool, open the roadmap and select the tool labeled C1, Prioritization Matrix. In addition, an example of a completed prioritization matrix is provided as Tool C2.
I'm Donna Farley with RAND and I served as the lead of the RAND/UHC team that developed and tested this toolkit. Today I'm interviewing Julie Cerese about the process that hospitals can use for identifying improvement priorities.
Ms. Cerese is the vice president for performance improvement at UHC, which is a consortium of 116 academic medical centers, along with 261 of their affiliated hospitals and 80 associated physician practice groups. She oversees the UHC patient safety program, imperatives for quality program, quality research, and accreditation services. She also was the lead of the UHC team who partnered with our RAND toolkit work. Julie, we're very pleased to have you with us today.
Julie: Thanks Donna. I really appreciate the opportunity to speak about one of the tools in the AHRQ Quality Indicators Toolkit.
Interviewer: Let me start with a very obvious question. At any given time, a hospital may be facing a number of quality and performance issues, knowing that they can't address all of them. What approaches can a hospital take to decide which of these issues are most important for them to address first?
Julie: Well, traditional methods that have been used include focusing on issues that are priorities of external regulatory bodies or insurers, responding to the local media, sometimes the loudest clinical voice in the organization, or focusing on single events. Each of these mechanisms for identifying organizational priorities is individually important and each will have individual defined focus. However, when a hospital team compares the issues to one another on multiple dimensions, it's possible to identify a few of the highest priorities for the hospital.
Really, to put it another way, it's important to focus effort and in order to do that well, you need to look at these issues in context of one another. This can be done systematically by comparing the attributes of the candidate issues to evaluate them for individual merit and the impact on the organization.
One of the tools from the toolkit is the prioritization matrix. It is actually Tool C1. That tool creates a structure to help guide decisions on where resources should be assigned for the improvement priorities.
Interviewer: How important is it for a hospital to use such a structured process for identifying priorities for its quality improvement?
Julie: Well, with a demanding national agenda for high-quality health care, there are hundreds of areas for potential focus. The assessment of multiple performance measures on multiple dimensions is very difficult. Therefore, it's critical that senior leaders have and use a structured approach for priority setting. The prioritization matrix which we've developed provides senior leadership with a framework for coming to consensus on the key organizational opportunities for improvement, and then allowing for alignment of organizational efforts and resources.
The prioritization matrix ensures that areas selected will have the greatest impact and the highest potential for success. And as you know, success can be defined in a variety of ways. The matrix allows for some flexibility to define success and assess each measure then accordingly. Each hospital will have its own local pressing conditions as well as the national priorities. The tool allows for those types of tradeoffs and other considerations that are unique to each hospital.
Interviewer: That's very helpful. So it sets the stage very nicely for the importance of actually using this kind of a resource to help organize your thinking. Having said that, how can hospitals best use the prioritization matrix in their process? What are some of the step-by-step kinds of things that they need to do to work with it effectively?
Julie: The prioritization matrix provides this structure to assess each individual patient safety and quality indicator on multiple dimensions. You can look at it for the actual rate of performance as compared to a national benchmark. It provides you with information about the annual cost associated with the current level of performance as compared to the estimated cost to implement the change, the level of strategic alignment or impact on regulatory mandates, and an assessment of barriers to implementing change needed to improve performance.
The completion of the prioritization matrix requires effort from a variety of individuals. But two key sets of players play a critical role. First is the quality leaders and analysts, because they are going to be gathering and organizing the information into the matrix. And then the hospital leaders will use that information to reach consensus about the priorities for improvement.
The organizational quality leaders can take the initiative to populate the matrix with factual information: the actual Patient Safety Indicators and Inpatient Quality Indicators; the performance, including the numerator cases, denominator cases, and the rate per thousand; the cost per case; and the total cost of these events to the organization—and costs can either be derived from actual organizational data or identified from the literature.
Once the matrix is populated with as much factual information as possible, it's been shared with executive leaders, and then these leaders have to go through an exercise of vetting each measure to evaluate the implications of working to improve the performance on this measure and the risk of not improving the measure. Executives will go through a series of questions that will help them determine the likelihood of success, assessing the resource requirements.
So they ask questions like, Does this PSI or IQI align and support our organizational strategic plan? Would the reduction of the rate of this PSI or IQI align with our organizational goals and priorities and our culture? Do we currently have an RFI from the Joint Commission regarding this PSI or IQI, making it a priority? Have we had patients who have experienced a major sentinel event associated with this PSI or IQI? Is this PSI or IQI publicly reported? What is the public perception of care we deliver related to this PSI or IQI? And are we considered a go-to organization for care related to this PSI or IQI? Finally, do we have any press around the quality of care around this PSI or IQI? Is that press positive or negative?
At the conclusion of this entire exercise, some of the areas of focus will be glaringly apparent. But there may be others that require further debate. In the end, decisionmakers should forge a consensus on the priorities and the quality improvement plan.
Interviewer: Thanks, Julie. How acceptable, then, in that context working with the matrix, is it to modify the factors that are listed in the matrix to better fit to a particular hospital situation?
Julie: Well, the tool is flexible. And yes, it can be modified to better reflect the issues facing a specific organization. However, we do encourage organizations to use it as intended first to determine whether or not the assessment items are relevant to the particular hospital. The matrix was designed to consider external and internal forces, enablers, barriers; and there's an underlying evidence base to support the factors we've included in this matrix.
So factors can be added with little harm to the scope considered in the matrix, but it's important to be careful not to delete something that we know has demonstrated relevant consideration when setting priorities. You know, with the actual use of this matrix as presented, a hospital might find that it works better for them then they might have originally thought.
Interviewer: Thanks so much. That is very useful guidance for the hospitals as they consider how to apply it to their situation. Now, once a hospital team has gone through the matrix, what are the next steps that they need to take?
Julie: The next step is to outline your individual areas of focus and understand why the items are chosen and why the items are not chosen to be on your priority list as well. An organization may end up with about four to seven things that they may want to focus on for the next year. Since the prioritization matrix provides a picture of today's performance and the impacts today, the next step is really to determine where you want to be a year from now. What's the target?
And then you need to identify who will be responsible to oversee the effort: Who is going to be the champion of the effort and lead the team to identify the next steps for improvement? Identification of the executive sponsor and the team leader is really critical as the next step because they are going to be accountable for the results and they are going to be reporting up to senior management about how the process is going toward improvement.
Interviewer: And this really positions them right at the front of the process of developing their implementation plan to make those improvements, right?
Interviewer: Julie, thank you so much for this. This has been extremely helpful. You have provided a nice introduction to the priority-setting process and you've also offered some great perspective on how hospitals can use the prioritization matrix to help make effective decisions on their quality improvement priorities.
As I mentioned earlier, you can download the prioritization matrix and example from the AHRQ Quality Indicators Toolkit by going to http://www.ahrq.gov/qual/qitoolkit. When you're there, click on the link for the roadmap, and select the tool labeled C1, Prioritization Matrix, or C2, Completed Prioritization Matrix Example. In fact, the roadmap is a great way to orient yourself to all of the tools in the toolkit.
I also suggest checking out a video recording that you can use to introduce the toolkit to quality improvement teams and other staff. You can find the video and other materials from a Webinar about the toolkit by clicking a link at the bottom of the toolkit page or by going directly to http://www.ahrq.gov/qual/qitoolkit/webinar0215/.
Again, this is one in a series of audio interviews about the use of specific tools in the quality improvement process, so please check the toolkit pages for additional interviews and watch for announcements from AHRQ. Thank you.