Ministry facilities among participants in Robert Wood Johnson quality effort
By JULIE MINDA
Changing routines is hard, and that can be particularly true for clinicians who are asked to follow new protocols they did not create themselves.
One solution: Empower frontline staff to determine how best to implement clinical protocols developed elsewhere, and inspire them to design or customize clinical routines that advance care quality.
The Robert Wood Johnson Foundation espouses that two-pronged approach for promoting staff commitment to change in its "Aligning Forces for Quality" program. Launched in 2006, the 10-year, $300 million Aligning Forces initiative promotes collaboration between hospitals, community organizations, payers, independent clinicians, academics, government agencies, businesses, citizens and labor groups to improve care quality and address other concerns with health care delivery. The hospitals contribute by implementing clinical protocols and sharing ideas for improving care and problem solving that come from the administrative offices and the bedside.
"Before, we would train staff on a best practice and say, 'Go do it,'" explained Terri Martin, clinical director at Cincinnati's Mercy Health-Anderson Hospital. Needless to say, staff didn't always toe the line, "but now we take the goal back to the team and ask them how they can accomplish it" and implement a better way of performing a recurring task.
For instance, prior to applying the new methodology, Anderson Hospital leaders had trouble getting clinicians to fully adopt an hourly patient rounding protocol. The hospital got much greater compliance by allowing frontline staff to determine how to round on each patient every hour in a way that worked for their particular unit.
The motivation and innovation "takes place on the front lines," said Martin.
Big tent
Most organizations — but not all — participate in Aligning Forces as part of a regional group, or alliance, of organizations that share what they're learning with each other and coordinate their efforts. In one such alliance in Humboldt County, Calif., sister hospitals St. Joseph Hospital of Eureka, Calif., and Redwood Memorial Hospital of Fortuna, Calif., are part of Aligning Forces Humboldt. That group includes the California Center for Rural Policy at Humboldt State University, the Humboldt-Del Norte Independent Practice Association, patients and consumer advocates.
Aligning Forces focuses on these goals: improving the quality of care, reporting publicly on quality and performance data, engaging patients in their care, reducing disparities in care and aligning payment structures with outcomes. It helps participants address these goals by training them to approach change in a methodical way. It provides participants with funding, coaching, consulting, materials, in-person training at conferences and meetings, access to online forums of participants and other resources so that they can learn from experts and peers around the country which approaches work, and which don't, to address the goals.
Participants have leeway in the goals they choose to pursue. Hospitals — and particularly their quality improvement experts — involved in Aligning Forces learn to improve quality by getting buy-in from the clinicians closest to the patient — normally nurses who work directly with patients.
Anderson Hospital is undertaking most of its related quality improvement work through "Transforming Care at the Bedside," an Aligning Forces initiative with the Institute for Healthcare Improvement and the American Organization of Nurse Executives. Its approach to change is textbook Aligning Forces: It engaged its nurses and other frontline staff in developing ideas for improving patient care by asking them to offer their own suggestions on how to reach specific care goals. The clinicians tried out their ideas, measured the results, adjusted as needed and then spread successful tactics to other units.
In the three years since the hospital joined Aligning Forces, participating clinicians developed new ways of working with patients at risk for falls, they reduced noise levels in busy units, organized supply storage areas more logically and established a patient family council. They refined protocols for patient handoffs between caregivers, between units and for discharge.
Martin said the Aligning Forces method completely changed how Anderson Hospital approaches problems. It taught leaders to let go of some control and give staff sway in addressing patient care challenges. "Nurses felt they got a voice for the first time"; and the units "were thrilled to see" patient satisfaction scores improve, she said.
Challenging assumptions
Ministry Saint Mary's Hospital of Rhinelander, Wis., and Ministry Sacred Heart Hospital of Tomahawk, Wis., joined Aligning Forces in early 2011 through a state alliance organized by the Wisconsin Hospital Association. The hospitals used the Aligning Forces methodology, in conjunction with Lean Six Sigma management concepts, to identify gaps that happen
in patient care delivery and then to engage clinicians in developing procedures to close those gaps. They concentrated on standardizing clinical care, improving how they address disparities, reducing readmission rates and improving how providers communicate with one another.
In the past, information didn't always reach the right people at the right time as patients moved from one unit to another or were discharged, according to Cynthia Heenan, Lean master black belt for the hospitals. Susan Klemm is quality improvement clinical specialist for the hospitals. She said the primary care provider was not always notified when their patient was admitted to — or discharged from — the hospital. Neither did hospital staff consistently communicate care plans to home health providers or nursing home personnel who would be involved in follow-on care. Clinicians sometimes made assumptions that other providers were aware of care plan details when they weren't, said Klemm.
Hospital staff tightened up communications and the patient flow process across the care continuum. Prior to discharge, staff make sure the patient has follow-up appointments on the books with a primary care physician or specialist. It's now standard procedure for the hospital to notify primary care physicians when their patients are discharged. "No-shows" at follow-up appointments get a phone call from case managers called clinic personal service representatives to check on their health status.
Klemm said the hospitals' readmission rates are below the national average, in part because of the Aligning Forces work.
Better transitions
In Humboldt County, each main participant in the alliance — the hospitals, the provider group and the rural policy center — has chosen different Aligning Forces focus areas.
St. Joseph and Redwood key in on quality improvement and consumer engagement. They geared their initial efforts toward improving how heart failure and chronic obstructive pulmonary disease patients transition through the health care system. Using the Aligning Forces methodology, clinicians identified concerns with communications — particularly when it came to communicating with community-based providers. They developed new approaches to ensure that when patients move from one care venue to another, the next provider is well-prepared for their arrival. They now use Care Transitions nurses to communicate with patients and their providers outside of the hospitals in preparation for and after discharge from the hospitals.
Sharon Hunter, Care Transitions program coordinator for St. Joseph and Redwood, said readmission rates are falling. She said the hospitals now are applying their care transitions approach to respite care after discharge for homeless people. Also, the facilities are planning to use the approach to improve how "superutilizers" access the health care system. Superutilizers are people who frequently seek care in the emergency department and other expensive care venues, when they could safely be treated in a less costly setting.
Hunter said that the quality improvement work addresses issues that are important to the ministry, including patient dignity, care excellence, service and justice.