Ask 25 healthcare executives to define "quality," and their answers may surprise you.
This content is sponsored by athenahealth
Executives examined quality improvement — the leadership skills necessary to drive it and the greatest opportunities for it in their organizations — during an executive roundtable discussion sponsored by athenahealth at Becker's Hospital Review 8th Annual Conference in Chicago April 19.
The roundtable included presidents, directors and C-level executives from health systems nationwide. CEOs (33 percent), CFOs (33 percent) and COOs (22 percent) represented the majority of participants. About 60 percent of attendees came from medium to large hospitals (100-400+ beds), 28 percent came from small hospitals (less than 100 beds) and 12 percent represented physician groups or other providers.
Participants answered a series of survey questions about quality during the roundtable. This article summarizes key points that emerged from the discussion, including the semantics of quality and value as well as tactical plans to implement quality improvement.
Quality now spans beyond clinical excellence
The Institute of Medicine defines quality as "the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Delivering high-quality care is mission critical to hospital systems, especially as payers base an increasing amount of reimbursement on patient outcomes.
However, the industry shift to value-based medicine has also transformed and expanded what "quality" means to many hospital leaders.
"Quality is more than just clinical," said the CFO and executive vice president of a 10-hospital system on the West Coast. "We are looking at what it means to drive patient value. Quality is now about population health and revenue cycle management, not just a contractual issue that relates to reimbursement or measurements of quality and outcomes."
She suggested the terms "quality" and "value" have become nearly interchangeable among industry stakeholders when evaluating hospital performance. Furthermore, the term quality today often includes nonclinical factors, such as patient financial experience, the physical hospital environment and patient-provider communication.
Changing patient expectations is one reason the meaning of quality now encompasses more than clinical outcomes. Fifty-six percent of executives at the roundtable discussion said clinical quality is an "important" factor in their organization's success moving forward. At the same time, executives generally agreed that a healthcare provider's clinical quality is already assumed by today's consumer, meaning that clinical excellence is an expectation rather than a selling point.
"[Hospital systems] have to go beyond just clinical excellence and get into delivering an experience, that's the real differentiator" in today's competitive market, said the associate CMO of a multispecialty hospital in the Midwest.
Nonclinical metrics like HCAHPS survey results, CMS star ratings and public physician reviews and ratings all underscore how important the patient experience has become to hospitals' reputation and strategy over the last 10 years. However, executives of ancillary healthcare providers — urgent care centers, skilled nursing facilities and rehabilitation centers, for instance — said patient experience was a core competency at their organization even before these mechanisms gained traction.
An executive at a national rehabilitation hospital chain said demonstrating clinical, environmental and interpersonal quality to patients and their families is integral to her organization's longevity. Unlike acute care facilities, "post-acute hospitals are a place of choice," leaving them competing for patients based on qualitative factors, she said. Some hospital patients, like emergency patients, don't have the time or opportunity to choose their acute care facility, whereas patients and care teams generally choose post-acute providers.
Defining what quality means to an institution is the first step toward implementing a quality improvement initiative. Before creating a quality task force, hospital leaders must decide who should be involved in driving enterprisewide change.
Charting a path to quality, starting from the top
To decide which leaders or departments should chart the course to quality improvement, providers should consider several factors. One important consideration that emerged from the discussion was a department's ability to lead, model and inspire change across an enterprise.
Roughly 67 percent of attendees believed the hospital executive team should set the tone and vision for quality in their respective organizations. The CIO of a mid-sized system on the West Coast said executive leaders already possess the tools and characteristics necessary to drive large-scale change — mature leadership skills, goal-oriented mindsets, authoritative positions and emotional intelligence, among other traits.
"Each one of us in the C-suite have a role in guiding the organization to value," he said. "As the administrative leaders, [executives] can allocate the resources, direct the organization and direct the resources to get behind value."
Another executive said C-level leaders' position at the helm of an organization makes them inherent role models. "I need to be transparent at all times. My behaviors and actions mean something and people in [our] organization are watching what [our] C-suite does," said the CEO of a large system on the East Coast. Moreover, the executive team embodies and represents a system's core values to its community leaders, hospital peers and prospective business partners.
Several discussion participants said their organizations are incorporating input from physician leaders to inform executive teams' leadership in quality efforts. The CIO of a three-hospital system in the West said her organization is preparing and selecting physicians to work collaboratively with executives in driving quality improvement. "We are putting more physicians in leadership roles and we've established a physician leadership program to hone their leadership skills," she said.
Chronic disease management: The greatest opportunity for quality improvement
As more providers engage in risk-based payment models, they see chronic disease management as an ample opportunity to reduce healthcare spending and improve patient outcomes. In fact, nearly half of executives (47 percent) said improving chronic disease management was the greatest quality-related opportunity to drive success at their organization.
"The amount of patients [with co-morbidities] who come through our system is amazing," said the president of one hospital in a 10-hospital system on the East Coast. "So many of our transactions come from so few people. If we have less variation in how we treat [chronic-needs patients], we can start to reduce utilization, then we can start to drive value."
Provider organizations already involved in risk-bearing contracts have taken steps to make complex care more cost-effective. The CMO of a small hospital system in the South said as soon as his organization started taking on risk, it focused on remodeling care for its chronic needs patients. "Chronic disease is the big elephant [in the room] in terms of lowering the cost of care. As you take on risk-based contracts, each organization has to figure that out for themselves," he said.
Although many executives agreed on the opportunities for driving quality and value, they said the path to achieving and demonstrating them, respectively, is less obvious.
"The challenge is the definition of quality changes based on who you talk to. Clinicians talk about clinical value, and consumers think about experience, and payers are all over the board as to what they want, they just want to pay less," said the CFO of a four-hospital system in the Midwest. "Until we can unite as an industry on what value means, we are trying to ... take the bull by the horns ourselves."
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