Leadership alignment

From HMCwiki

Effective leadership alignment within healthcare organizations is swiftly becoming critical as healthcare expenses become a greater percentage of the United States gross domestic product (GDP). Healthcare premiums are increasing at an alarming rate, and, at the same time, change in hospital productivity is decreasing. Moreover, the ability to maintain a competitive cost position will be further compounded as hospitals now have a portion of their reimbursement at risk based on quality outcomes. Trustees can play a leadership role in putting the organization on course to achieve improvements in productivity and quality outcomes. To accomplish this successfully, trustees first need to understand the varying perspectives of multiple stakeholder groups and, secondly, recognize that a paradigm shift may be necessary in order to implement the processes and programs that will help the organization achieve its goals.

During a recent conference sponsored by the California Healthcare Foundation, attendees were asked to prioritize twenty-four practices that most significantly contribute to California hospitals’ pursuit of high quality patient care. The results of the poll were grouped according to the respondent’s position or role in the organization. When analyzing the results, it is interesting to note the alignments between various stakeholder groups (board members, physicians, nurses and senior management) and how their perspectives differ.

• Board members and nurses were aligned in placing the highest importance on having evidence-based protocols and care guidelines.
• Physicians believed investments in information systems supporting medical error reductions would have the most significant impact on providing high quality patient care.
• Senior managers ranked having interdepartmental cooperation as the most influential aspect of providing quality care.

Not only does this comparison indicate there is little agreement on how hospitals should approach delivering quality care, more importantly, it points out the need for understanding the dynamics between evidence-based protocols, technology and interdepartmental cooperation. The foundation for driving and achieving improvements in productivity and quality outcomes is at the intersection of these three factors.

Evidence-based protocols and care guidelines

The objective of evidence-based protocols is to reduce variation and create a performance baseline. When correctly developed and appropriately utilized, the application of evidence-based protocols can simultaneously improve quality of care and reduce costs. The premise behind this idea is that poor quality is the result of a performance glitch. Since a poor outcome costs more than a good outcome, savvy boards will focus their search for improvements in quality care on those service lines that are comparatively higher in cost. In any facility, if a product or service is not delivering expected outcomes, as indicated by excessive cost, then there is also an opportunity to improve quality. Structured as such, the quest for improved quality and enhanced productivity go hand-in-hand.

Another objective of evidence-based protocols is to create a baseline against which outcomes can be compared. Without a baseline, it's difficult to determine exactly what causes variance from a norm. A baseline of care creates a platform from which to make adjustments to methods and care patterns. These minor adjustments are what provides evidence for modifying care and creates a path for continuous quality improvement. Many physicians have been providing evidence-based medicine within their own practice, but to effect change throughout the healthcare system, breakthrough methods of collaboration are required.

Platforms for collaboration between physicians are becoming increasingly important. LDS Hospital, which is located in Salt Lake City, Utah, and is part of the Intermountain Health System, has had success with implementing and maintaining CAP guidelines for pneumonia patients. LDS' success with evidence-based protocols, which has been ten years in the making, began with active measures to demonstrate the need for change. Since physicians respond best to data, collaboration resources that encourage physicians to look beyond the confines of their own hospital's walls are very powerful tools for mitigating reluctance to pathways and protocols. Physicians and nurses alike want to do right by their patients and if they see something is not working, they will want to change it. LDS Hospital found that displaying variances in quality of care created enthusiasm for the creation of a pneumonia guideline.

Trustees can encourage the senior team to measure variation within and outside the walls of their hospital and isolate the service lines with the greatest opportunity for improvement. From there, they can create a business case that supports the need to prioritize efforts around those areas that have the greatest need for improvement, not necessarily the highest volume of activity. Encourage prioritization by finding the service lines with the greatest excess costs and then develop a corrective action plan. Trustees can ask for objective data that leads to the prioritization of quality projects. Without objective information, priorities can become subject to internal political processes. In the long run, these initiatives may not serve the patient population.

The objective of information systems

The objective of information systems is to support internal processes, so it is not surprising there has been an extensive emphasis on the importance of information systems in the healthcare environment. Root causes for the lag in productivity have been linked to a lack of investment in computer systems that support the patient continuum of care. President Bush believes that innovations in electronic health records and the secure exchange of medical information will help transform health care in America. But the initiatives that are cited to explain an extraordinary investment in technology are related to transmitting x-rays over the Internet, electronic laboratory results and electronic prescriptions. All of these technologies have been available over the last ten years, and many hospitals are already using them. Yet there have been no significant increases in hospital productivity.

Like any information system implementation effort, processes need to change first before the hardware and software is in place. Otherwise, institutions run the risk of either duplicating poor processes or implementing a computer system where there are no standardized practices. In the first instance, poor processes get locked into place with computer code. In the second instance, programmers have to try to code every conceivable contingency provided for in the current system. Either way, the cost of implementing "technology first" systems quickly becomes expensive in the short-run, and exorbitant in the long run. Without positive changes in productivity, technology alone cannot deliver a return-on-investment.

Trustees can play a critical role in avoiding the pitfalls of “technology first” systems by first identifying the strategic gap. Too often hospitals identify strategies strictly based on current operating performance, an approach that is limited in its capability to reveal the organization’s true potential. Trustees can (and should) thwart this flawed approach to strategic planning and, instead, identify the difference between the current operational outcomes and the funding that is necessary to achieve the hospital strategy. Once the gap is identified, the organization should look for opportunities for technology to support the required changes. Trustees need to set the hospital’s mandate to have sound processes that have been tested first and technology to amend those processes second.

Stakeholder perspectives: nursing

With the exception of patients, of course, nursing has perhaps the most to gain from implementing clinical protocols and pathways. One of the greatest advantages of managing patients according to care guidelines is that all of the providers of care, throughout the continuum of care, can plan their activities based on an expected path. Planning the patient's expected hospital release date at the time of admission provides a set of expectations for the care team. This is a common goal, which produces alignment between the key stakeholders within the organization. As Marc-Auriel Marial, a Quality Consultant who worked with Dr. Nathan Dean at LDS Hospital on implementing their pneumonia guidelines, points out, “Amongst other things, simple guidelines, when based on best practices, help dictate expectations for nurses and aide in facilitating timely order completion. Protocols also allow nurses to be more independent. They don’t have to make as many calls to doctors because the decision to provide the best care has already been made in the protocol.”

Setting expectations for the care team is especially useful for patients entering the hospital through the Emergency Department (ED). Particularly damaging to a hospital's reputation is the amount of time patients need to wait for an Emergency Department visit. Crowded waiting rooms, little patient privacy, collection of co-pays and unmanaged expectations are just a few of the inconveniences that have become the norm for too many ED patient encounters. But ED overcrowding is a symptom, not a root cause, of excessive wait time. When Emergency Department systems breakdown, it is typically because there are either too many patients waiting to be admitted or there are a large number of patients being held in observation while the decision to admit is made. Also, when the intensive care unit becomes full, hospitals need to arrange for other emergent patients to be diverted to other hospitals. This leads to decreased levels of service for the community being served.

Aligning the care patients require with the area of the hospital that is best prepared to care for them goes a long way, especially with nursing staff. For example, determining the appropriate level of care for a patient with community-acquired pneumonia (CAP) is an important decision in the management of this condition. Aligning the care patients require with the area of the hospital that is best prepared to care for them goes a long way. Patients assigned inappropriately to the ICU, at the highest level of care, end up utilizing beds that would be best used for more acute patients, at excessive costs. Assigning patients that require the ICU to any other floor means nurses are unexpectedly taking care of more acute patients. Time required to care for their other patients becomes stretched, and levels of care can diminish. This mismatch of patient requirements and nurse staffing is a breading ground for medical errors. Since ensuring that a patient receives the optimum level of the care is at the core of every hospital’s mission, it should be the focus of every trustee to encourage the use of mechanisms, such as care guidelines that support adherence to evidence-based standards of care. Furthermore, providing the best possible work environment for nurses is critical when RN staff is at a premium.

Perhaps the root cause of ED wait times is delayed and inappropriate placement of patients within the hospital, rather than inadequate facilities or staffing. The board can play a critical role in ensuring productivity gains from healthcare providers by focusing first on improving processes (and improved quality and productivity) and second on implementing technological advancements, enlarge facilities or increase staffing to support those improved processes (at increased cost).

Stakeholder perspectives: senior management

Without strong leadership, politics will interfere with efforts to change core hospital processes. It's not surprising that in the California Healthcare Conference poll, senior managers ranked having a culture that supports interdepartmental cooperation for clinical process improvements as being the most significant factor influencing the hospital's ability to provide quality care. Senior managers are acutely aware of the difficulty of managing investments in information systems in a way that allows the hospital to achieve gains in both quality and productivity.

In order to be effective, senior management needs to promote the quest for cost and quality as a single journey, not two separate pathways. In doing so, they set the stage for ensuring that gains in both productivity and quality are achieved. Passive expectations for improvements are not enough. The most successful senior managers proactively manage to higher productivity.

Senior management should play an integral role in collecting data to pinpoint those procedures that have a large variation in cost or quantity of supplies, drugs or lab tests. Once protocols are developed, senior management needs to work with physicians and nurses to develop measures that can show in real-time whether or not there is evidence that a new system is working. Trustees should insist on a dashboard, with drill down capabilities, that provides easy access to these real-time reporting measures. Such a tool gives trustees the capability to quickly assess whether their organization in on course. Senior managers need to understand they cannot accept a status quo and that they need to take responsibility for perpetuating the improvement momentum by continually building awareness. Trustees need to encourage senior management as they pursue the path of improved performance by emphasizing the value of borrowing from the experiences and successes of other institutions.

Stakeholder perspectives: physicians

In the California Health Institute's survey, physicians felt that more investment in technology would go further in improving the quality of care provided in their hospitals. Historically, physicians have been reluctant to implement evidence-based guidelines. It's important to understand why some physicians might be apprehensive to follow prospective guidelines, even if evidence suggests that certain treatment plans have been successful. They have valid reasons for being apprehensive. Understanding their perspective is critical. If physicians believe evidence-based protocols are going to restrict their ability to provide patient care and impede their workflow by creating more paper work, generating the momentum for change will become more difficult. Accordingly, it is important to develop guidelines that are supported by medical literature. Involve physicians in the development of the guidelines, and create avenues for them to collaborate with colleagues. Since change is never easy, it's important to elicit the support of a physician champion who can mobilize the less reluctant group to start following the protocol. Those physicians who are figuratively “stuck in the middle” generally respond positively to the strong leadership of a physician champion.

One reason physicians are less likely to participate in quality initiatives is because evidence-based pathways are developed based on objective larger data sets, regardless of hospital geography, devoid of patient preference. A physician’s experience is drawn from a smaller subset, and his/her opinion can be swayed by individual experiences (perhaps poor outcomes with methods that could be ironically supported in pathways) and by the likes and dislikes of patients. That is, researchers create evidence-based practices based on information at a macro level, whereas each physician is dealing with individual patients on a micro level. The individual physician process of implementing clinical guidelines is affected by the personal and professional experiences of the doctor.

Secondly, many doctors prefer to be engaged in a 1:1 discussion, usually occurring in the hospital hallway or over lunch. Their hours are billable. They have an entrepreneurial style that is a perfect fit for primary practice management. In addition, they are more reactive and tend to solve problems on their own, sometimes striving for immediate corrections in a business environment. They are business owners who prefer a more congenial approach and are sometimes mystified at the slower progress of larger bureaucracies.

That being said, physicians tend to react to good data and information. They prefer not to be outsiders and are likely to move to a more central position when evaluated against their peers. And physicians want a financially sound place to work in, reflective of their own excellent outcomes. Accordingly, trustees can play a critical role in educating the physician population around revenue and costs from the hospital perspective. Trustees need to define the "burning platform" and explain the reasons for cost containment. Seek out those who may not be on-board, and give physicians the chance to express concerns in a 1:1 situation.

The hospital trustee’s role

The board sets the culture for collaboration, and developing evidence-based guidelines requires two kinds of collaboration. First, there needs to be collaboration within an organization. There needs to be a common platform for sharing outcome data. Developing common internal measures creates a consistent set of goals and objectives. A well constructed hospital dashboard, which includes meaningful measures, not just the measures that are readily available, is perhaps the single greatest step in aligning the organization.

Secondly, there needs to be a method for sharing information between hospitals, external collaboration. The primary source for evidence-based practices will be from outside the organization. And the fastest way to jump-start improvement efforts is to learn from other organizations that have experienced the same difficulty. Trustees can trigger meaningful research by simply asking how other hospitals have tackled a similar problem. Trustees can further encourage knowledge exchange by developing a dashboard that can be linked with other management tools, especially those which support collaboration within and between hospitals.

Boardroom discussions that center around quality of care often take place adjunct to those that focus on financial issues. However, strategic and quality discussions do not need to be on the opposite sides of the spectrum; in fact, structuring the boardroom agenda as such is arguably to the detriment of the organization. There is a real opportunity for board members, who generally represent non-healthcare industries, to introduce non-healthcare management strategies to help hospital employees understand that productivity and quality should not be managed separately. Other industries understand the importance of managing quality and productivity simultaneously. Since strategic goals need to come from the top, that message needs to be communicated from the boardroom throughout healthcare organizations.

Placing patient care issues first, building the best evidence-based processes and actively seeking the input of primary care givers are critical elements to achieve productivity and quality advances. Remember, achieving improved quality is not a technology project. Investments in technology can only support those practices once they are deliberately defined. Those organizations that lead first with technology, and improve practices later, may fall short of achieving the goals and objectives of the institution - providing the best possible care for their community.

Summary

There is a real opportunity for board members play a role in aligning the organization around mission critical objectives; managing quality and productivity simultaneously. Recognizing the varying perspectives of hospital stakeholders is a logical first step towards building a climate that supports collaboration. Placing patient care issues first, building the best evidence-based processes, and actively seeking primary caregivers' input are strategic imperatives that drive productivity and quality advances. Aligning these caregivers around similar goals and objectives can lead to the best possible care for the community at large. Since strategic goals need to come from the top, that message must be communicated from the boardroom throughout the organization.

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