Case Study High-Performing Health Care Organization • December 2008 Gaston Memorial Hospital: Driving Quality Improvement with Data, Guidelines, and Real-Time Feedback J ack M eyer, P h .D. H ealth M anagement A ssociates The mission of The Commonwealth Vital Signs Fund is to promote a high performance Location: Gastonia, N.C., near Charlotte health care system. The Fund carries out this mandate by supporting Type: Nonteaching, nonprofit hospital independent research on health care Beds: 435 issues and making grants to improve Distinction: Top 1 percent of hospitals in composite of 22 process-of-care quality measures among health care practice and policy. roughly 2,000 hospitals (about half of U.S. acute-care hospitals) eligible for this analysis. Timeframe: Second quarter of 2006 through first quarter of 2007. To be included, hospitals must have submitted data to the Centers for Medicare and Medicaid Services for all 22 measures, with a minimum of 30 cases for at least one measure in each of four clinical areas. See the Appendix for full methodology.      For more information about this study, Summary please contact: Adherence to evidence-based practice guidelines, perfomance benchmarking and Jack Meyer, Ph.D. Health Management Associates feedback, multidisciplinary committees engaged in root-cause analysis, and jmeyer@healthmanagement.com strong leadership combined to produce near-perfect compliance with evidence- based process-of-care (“core”) measures in four clinical areas at Gaston Memorial Hospital, near Charlotte, N.C. Hospital leaders also stressed the importance of working closely with the Institute for Healthcare Improvement participating in a demonstration program led by the Centers for Medicare and Medicaid Services To download this publication and (CMS), and identifying physician champions in reducing variance in practice learn about others as they become available, visit us online at patterns and adhering to best practices. www.commonwealthfund.org and register to receive Fund e-Alerts. Commonwealth Fund pub. 1195 Vol. 3 2T he  C ommonwealth F und Organization ing full or close to complete compliance with these Gaston is a not-for-profit organization established in process-of-care measures has the potential to improve 1946 as a memorial to all local soldiers who died in the quality of care and save lives. Quality leaders at World War II. The hospital’s current main facility Gaston credit the CMS demonstration program for opened in 1973. Specialty centers include CaroMont “getting them going” on their drive to adhere to evi- Cancer Center, CaroMont Heart Center, Neurosciences, dence-based practice patterns, or order sets. Advanced Spine Care, Surgical Services, Psychiatric Services, Birthplace and Neonatal, and the CaroMont Data Analysis and Benchmarking Wound and Diabetes Center. Gaston collected data on all 22 process-of-care mea- The CaroMont Heart Center provides compre- sures and submitted them to CMS. In addition, they hensive cardiac care, from chest pain evaluation to used the data to develop profiles of individual physi- open heart surgery and post-hospitalization education cians, with comparisons to their peers. Gammon cred- and support. Procedures include open heart surgery, its Gaston’s skilled administrative staff with generating bypass surgery, valve repair and replacement, diagnos- timely data on adherence to order sets and tracking tic and interventional care, angioplasty and pacemaker physician performance over time. implantation, a cardiac rehabilitation center, and step- To identify areas for improvement, Gaston com- down progressive coronary care.1 pares its results with statewide data as well as perfor- Jan Mathews, R.N., director of clinical perfor- mance levels achieved in other hospitals. The hospital mance improvement, leads Gaston’s quality improve- also benchmarks its performance using HealthGrades ment initiatives. Gary Gammon, M.D., is the medical reports. An important part of the analysis is to look for director of the Hospitalist Practice at Gaston variances in practice patterns. For heart attack patients, Memorial. He is a leader in developing order sets to for example, the hospital assesses how much variation guide physician practice patterns. occurred in the percent of patients given aspirin at In 2003, Gaston Memorial Hospital joined the arrival, a beta blocker at arrival, fibrinolytic medica- CMS/Premier hospital quality improvement demon- tion within 30 minutes of arrival, and percutaneous stration project. By the end of 2004, participation in coronary intervention within 90 minutes of arrival. The this demonstration, coupled with heightened interest wider the variance across the hospital, the more likely on the part of the Board of Trustees, led the hospital to a procedure will be flagged for improvement. launch its own quality improvement programs. In Each department sets a standard of compliance 2004, Gaston began reporting data to CMS through the with various procedures. This may be doing the right Hospital Quality Alliance program. It also reports on thing 95 percent of the time, 97 percent of the time, or, the Hospital Consumer Assessment of Healthcare in some cases, 100 percent of the time. Performance Providers and Systems measures of patient satisfac- data are then examined to determine which physicians tion. Gaston focused its quality improvement efforts comply with these standards. on patients in the CaroMont Heart Center (heart attack Gaston also shares its performance information or heart failure patients), patients with pneumonia, and with other hospitals around the state. A group of North patients who undergo surgery. In addition, some initia- Carolina hospitals has developed a listserv (ncquality. tives are hospital-wide. org) to disseminate best practices. Strategies for Success Real-Time Feedback to Physicians The main quality improvement goal at Gaston Gaston follows a two-step process to bring data to the Memorial Hospital is to reduce variance in provider attention of physicians and encourage them to adhere practice patterns. Gaston officials believe that achiev- to evidence-based practices. In the first step, a secre- G aston M emorial H ospital : D riving Q uality I mprovement with D ata , G uidelines , and R eal -Time F eedback 3 tary of the relevant hospital department receives a per- with and field inquiries from these physicians in an formance report and sets up a meeting to talk with informal effort to bring their practice patterns in line physicians whose results are sub-optimal. (Secretaries with those of physicians practicing within the hospital. are physicians who are typically next in line to become department chairmen). This is not a formal proceeding, Multidisciplinary Committees but an informal conversation in which the tenor is, “I Gaston Memorial formed several multidisciplinary thought you would like to know how you stand com- committees to delve into the causes of quality prob- pared with others in the hospital, and beyond the hos- lems and develop solutions. pital.” No record of this conversation is placed in the A Cardiac Care committee meets monthly to physician’s file. develop, refine, and implement order sets in the areas These discussions frequently indicate that the of heart failure, coronary artery bypass grafts, and basis of a problem is not that the wrong thing was heart attack care. done, but that the right thing was not properly docu- A Surgical Committee of surgeons, nurses, mented. In some instances, a physician did not pre- anesthesiologists, and respiratory care specialists has scribe a certain medication because it was contraindi- developed a Surgical Care Improvement Project. This cated, but he or she did not note this in the patient’s file. committee has been carefully examining every aspect If progress is not made following this initial of surgery for which quality and patient safety can be encounter, the physician then goes through a formal improved. In the case of coronary artery bypass graft peer review, which is documented in the physician’s surgery, the committee might examine pre-surgical file. Instead of the secretary of the department, the procedures such as prep and drape, standardize surgi- chairman of the department delivers the message. cal techniques such as reducing cardiopulmonary Gaston provides performance information to bypass time, and implement post-op measures such as physicians “on the floors” and “at the bedside.” Often, alerts to notify attending physicians about problems such information is offered to doctors retrospectively and glucose monitoring for heart patients who also (“this is how you did”). The approach at Gaston is to have diabetes. deliver information in real time to physicians in a way There are also committees on Patient Care/ they can incorporate into their practices (“this is how Specialty Care (with responsibility for improving you are doing”). pneumonia care) and Emergency Department Gammon stresses that a hospital not only has to Quality. The latter committee is developing initiatives work with physicians based in that institution, but also related to “door-to-balloon” care patterns designed to with physicians in the community. The latter, he notes, improve patient flow and safety from the moment patients arrive for their angioplasty or surgery. Gaston feeds performance data to physicians “on the floors” and “at the bedside.” Evidence-Based Practices Gaston has focused attention on evidence-based prac- tice guidelines. To begin, any physician who is inter- account for about half of all admissions. Since a num- ested works with Gammon in developing the order ber of these physicians are not directly involved in the sets. Gammon takes the lead to ensure a consistent hospital’s general staff meetings and lack clear feed- methodology and format, and consults with specialists back channels, it is somewhat more difficult to “get as needed (e.g., a pulmonologist for a pneumonia order them on the same page” with regard to adhering to set). Gammon will compare five to six different order practice guidelines and adopting new or emerging best sets for a particular disease. He culls features from practices. Gammon does frequently initiate contact these order sets, supplementing or adjusting them based 4T he  C ommonwealth F und on the experiences of the physicians at Gaston, so that Participation in National Quality the final order set is, to some degree, “homegrown.” Improvement Initiatives Gaston attributes its success in part to active participa- tion in national quality improvement programs, which The physicians cull features from provided technical assistance for data collection and evidence-based order sets, in some cases improvement efforts. In addition to the CMS/Premier supplementing or adjusting them based on their demonstration project, Gaston has participated in the own experiences, so that the final order set is, to Institute for Healthcare Improvement’s (IHI) 5 Million some degree, “homegrown.” Lives Campaign, which aims to avoid 5 million patient injuries over two years. The initiative that has captured All of the order sets follow the same format; the most attention at Gaston is IHI’s "Move Your this would not be the case if the guidelines were Dot" program. imported from other sources. Gammon believes that The program, supported by a grant from the this standardization introduces a degree of rigor and Robert Wood Johnson Foundation, helps hospitals in consistency that is important to the successful adoption measuring, evaluating, and reducing hospital mortality and use of the order sets. For example, an Emergency rates. A new methodology was developed to standardize Department physician who determines that a patient hospital mortality rates in order to fairly compare them. has pneumonia can select this diagnosis on the com- Hospital standardized mortality rates are calculated as puter system and immediately view the order set for the ratio of the actual number of deaths to the expected pneumonia, so that the recommended practices can be number of deaths for each hospital, multiplied by 100. followed from the moment of diagnosis. The researchers found that only 30 Clinical The formulation and adoption of order sets Classification Systems are needed to cover the diagno- began with Gaston’s hospitalists, led by Gammon. The ses leading to 80 percent of all deaths. hospitalists focused initially on making themselves A "Move Your Dot" improvement project starts more efficient, as using order sets can save time as with a scatter diagram with “dots,” or data points, plot- well as promote better outcomes. After having some ted on a graph showing the adjusted mortality rates and success, they began to sell the idea of using order sets reimbursement rates for the 1,739 participating hospi- to specialists, including cardiologists and pulmonolo- tals. The higher a hospital’s dot, the higher their mortal- gists. They are currently developing an order set ity rate. The further a hospital is to the right on the for geriatricians. graph, the higher the costs. Notably, there is a 450 per- cent variation across the hospitals in a patient’s chance of dying as well as an 800 percent variation in levels of There is an emphasis on “bottom line” standardized reimbursement.2 accomplishments and showing results, not just Each participating hospital starts by examining better “inputs” to the hospital production system. where it is on the scatter diagram and how far it has have to go to catch up with the leaders. Next, hospitals use a Hospital Mortality Review Tool to review patient Gaston’s leaders are committed to improving records for 50 consecutive patients who died in their health outcomes through greater adherence to best hospitals and determine the number of these patients for medical practices. The use of order sets is not an end whom it was possible to identify a major diagnosis (e.g., in itself; the ultimate goals are to lower mortality rates pneumonia) and a minor diagnosis (e.g., dehydration) and have fewer complications from surgery, fewer returns upon admission, the number of cases for which the to the operating room after surgery, and other targets. admission diagnoses matched, and whether the patients G aston M emorial H ospital : D riving Q uality I mprovement with D ata , G uidelines , and R eal -Time F eedback 5 could have been placed into higher-risk categories on forming centers of excellence for various procedures admission. This helps identify high-risk patients and has spurred interest among Gaston staff in achieving apply corresponding protocols, including: increasing better performance results. Gaston has submitted per- the number of nursing and physician contacts; stan- formance data to Blue Cross in an effort to be selected dardizing hand-off processes; identifying attending as a center of excellence. physicians; reviewing flu vaccine and pneumonia sta- tus; using remote monitoring of ICU patients with Results intensivists and nurses; and establishing partnerships Gaston Memorial is among the top 1 percent of hospi- in the community to promote care for patients before tals in a composite of 22 process-of-care measures they become critically ill. Improvement projects are (among about 2,000 hospitals eligible for the analysis). initiated based on the data reviewed and deficiencies The Table on page 7 compares Gaston’s performance identified.3 with national and state averages. Gaston has achieved 100 percent compliance with numerous core measure Support from Senior Administrators standards. Gaston Memorial officials stress that many if not all of Gaston has four Centers for Excellence from the key elements of quality improvement are supported HealthGrades.4 Gaston also has five stars in the fol- by senior administrators and the Board of Directors. At lowing areas: least 20 percent of the time of every Board Meeting is • sepsis; reserved for discussions related to quality of care. The • respiratory failure; Board meets monthly, and improvement issues and • chronic obstructive pulmonary disease updates appear on the agendas of each meeting. The (COPD); quality improvement director makes a quarterly presen- • community-acquired pneumonia; tation and progress report to the Board in a standard • gastrointestinal procedures and surgeries; and format. All of the Board members, rather than just a • back and neck surgery (except spinal fusion). sub-committee, discuss the quality issues and initiatives. The Board of Trustees asked to be briefed regu- larly on the implementation and impact of the hospi- Lessons Learned tal’s quality improvement programs. This is consistent A constellation of internal and external factors has with Gaston’s adoption of the Plan-Do-Study-Act been responsible for the achievement of top-level per- approach, which involves collection of baseline infor- formance at Gaston Memorial Hospital. An emphasis mation, identification of problems, development of on data analysis, benchmarking to state and national action plans, monitoring of results, and “hard-wiring” norms, real-time feedback to physicians, and peer innovations that prove successful. review has reduced variations in practice patterns and The Board and senior management have estab- increased adherence to evidence-based standards. lished a committee to reduce avoidable mortality—one These activities have been reinforced by a strong inter- of five components in the CMS/Premier demonstration est in quality improvement among the hospital’s leaders. of a “360 degree quality package”—in the medical/ A clear lesson from Gaston’s experience is that surgical area as well as critical care. participation in national quality improvement and Most of the quality improvement programs at patient safety programs can jump-start and facilitate Gaston Memorial are generated within the hospital or homegrown solutions to deficiencies and unexplained through participation in national quality improvement pro- variations in medical practice. grams. Hospital leaders note, however, that Blue Cross, Another lesson learned is that the achievement Blue Shield of North Carolina’s sustained interest in of excellent performance scores does not come quickly 6T he  C ommonwealth F und or easily. When evidence of shortfalls is presented, some physicians are likely to champion the cause of A number of physicians who were initially reducing variations while others are likely to be skeptical about performance improvement efforts wary. Gaston’s use of HealthGrades information began to say, “If they did it, why not me?” showed they had room for improvement in some clinical areas. This helped spur the adoption of evi- success can bolster confidence and suggest lessons to dence-based standards. be applied to subsequent efforts. According to Jan Mathews, a number of Mathews believes that Gaston’s progress toward physicians who were initially skeptical of the more complete compliance with best medical practices hospital’s improvement efforts began to say “If they is replicable in other hospitals. It will require changes did it, why not me?” after viewing data comparing in attitudes, investments in information technology, their performance with other physicians. Some participation in national quality programs, and the physicians will now check in with Mathews if they real-time use of quality measures to improve physician have not received feedback and ask “Am I doing adherence to evidence-based standards. things right? You’ll let me know if I fall short, won’t you?” For More Information: Mathews and her colleagues view quality Contact Jean Waters, director, Marketing and Public improvement as an ongoing journey rather than a plan Relations, Gaston Memorial Hospital, at (704) 834- to be completed. Starting with a few clinical areas as 3560 or watersj@gmh.org. targets of improvement is realistic and feasible; early N otes 1 http://www.caromont.org/body.cfm?id=33. 2 Institute for Healthcare Improvement, “Move Your Dot: Measuring, Evaluating, and Reducing Hospital Mortality Rates (Part 1),” Innovation Series 2003, p. 6. 3 Ibid, pp. 6–9. 4 HealthGrades provides ratings and profiles of hospitals and other health care institutions. See http://www.healthgrades.com. G aston M emorial H ospital : D riving Q uality I mprovement with D ata , G uidelines , and R eal -Time F eedback 7 Table. Gaston Memorial Hospital’s Scores on 24 CMS Core Measures Compared with State and National Averages North Gaston National Carolina Memorial Indicator Average Average Hospital Heart Failure Percent of heart failure patients given discharge instructions 69% 71% 96% of 570 patients Percent of heart failure patients given an evaluation of LVS function 87 92 100% of 663 patients Percent of heart failure patients given ACE inhibitor or ARB for LVS dysfunction 87 89 99% of 222 patients Percent of heart failure patients given smoking cessation advice/counseling 89 94 100% of 152 patients Pneumonia Percent of pneumonia patients given oxygenation assessment 99 100 100% of 852 patients Percent of pneumonia assessment patients assessed and given 78 82 99% of 600 patients pneumococcal vaccination Percent of pneumonia patients whose initial emergency room blood culture was 90 90 98% of 585 patients performed prior to the administration of the first hospital dose of antibiotics Percent of pneumonia patients given smoking cessation advice/ counseling 85 92 100% of 397 patients Percent of pneumonia patients given initial antibiotics within six hours after arrival 93 93 98% of 436 patients Percent of pneumonia patients given the most appropriate initial antibiotic(s) 87 87 99% of 364 patients Percent of pneumonia patients assessed and given influenza vaccination 75 80 98% of 202 patients Heart Attack Percent of heart attack patients given aspirin at arrival 94 93 99% of 391 patients Percent of heart attack patients given aspirin at discharge 91 92 100% of 367 patients Percent of heart attack patients given ACE inhibitor or ARB for LVS dysfunction 88 87 95% of 81 patients Percent of heart attack patients given smoking cessation advice/counseling 92 94 100% of 186 patients Percent of heart attack patients given beta blocker at discharge 92 94 99% of 388 patients Percent of heart attack patients given beta blocker at arrival 89 91 98% of 265 patients Percent of heart attack patients given fibrinolytic medication within 40 43 100% of 2 patients1 30 minutes of arrival Percent of heart attack patients given PCI within 90 minutes of arrival 67 80 84% of 74 patients Surgical Care Improvement/Surgical Infection Prevention Percent of surgery patients who received preventive antibiotics one hour 84 89 98% of 893 patients2 before incision Percent of surgery patients who received the appropriate preventive antibiotics for 91 92 97% of 902 patients2 their surgery Percent of surgery patients whose preventive antibiotics are stopped within 24 82 84 96% of 829 patients2 hours after surgery Percent of surgery patients whose doctors ordered treatments to prevent blood clots 80 83 95% of 1063 patients2 (venous thromboembolism) for certain types of surgeries Percent of surgery patients who received treatment to prevent blood clots within 24 77 78 92% of 1063 patients2 hours before or after selected surgeries Note: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blockers; LVS = left ventricular systolic; PCI = percutaneous coronary intervention. 1 The number of cases is too small (<25) to reliably tell how well a hospital is performing. 2 Measure reflects the hospital’s indication that its submission was based on a sample of its relevant discharges. Source: www.hospitalcompare.hhs.gov Accessed on 11/10/08. Data are from CY 2007. 8T he  C ommonwealth F und Appendix. Selection Methodology Selection of high-performing hospitals in process-of-care measures for this series of case studies is based on data submitted by hospitals to the Centers for Medicare and Medicaid Services (CMS). We use 22 measures that are publicly available on the U.S. Department of Health and Human Services’ Web site, Hospital Compare (www.hospitalcompare.hhs.gov). The 22 measures, developed by the Hospital Quality Alliance (HQA), relate to practices in four clinical areas: heart attack, heart failure, pneumonia, and surgical infections. Heart Attack Process-of-Care Measures Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) Percent of Heart Attack Patients Given Aspirin at Arrival Percent of Heart Attack Patients Given Aspirin at Discharge Percent of Heart Attack Patients Given Beta Blocker at Arrival Percent of Heart Attack Patients Given Beta Blocker at Discharge Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes of Arrival Percent of Heart Attack Patients Given PCI Within 90 Minutes of Arrival Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling Heart Failure Process-of-Care Measures Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function Percent of Heart Failure Patients Given Discharge Instructions Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling Pneumonia Process of Care Measures Percent of Pneumonia Patients Assessed and Given Influenza Vaccination Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination Percent of Pneumonia Patients Given Initial Antibiotic(s) Within 4 Hours After Arrival Percent of Pneumonia Patients Given Oxygenation Assessment Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior to the Administration of the First Hospital Dose of Antibiotics Surgical Care Improvement/Surgical Infection Prevention Process-of-Care Measures Percent of Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision Percent of Surgery Patients Who Received the Appropriate Preventative Antibiotic(s) for Their Surgery Percent of Surgery Patients Whose Preventative Antibiotic(s) Are Stopped Within 24 hours After Surgery The analysis uses all-payer data from the second quarter of 2006 through the first quarter 2007. To be included, a hospital must have submitted data for all 22 measures (even if data submitted were based on zero cases), with a minimum of 30 cases for at least one measure in each of the four clinical areas. Approximately 80 percent of U.S. acute care hospitals submitted data on the 22 measures. Approximately 2,000 facilities—about half of acute care hospitals—were eligible for the analysis. No explicit weighting was incorporated, but higher-occurring cases give weight to that measure in the average. Since these are process measures (versus outcome measures), no risk adjustment was applied. Exclusion criteria and other specifications are available at http://www.qualitynet.org/dcs/ContentServer?cid=1141662756099&pagename= QnetPublic%2FPage%2FQnetTier2&c=Page)  G aston M emorial H ospital : D riving Q uality I mprovement with D ata , G uidelines , and R eal -Time F eedback 9 A bout the A uthors Jack Meyer, Ph.D., is a principal in the Washington, D.C. office of Health Management Associates, a research and consulting firm specializing in health care, and a visiting professor in the Graduate School of Public Policy at the University of Maryland. He was the founder and president of the Economic and Social Research Institute (ESRI). Dr. Meyer has conducted policy analysis and directed research on health care access issues for several major foundations as well as federal and state government. Many of these projects have highlighted new strategies for building quality measurements and improvement into health care purchasing. Dr. Meyer has also directed studies on overcoming barriers to health care access and on innovative designs for extending health insurance coverage to the uninsured. He is the author of numerous books, monographs, and articles on topics including health care, welfare reform, and policies to reduce poverty. Dr. Meyer received a Ph.D. in economics from Ohio State University. A cknowledgments We wish to thank Jan Mathews, R.N., and Gary Gammon, M.D., for generously sharing their time, knowledge, and information with us. Editorial support was provided by Martha Hostetter. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.