Transcript: Achieving Sustainable Improvements
Speaker: Martha Radford, M.D., Chief Quality Officer, New York University (NYU Langone Medical Center)
Interviewer: Lise Rybowski
Date: May 2012
Audio format: Achieving Sustainable Improvements (MP3 audio file; 11 min., 13 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 (IQIs) and the Patient Safety Indicators (PSIs).
Subject: Today's topic is planning for the sustainability of your hospital's improvements to the AHRQ QIs. This issue is addressed in the toolkit 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 E1, Monitoring Progress for Sustainable Improvement.
I'll be speaking today with Dr. Martha Radford, who is currently the chief quality officer at NYU Langone Medical Center, and previously served as the director of clinical quality for the Yale New Haven Health System. For 20 years, Dr. Radford has been actively involved in quality performance measurement and improvement at the local, State, and national level. Dr. Radford, thanks so much for joining me today to talk about the challenge of making quality improvements sustainable.
Dr. Radford: It's my pleasure. Thank you for the honor.
Interviewer: So Dr. Radford, most hospitals are just getting started with improvement projects focused on the AHRQ QIs. Why do you think they need to think about sustainability now?
Dr. Radford: Quality improvement projects have an arc and it helps to consider sustainability as you are getting started, have a look ahead, anticipate the arc of the project. What will it look like during the maintenance phase? There is a lot of momentum that starts off the project. You can take advantage of that to get off the ground and make small changes quickly with your team. You generally can meet often, maybe every 2 weeks, maybe even weekly.
But with every single project, the focus of senior management can be fickle, especially if there is improvement, and sometimes it's hard to maintain enthusiasm and energy. At that point, you are entering the maintenance phase. During that phase, you meet less often and focus on identifying what's working well and what needs to be tweaked. It's a less intense experience but it's important to maintain the gains.
Interviewer: So tell me, how do you approach anticipating these kinds of sustainability issues upfront?
Dr. Radford: Well, particularly for the AHRQ Patient Safety Indicators, each of those is really two projects: a coding and documentation project and a potential clinical process improvement project. Each of those two sides of the coin involves different people, different teams, and different project focus areas.
To improve the PSIs, it's absolutely critical to build a strong relationship with coding and documentation. Most hospitals have a coding and documentation team and those people are absolutely critical to bring in at the beginning and maintain that relationship. You have to get that going first in order to make sure that your coding and documentation are as optimal as possible, and to sustain the improvements, you need to engage with both the coders and the clinicians doing the documentation.
It's very difficult to engage in a clinical improvement project unless you've taken the coding issues off the table. In other words, you can prove to the clinicians that are going to be working on this that coding is not an issue. If not, they will assert that coding is entirely the problem and that care is not the issue. But in fact, there are almost always two sides to that coin.
The process improvements with clinical may have shorter cycles with less intense maintenance. For example, let's say you are aiming to decrease iatrogenic pneumothorax. You first have to deal with the coding and documentation issues; then, if you see a real medical safety issue, you have to figure out what the contributing factors are, what processes we could change, and who would be on that team. Once those changes are made, you can almost back off a little bit and make sure that you are monitoring, but not necessarily involve the team all that much.
The ongoing relationship with coding and documentation will never stop because there are always issues that will need to be resolved and you need to maintain oversight over that or there's backsliding. Out of our experience, we've had issues with coding on hospital-acquired conditions such as venous thromboembolism. But ongoing monitoring of coding has helped us maintain high-quality coding and documentation on that.
Interviewer: From your experience, what does a hospital need to do to ensure that the quality improvements it achieves actually stay in place?
Dr. Radford: If you set up in the beginning the necessary relationships that have to be sustained, that helps. For clinical improvement teams, of course, the relationships are with the clinicians who just about always have another day job. So that the work that you're there doing on quality improvement is seen as extra.
During the maintenance phase, we typically rely on much less frequent meetings, bimonthly or quarterly with occasional, usually monthly, emails to just remind everybody that the project still is in play and that here's the current performance and here is the current to-do list. During the maintenance phase, you really don't want, particularly your clinician collaborators, to be overburdened by meetings.
Even during the maintenance phase, everybody finds quality improvement a bit overwhelming. So it's important after every meeting to break down all the to-do items into very small chunks and assign the work to the right person on the right team. You want the task to be in that person's comfort zone so that they won't see it as overwhelming. However, during the course of a quality improvement project, people generally expand their comfort zone and so you can call on them to do things during the maintenance phase that they might not have thought they could do during the project initiation phase. They've developed skills and capacity they hadn't started with.
It's also important to have a clear leader of the work on an ongoing basis to manage the process and maintain accountability. Sustainability can be challenging if the responsibility has to be passed on to someone else. We usually have the same team leader during initiation and improvement and maintenance phases if we possibly can. This may mean training people in skills like project management in order to have such skill sets available.
Interviewer: Can you talk a little bit about how the tool—which again is called "Monitoring Progress for Sustainable Improvement"—how that tool would be helpful to hospitals in this process?
Dr. Radford: The tool is actually quite useful. I think that the five essential elements are really quite critical and are well laid out in the tool. You need to have a limited set of effective measures. And effective means that it's measuring what you want it to measure and it's measuring the process you need to measure. As you enter maintenance phase, the number of measures may actually decrease, but you have to kind of pick your battles here: what are the key measures? Usually there is one outcome measure and there may or may not be a process measure along those lines. For example, on coding and documentation, it's usually a measure of coding accuracy. So you'll have that coming along every quarter for the coding and documentation folks.
Then you need to establish a schedule for regular reporting. I find that quarterly measurement, particularly in maintenance phase, works best, particularly for issues that are rare events really. The AHRQ Patient Safety Indicators measure relatively rare events. So quarterly seems to work best.
Report formats to communicate clearly: You want something simple, you want something trended. You want something that people can digest in a very short period of time. They don't have to read a long and involved table.
You need to have a procedure in place for acting on the problems identified. The improvement group that you started in the beginning may morph into this kind of oversight group, particularly if you are meeting quarterly and you can go over those measures that are key and decide which things may need to be tweaked in order to continue to maintain your gains. And you assess sustainability on a periodic basis; that also works within an oversight group that meets relatively infrequently.
Interviewer: What words of advice do you have for hospitals as they embark on improving performance on the QIs and look ahead to the maintenance phase?
Dr. Radford: Well, as I mentioned, it really is a long-term process. I've got groups that have been going for 4 or 5 years. And improvement always takes a while. You may not see real improvement for over a year. So you have to be able to see what you are doing over time.
One way to keep improvements going when you are not getting rapid cycle data is for teams to develop intermediate measures. For example, you may need a process measure for iatrogenic pneumothorax. Let's say you decide to have a standard procedure; you may need to monitor from time to time how frequently your standard procedure is being used. So that would give you a process measure that would give some intermediate information to keep the iatrogenic pneumothorax rate low.
And then finally, as you enter the maintenance phase, your organizational understanding of what needs to be maintained will become clearer. Not all of the PSIs will remain relevant and it's important to choose which of those you need to focus on to maintain your gains and to maintain the attention of the caregivers. For example, with respect to infection prevention, we do monitor outcomes. We also measure compliance with the CLABSI [Central Line-Associated Bloodstream Infection] bundle, for example, as a process measure because driving down infections is very important to us.
Interviewer: Thanks so much, Dr. Radford, for sharing this expertise with us. Your concrete advice and insights into the ongoing nature of the improvement process have really been very helpful. As I mentioned earlier, you can download the Sustainability tool from the AHRQ Quality Indicators Toolkit by going to http://www.ahrq.gov/qual/qitoolkit. Click on the link for the roadmap, and select the tool labeled E1, Monitoring Progress for Sustainable Improvement. 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 for listening.