Case Study High-Performing Health Care Organization • March 2009 December 2009 St. Luke’s Medical Center: Bottom-Up Approach to Quality Improvement in Pneumonia Care Aimee Lashbrook, J.D., M.H.S.A. H ealth M anagement A ssociates Vital Signs The mission of The Commonwealth Fund is to promote a high performance Location: Sioux City, Iowa health care system. The Fund carries out this mandate by supporting Type: Private, not-for-profit hospital independent research on health care issues and making grants to improve Beds: 154 staffed beds health care practice and policy. Support Distinction: Top 3 percent in a composite of seven pneumonia process-of-care measures, among for this research was provided by more than 2,800 hospitals (more than half of U.S. acute-care hospitals) eligible for the analysis. The Commonwealth Fund. The views presented here are those of the authors Timeframe: April 2007 through March 2008. See Appendix for full methodology. and not necessarily those of The This case study describes the strategies and factors that appear to contribute to high performance Commonwealth Fund or its directors, on pneumonia care measures at St. Luke’s Medical Center. It is based on information obtained from officers, or staff. interviews with key hospital personnel, publicly available information, and materials provided by the hospital during July and August 2009.      For more information about this study, Summary please contact: St. Luke’s Medical Center has made significant improvements in its performance Aimee Lashbrook, J.D., M.H.S.A. Health Management Associates on the pneumonia care core measures over the last five years. The core measures, alashbrook@healthmanagement.com developed by the Hospital Quality Alliance, relate to achievement of recom- mended treatment in four clinical areas: heart attack, heart failure, pneumonia, and surgical care. St. Luke’s, which was once achieving as low as 30 percent to 50 percent compliance with the pneumonia care core measures, now performs well above state and national averages. It also performs above the 90th percentile on other core measures. To download this publication and learn about others as they become Those interviewed credit the organization’s improvement in pneumonia available, visit us online at care to the energy and attention to quality improvement provided by the frontline www.commonwealthfund.org and register to receive Fund e-Alerts. staff, who have embraced the core measures as an opportunity to improve patient Commonwealth Fund pub. 1359 care. Concurrent review, ongoing nursing staff education, and streamlined stand- Vol. 34 ing order sets also have helped the hospital improve its performance. 2T he  C ommonwealth F und Organization Leadership from the Bottom Up St. Luke’s is located in Sioux City, Iowa, and serves Leadership for St. Luke’s core measure performance patients in Iowa, Nebraska, and South Dakota. It is improvement efforts has come from the bottom up, one of 26 hospitals that make up the Iowa Health with frontline physicians and nurses analyzing prob- System, an integrated health system in Iowa and west- lems and identifying solutions at the point of care. Deb ern Illinois. It has 154 staffed beds and 286 physicians Colshan, R.N., clinical nurse specialist, believes the on its medical staff, and approximately 9,000 inpatient engagement of frontline staff has provided the momen- admissions, 77,000 outpatient visits, and 4,700 surger- tum needed to get staff throughout the organization ies each year. excited about quality improvement. Colshan’s colleagues credit her with providing Hospital-Wide Factors focused and passionate leadership. Craig Bainbridge, Being part of a larger health system has aided St. M.D., pulmonologist, says Colshan’s commitment has Luke’s in its performance improvement efforts. improved patient outcomes and created a culture of Systemwide collaborative workgroups tackle quality excellence within the organization. Bainbridge and patient safety matters such as meeting the core believes an organization must have leaders such as measure requirements and avoiding pressure ulcers, Colshan to motivate staff and champion patient care stroke sepsis, and patient falls. Typically, a workgroup initiatives from start to finish. from each affiliate hospital participates in the collabor- ative workgroups, through face-to-face meetings as Multiple Benefits of Concurrent Review well as teleconferences. Performance improvement clinicians, nurse managers, A typical quality improvement initiative at St. and clinical nurse specialists perform concurrent Luke’s begins with quality improvement staff review of medical records for patients with pneumonia researching clinical evidence and best practices. It also as well as other diagnoses. As has been articulated by may include participation in an initiative sponsored by other hospitals in this pneumonia care series, concur- organizations such as the Institute for Healthcare rent review provides an opportunity to mitigate fail- Improvement or the Iowa Foundation for Medical ures and correct noncompliant cases before patients Care, the state’s quality improvement organization. are discharged. St. Luke’s tests any process change on a small When a case falls out of compliance, the physi- scale before rolling it out across the organization. The cians and nurses involved are notified. The nurse man- hospital reviews its performance data and problem- ager also is made aware of the failure. Every failure solves areas in need of improvement. The hospital triggers a mini root-cause analysis by the quality does not seek to reinvent the wheel, often looking to improvement department and frontline staff. Since it other hospitals in the Iowa Health System for best can be difficult to schedule formal meetings, Colshan practices as well as to external organizations and col- and frontline staff meet informally to talk about the laboratives focused on quality improvement. failure and possible solutions. St. Luke’s electronic medical record system Kathy Collins, R.N., B.S.N., performance includes some built-in alerts and patient care remind- improvement director, appreciates the educational ers. However, the staff interviewed say it does not play opportunities afforded by concurrent review. When a a large role in improving core measure performance, case falls out of compliance, quality improvement staff noting that it does not yet have physician order entry use it as an opportunity to educate staff and develop capabilities (though St. Luke’s plans to invest in strategies for improvement, such as introducing new such functionality). alerts in the electronic medical record system. Collins finds this “real-time” education to be very effective in changing behaviors. P arkview M edical C enter : U nderscoring the I mportance of C ommunication in P neumonia C are 3 Nurse Education to participate in all meetings, they are kept informed In addition to the one-on-one educational opportunities of the improvements being made and alerted when provided when concurrent review uncovers a noncom- their help is needed. pliant case, quality improvement staff dedicate many “We have worked hard at getting past the fear hours to educating clinical staff about the core mea- of ‘cookbook medicine,’” says Collins. “We want to sures and their relationship to improved patient care. ensure that our physicians understand that the changes Most efforts are targeted at nurses. Posters and other are evidence-based and that by process improvement educational materials are placed throughout the hospi- we in turn make it easier for them to practice excellent tal. An introduction to the core measures is provided in medicine.” nursing orientation sessions and personnel meetings. Web-based training opportunities are also available. Pneumonia Care Improvement Whatever the measure, quality improvement Strategies staff make sure to explain “the why” behind “the Updating Standing Order Sets what.” Repetition is also key, says Colshan. Through In the past five years, St. Luke’s has been working on concurrent review and other educational opportunities, standardizing disease-specific order sets. The hospital the core measure standards have now become “second relies on a recognized provider of clinical decision- nature” to St. Luke’s nurses. support tools to ensure its order sets are up to date with the most current evidence-based medicine. Using Data to Motivate Change St. Luke’s experienced pushback from the medi- Public reporting of the core measures motivates staff, cal staff when the pneumonia order set was introduced. as they want to achieve 100 percent compliance. It According to Bainbridge, “the hospital’s first order set also has captured the attention of upper management for pneumonia was long and included everything and the hospital board. Managers support the frontline under the sun.” Physicians were not accustomed to staff by ensuring they have time to devote to quality using order sets and were reluctant to incorporate them improvement efforts. The board becomes involved into their routines because they were too cumbersome. when there is a problem, such as a negative trend in “There was a real need to make the order sets easier to core measure performance, and inquires about the hos- use, more convenient, and more accessible,” he says. pital’s plans to address it. The team of quality improvement staff and frontline Performance results are shared with physicians nurses sought feedback from physician champions and at all medical staff meetings. The hospital asks for removed extraneous information from the order set. physicians’ input on how to continue to improve as an They also brought in an infectious disease specialist to organization, and they have helped identify barriers validate the recommendations, which are largely based and possible solutions. on the infectious disease society’s guidelines. The pneumonia order set includes both physi- Physician Engagement cian and nursing orders. Some orders, such as smoking According to Collins, engaging physicians has been cessation counseling, vaccination screening, and blood key to the success of St. Luke’s improvement efforts. culture prior to antibiotic administration, are standing “Many of our early efforts centered around having a orders and must be initiated unless the physician draws physician champion lead the way and get the other a line through the order. The order set also includes a physicians on board,” she says. Physician champions list of recommended antibiotics for pneumonia have helped develop order sets and provided direction patients, which have proven particularly helpful for on the best ways to present change to the medical physicians who do not routinely treat pneumonia staff. Although physician champions are not expected 4T he  C ommonwealth F und Exhibit 1. St. Luke’s Medical Center Scores on Pneumonia Care Core Measures Compared with State and National Averages National Iowa St. Luke’s Regional Medical Pneumonia Care Improvement Indicator Average Average Center Percent of pneumonia patients given oxygenation 99% 99% 100% of 291 patients assessment Percent of pneumonia patients assessed and given 83% 88% 97% of 222 patients pneumococcal vaccination Percent of pneumonia patients whose initial emergency room blood culture was performed prior to the 90% 93% 100% of 216 patients administration of the first hospital dose of antibiotics Percent of pneumonia patients given smoking cessation 88% 84% 99% of 83 patients advice/counseling Percent of pneumonia patients given initial antibiotic(s) 93% 94% 100% of 232 patients within 6 hours after arrival Percent of pneumonia patients given the most appropriate 87% 87% 97% of 173 patients initial antibiotic(s) Percent of pneumonia patients assessed and given 79% 84% 96% of 169 patients influenza vaccination Source: www.hospitalcompare.hhs.gov. Data are from July 2007 through June 2008. patients. The order set leaves room for deviations from changed to within six hours of arrival). Pneumonia the core measures when medically appropriate. cases can be difficult to diagnose in the emergency Since its introduction, the pneumonia order set department because patients may experience symp- has been revised on more than one occasion; as it has toms related to other diseases, such as congestive heart been streamlined and become easier to use, physicians failure, that mimic pneumonia. Physicians do not like have increasingly used it. When it was instituted, qual- proceeding down the pneumonia pathway with “blind- ity department staff educated nurses about the role of ers on,” which potentially could cause them to miss standing orders in improving core measure perfor- the correct diagnosis. When the diagnosis is delayed, it mance and patient care. They also hung posters can be difficult to ensure administration of antibiotics encouraging order set use on the walls of the emer- within a certain time of arrival. Physicians also do not gency room. Nurses responded by pressing physicians want to unnecessarily give their patients antibiotics. to use the pneumonia order set until it became part of St. Luke’s has been able to improve the timeli- their routines. ness of antibiotic administration by assigning the St. Luke’s intends to build its order sets, includ- emergency room physicians responsibility for ordering ing the pneumonia order set, into a computerized phy- the first dose of antibiotics. This saves time when the sician order entry system. alternative is waiting for a physician on the floor to which a patient is ultimately admitted to order and Administration of Antibiotics administer the antibiotic. Both the pharmacy and the It took time and effort before St. Luke’s was able to emergency department nurses know that the antibiotic show significant improvement in meeting the core must be filled and administered as soon as the order measure standard of antibiotic administration within comes in. Nurses complete a checklist form document- four hours of arrival (this standard has since been ing the time the antibiotic is administered. P arkview M edical C enter : U nderscoring the I mportance of C ommunication in P neumonia C are 5 Exhibit 2. St. Luke’s Medical Center Exhibit 3. St. Luke’s Medical Center Pneumococcal Vaccination Performance, 2004–09 Timely Antibiotic Administration Performance, 2004–09 Pneumococcal Vaccination Percent Antibiotic w/in 4 hrs of arrival Percent 100 100 80 80 60 60 40 40 20 20 0 0 Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06 Q3 06 Q4 06 Q1 07 Q2 07 Q3 07 Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 04 Q1 09 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06 Q3 06 Q4 06 Q1 07 Q2 07 Q3 07 Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09 Source: St. Luke’s Medical Center, 2009. Source: St. Luke’s Medical Center, 2009. Results Electronic Support St. Luke’s outperforms most hospitals in this country Some parts of St. Luke’s electronic medical record on all of the pneumonia care core measures submitted system and other systems are hardwired to encourage to the Centers for Medicare and Medicaid Services. compliance with the pneumonia care core measures. Exhibit 1 compares St. Luke’s compliance on the For example, the pneumonia order set includes a pneumonia care core measures with state and national standing order to initiate the vaccination screening. averages. Exhibits 2 and 3 show the trends over time Like other hospitals interviewed in this case study for core measures related to pneumococcal vaccination series, all patients, not only those with pneumonia, are and timely antibiotic administration. screened for vaccination need upon admission. The As Exhibit 3 indicates, it took a few years for protocol is built into the electronic nursing record, the hospital to achieve at least 90 percent compliance which locks until a nurse completes the vaccination in the timely administration of antibiotics measure, for screening as part of the admission process. For patients reasons discussed above. The greatest gains docu- who meet the criteria for a vaccination, the vaccination mented were for the smoking cessation measure, for is administered on the second day of their stay. which performance went from 30 percent to 100 per- St. Luke’s Pyxis medication system also is cent compliance (Exhibit 4). programmed to assist with pneumonia care core The hospital continues to struggle with adminis- measure compliance in the emergency department.1 tration of the appropriate antibiotics for patients in the Before dispensing an antibiotic, the system asks if a ICU. St. Luke’s is educating its physicians on the blood culture was performed. To allow the antibiotic to appropriate antibiotic choices in the ICU and reinforcing be given, the clinician must request an order for a this education with posters, letters, and other methods. blood culture or request assistance. As a further check on the process, phlebotomists mark a “C” on a dry- erase board located in the emergency department to indicate which patients have received a blood culture. 1 The Pyxis medication system promotes patient safety and the reduction of medication errors through medication order management, dispensing, and verification processes. See http://www.carefusion.com/products-and-services/ our-focus/end-to-end-medication-mgmt.aspx. 6T he  C ommonwealth F und Challenges and Lessons Learned Exhibit 4. St. Luke’s Medical Center Hospitals looking to improve their performance on Smoking Cessation Advice Performance, 2004–09 pneumonia care core measures might take the follow- ing lessons from St. Luke’s experience: Percent Smoking Cessation Advice 100 • Encourage and build momentum for quality 80 improvement from the bottom up—starting 60 with frontline staff. 40 20 • Look for physician champions and foster phy- 0 sician engagement in quality improvement Q1 04 Q2 04 Q3 04 Q4 04 Q1 05 Q2 05 Q3 05 Q4 05 Q1 06 Q2 06 Q3 06 Q4 06 Q1 07 Q2 07 Q3 07 Q4 07 Q1 08 Q2 08 Q3 08 Q4 08 Q1 09 activities. Source: St. Luke’s Medical Center, 2009. • Rely on a simple, user-friendly order set to increase performance in the pneumonia care core measures. For More Information • Concurrent review reduces the likelihood of a For further information, contact Kathy Collins, R.N., case falling out of compliance and provides an B.S.N., performance improvement director at opportunity to educate clinicians—and rein- CollinKL@stlukes.org. force messages—at the point of care. • Reminders and alerts can be programmed into existing patient care systems. Collins believes “without a doubt that St. Luke’s continued success with the measures is due to the dedication and teamwork of physicians and nurses working together to provide each patient the best out- come every time.” P arkview M edical C enter : U nderscoring the I mportance of C ommunication in P neumonia C are 7 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. We use seven measures that are publicly available on the U.S. Department of Health and Human Services’ Hospital Compare Web site, (www.hospitalcompare.hhs.gov). The measures, developed by the Hospital Quality Alliance, relate to practices in pneumonia care. Pneumonia Care Process-of-Care Measures 1. Percent of pneumonia patients given oxygenation assessment 2. Percent of pneumonia patients assessed and given pneumococcal vaccination 3. Percent of pneumonia patients whose initial emergency room blood culture was performed prior to the adminis- tration of the first hospital dose of antibiotics 4. Percent of pneumonia patients given smoking cessation advice/counseling 5. Percent of pneumonia patients given initial antibiotic(s) within 6 hours after arrival 6. Percent of pneumonia patients given the most appropriate initial antibiotic(s) 7. Percent of pneumonia patients assessed and given influenza vaccination The analysis uses all-payer data from July 2007 through June 2008. To be included, a hospital must have sub- mitted data for all seven measures (even if data submitted were based on zero cases), with a minimum of 30 cases for at least one measure, over four quarters. The top 3% among 2,887 hospitals eligible for the analysis and with 50 or more beds were considered high performers. In calculating a composite score, 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 adjust- ment was applied. Exclusion criteria and other specifications are available at http://www.qualitynet.org/dcs/ContentS erver?cid=1141662756099&pagename=QnetPublic%2FPage%2FQnetTier2&c=Page). While high score on a composite of pneumonia care improvement process-of-care measures was the primary criteria for selection in this series, the hospitals also had to meet the following criteria: at least 50 beds, not a gov- ernment-owned hospital, not a specialty hospital, ranked within the top half of hospitals in the U.S. in a composite HQA core measure score and in the percentage of patients who gave a rating of 9 or 10 out of 10 when asked how they rate the hospital overall (measured by Hospital Consumer Assessment of Healthcare Providers and Systems, HCAHPS), full accreditation by the Joint Commission; not an outlier in heart attack and/or heart failure mortality; no major recent violations or sanctions; and geographic diversity. A bout the A uthors Aimee Lashbrook, J.D., M.H.S.A., is a senior consultant in Health Management Associates’ Lansing, Mich., office. Ms. Lashbrook has six years of experience working in the health care industry with hospitals, managed care organizations, and state Medicaid programs. She provides ongoing technical assistance to state Medicaid programs, and has played a key role in the development and implementation of new programs and initiatives. Since joining HMA in 2006, she has conducted research on a variety of health care topics. Aimee earned a juris doctor degree at Loyola University Chicago School of Law and a master of health services administration degree at the University of Michigan. A cknowledgments We wish to thank Kathy Collins, R.N., B.S.N., performance improvement director, Craig Bainbridge, M.D., pulmonologist, Forrest Vickers, R.N., and Deb Colshan, R.N., clinical nurse specialist, for generously sharing their time, knowledge, and materials 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.