Of the 247 hospitals participating in CMS's Hospital Quality Incentive Demonstration project, run by CMS and Premier, North Shore University Hospital performed better than anyone else. The 731-bed hospital in Manhasset, N.Y., reaped more than $200,000 in pay-for-performance (P4P) funds, paid to hospitals that have the highest scores in providing treatment measures in five major disease categories. Other participating facilities in the 14-hospital North Shore-LIJ Health System also did well, winning the system a total of 57 awards and $767,067 in P4P payments, the highest overall award amount of any participating health system.
Kenneth J. Abrams, MD, MBA, senior vice president of clinical operations and chief quality officer for the system, explains how this extraordinary accomplishment was achieved.
Q: First of all, congratulations! It must have taken a lot of work. Tell me what you had to do to win this distinction.
Kenneth Abrams: North Shore University Hospital had to achieve high utilization of more than 30 evidence-based clinical quality measures in five clinical areas, ranging from acute myocardial infarction to and hip and knee replacement. One measure, for example, is how many AMI patients were given beta blockers, which are considered necessary for all AMI patients without contraindications. In an institution as complex as a hospital, making sure that every AMI patient gets a beta blocker would seem to be a daunting challenge, but we showed that it was possible to carry it out.
Q: Why does carrying out these measures matter?
KA: According to an analysis of mortality rates for participating hospitals, improvements made as a result of the HQID project have saved the lives of an estimated 4,700 heart attack patients over four years.
Q: What is your basic approach?
KA: We aim for sustainable, continuous improvement. We pilot different approaches, find out what works, share them, go back to out hospitals and redeploy. This is also referred to as the plan, "do, study, act" cycle.
Q: With a large healthcare system such as your own, how do you coordinate efforts?
KA: The leaders of all 14 hospitals in the system meet monthly in the same room. There are four from each hospital: the CEO, and heads of nursing (CNO), medicine (CMO) and quality (CQO). At this meeting, we review data analysis, share best practices and lessons learned. This helps us leverage our efforts throughout the health system.
Q: While all the hospitals in your system performed well, your flagship hospital, North Shore University Hospital, performed better than anyone else. Why do you think that is?
KA: North Shore University Hospital's success came down to the leadership team at the hospital. They were ready to execute delivery, accountability and systemization. A challenge like HQID involves constant observation and constant engagement.
Q: It's often said that physicians are not easy to get on board for any hospital initiative, because they are not employees of the hospital and can have strong opinions. How did you convince your physicians to believe in the core measures?
KA: The North Shore doctors are not employed, so it wasn't that we had any special influence over them. And, believe me, it wasn't the incentive payments themselves, which are comparatively small and are only given to the hospitals, not the doctors. But the fact is that physicians are very easy to convince once you give them all the facts, show them that what you are doing is good for patients and involve them in generating solutions. In addition, we give them regular reports on their adherence to the measures.
Another reason we have done so well with our physicians is that we entered the HQID process early on. We were one of the original organizations in the demonstration, which means we got in on the ground floor. That meant that our physician had an opportunity to provide input and feedback about the measures and see things change because they spoke up. For example, the core measures originally called for discontinuing antibiotics 24 hours after cardiac surgery, as is the case for hip replacement surgery. But a lot of cardiac surgeons across the country, and ours included, felt this to be too short a time and pointed to some convincing evidence. CMS ordered a study and, based on the results, agreed to raise to 48 hours for cardiac surgery.
In addition, we give our physicians information on how we are doing within the core measures program. The information comes in real time, which means that if they, let's say, missed one of the process measures for pneumonia, they will know that while the patient is still in the hospital and have a chance to correct it.
Q: Are there other groups in the hospital that are essential to meeting core measures requirements?
KA: Reaching out to the nurses and pharmacists is just as important as reaching out to the physicians. Take, for example, the core measure on administration of antibiotics. The physician generates the treatment plan, but it is carried out by a team of people.
Q: A hospital relies heavily on processes of care. How difficult is it to change a process in order to improve adherence to a core measure?
KA: It can be very difficult, indeed. For example, in order to change administration of antibiotics in our ORs, it was necessary not only to make sure staff administered it, but we also had to make sure those antibiotics were stocked in the OR. We had to change the entire storage process and the way the antibiotics were accessed for this to work. The timing to do this in is extremely narrow, so it had to be done just right.
Q: Does your interaction with other healthcare organizations within the HQID help you improve your quality initiatives?
KA: Absolutely. There tends to be a culture of sharing among hospitals, which is the opposite of commercial companies, which tend not to share trade secrets. For instance, Toyota probably doesn't want Honda to know about its new design features. But members of the HQID demonstration share information in conferences, Webinars and publications sponsored by Premier.
Q: What would happen if most hospitals got to the top performance level? Would the project have to stop?
KA: That would be a good thing for the American public. If it happened, we could move on to other conditions. If we could begin to really align the incentives and have a strong rationale, we could dramatically improve the care that is delivered.
Q: Policymakers are hoping that high-quality hospitals identified by the P4P program will be rewarded by higher market share. Are you advertising your HQID achievements to the public?
KA: We have put it in a release and announced it on our Web site, but we don't have ads about it and don't plan to do that. But our high core measures scores can be found on Hospital Compare (www.hospitalcompare.hhs.gov), the CMS Web site that compares hospitals for consumers. Research by Premier shows that HQID participants scored on average 6.9 percentage points higher than non-participants on the 19 performance measures reported by Hospital Compare.
Learn more about North Shore University Hospital.
Kenneth J. Abrams, MD, MBA, senior vice president of clinical operations and chief quality officer for the system, explains how this extraordinary accomplishment was achieved.
Q: First of all, congratulations! It must have taken a lot of work. Tell me what you had to do to win this distinction.
Kenneth Abrams: North Shore University Hospital had to achieve high utilization of more than 30 evidence-based clinical quality measures in five clinical areas, ranging from acute myocardial infarction to and hip and knee replacement. One measure, for example, is how many AMI patients were given beta blockers, which are considered necessary for all AMI patients without contraindications. In an institution as complex as a hospital, making sure that every AMI patient gets a beta blocker would seem to be a daunting challenge, but we showed that it was possible to carry it out.
Q: Why does carrying out these measures matter?
KA: According to an analysis of mortality rates for participating hospitals, improvements made as a result of the HQID project have saved the lives of an estimated 4,700 heart attack patients over four years.
Q: What is your basic approach?
KA: We aim for sustainable, continuous improvement. We pilot different approaches, find out what works, share them, go back to out hospitals and redeploy. This is also referred to as the plan, "do, study, act" cycle.
Q: With a large healthcare system such as your own, how do you coordinate efforts?
KA: The leaders of all 14 hospitals in the system meet monthly in the same room. There are four from each hospital: the CEO, and heads of nursing (CNO), medicine (CMO) and quality (CQO). At this meeting, we review data analysis, share best practices and lessons learned. This helps us leverage our efforts throughout the health system.
Q: While all the hospitals in your system performed well, your flagship hospital, North Shore University Hospital, performed better than anyone else. Why do you think that is?
KA: North Shore University Hospital's success came down to the leadership team at the hospital. They were ready to execute delivery, accountability and systemization. A challenge like HQID involves constant observation and constant engagement.
Q: It's often said that physicians are not easy to get on board for any hospital initiative, because they are not employees of the hospital and can have strong opinions. How did you convince your physicians to believe in the core measures?
KA: The North Shore doctors are not employed, so it wasn't that we had any special influence over them. And, believe me, it wasn't the incentive payments themselves, which are comparatively small and are only given to the hospitals, not the doctors. But the fact is that physicians are very easy to convince once you give them all the facts, show them that what you are doing is good for patients and involve them in generating solutions. In addition, we give them regular reports on their adherence to the measures.
Another reason we have done so well with our physicians is that we entered the HQID process early on. We were one of the original organizations in the demonstration, which means we got in on the ground floor. That meant that our physician had an opportunity to provide input and feedback about the measures and see things change because they spoke up. For example, the core measures originally called for discontinuing antibiotics 24 hours after cardiac surgery, as is the case for hip replacement surgery. But a lot of cardiac surgeons across the country, and ours included, felt this to be too short a time and pointed to some convincing evidence. CMS ordered a study and, based on the results, agreed to raise to 48 hours for cardiac surgery.
In addition, we give our physicians information on how we are doing within the core measures program. The information comes in real time, which means that if they, let's say, missed one of the process measures for pneumonia, they will know that while the patient is still in the hospital and have a chance to correct it.
Q: Are there other groups in the hospital that are essential to meeting core measures requirements?
KA: Reaching out to the nurses and pharmacists is just as important as reaching out to the physicians. Take, for example, the core measure on administration of antibiotics. The physician generates the treatment plan, but it is carried out by a team of people.
Q: A hospital relies heavily on processes of care. How difficult is it to change a process in order to improve adherence to a core measure?
KA: It can be very difficult, indeed. For example, in order to change administration of antibiotics in our ORs, it was necessary not only to make sure staff administered it, but we also had to make sure those antibiotics were stocked in the OR. We had to change the entire storage process and the way the antibiotics were accessed for this to work. The timing to do this in is extremely narrow, so it had to be done just right.
Q: Does your interaction with other healthcare organizations within the HQID help you improve your quality initiatives?
KA: Absolutely. There tends to be a culture of sharing among hospitals, which is the opposite of commercial companies, which tend not to share trade secrets. For instance, Toyota probably doesn't want Honda to know about its new design features. But members of the HQID demonstration share information in conferences, Webinars and publications sponsored by Premier.
Q: What would happen if most hospitals got to the top performance level? Would the project have to stop?
KA: That would be a good thing for the American public. If it happened, we could move on to other conditions. If we could begin to really align the incentives and have a strong rationale, we could dramatically improve the care that is delivered.
Q: Policymakers are hoping that high-quality hospitals identified by the P4P program will be rewarded by higher market share. Are you advertising your HQID achievements to the public?
KA: We have put it in a release and announced it on our Web site, but we don't have ads about it and don't plan to do that. But our high core measures scores can be found on Hospital Compare (www.hospitalcompare.hhs.gov), the CMS Web site that compares hospitals for consumers. Research by Premier shows that HQID participants scored on average 6.9 percentage points higher than non-participants on the 19 performance measures reported by Hospital Compare.
Learn more about North Shore University Hospital.