Healthcare Quality Improvement Programs: Models and Recommendations

Introduction and Purpose

This memo covers the reasons for implementing a quality improvement program in our healthcare institution. It then outlines three quality improvement programs that can serve as models for our institution. Finally, this memo recommends which elements of these quality improvement programs should be adopted in an eventual quality improvement program at our hospital.

Reasons for Adopting Quality Improvement

Quality improvement in healthcare has always been a goal ever since medicine was first practiced. It has become a special focus in the United States in recent years in response to three major trends. This paper addresses the increased incentives for quality improvement in healthcare and discusses programs designed to improve quality, with particular attention to the nursing and allied professions.

The impetus for quality improvement has been driven in recent years by three main factors.

First, the amount of money the United States spends on healthcare per capita and as a percentage of GDP is far higher than any other country in the world. The U.S. spends approximately 15% of GDP on healthcare, while the next-highest countries — Germany and France — spend around 10% of GDP. This high level of spending has not produced longer life spans or greater quality-of-life years. Those who pay the bills are therefore asking whether they are receiving quality commensurate with the money being spent on healthcare.

Second, healthcare institutions are under competitive pressure in a way that was less apparent in previous decades. Alternative healthcare delivery models have been encroaching on the market share of traditional hospitals and clinics. HMOs have introduced a capitated model with an emphasis on preventive care. Specialist hospitals have focused on high-profit procedures, such as cardiac catheterization and orthopedics, leaving traditional hospitals with less profitable procedures. These alternative institutions compete not on price, but on quality of outcomes and the patient experience. Traditional healthcare institutions must therefore adapt in order to compete.

Third, state and federal governments are now incorporating quality measurements into healthcare oversight. Some states, such as New York and Massachusetts, have published comparative results. The trends across hospitals and specialties are clear: quality is measured not only on an absolute basis, but also relative to peers. Hospitals and clinics that fail to continuously improve their quality — measured in patient outcomes — will fall behind in census and in their ability to attract top healthcare staff.

These trends make quality improvement particularly necessary in today's environment. Healthcare institutions have attempted to incorporate quality improvement schemes from industry, but success has been mixed at best. The most common approach has involved procedures-based medicine, in which best practices are instilled among staff and specific protocols are followed. These measures have sometimes met resistance from staff who challenge the comparability of patient cases.

Best Practices from Four Hospital Programs

Commonwealth Fund Survey

The Commonwealth Fund sponsored a study of the most improved hospitals in quality improvement (Silow-Carroll, 2007). In their general survey of hospital quality improvement, researchers found that there was typically a "trigger" event — unfortunately often a patient death or significant negative publicity — which could also include the replacement of a CEO who initiates a clean sweep of leadership.

The trigger leads to changes in organizational structure and a renewed focus on quality improvement. The most serious problems are addressed first, and practice changes are worked out collaboratively with healthcare staff. As practice changes are implemented, better patient outcomes emerge alongside the identification of new problems and new solutions.

An illustrative example, though not cited in the Commonwealth report, is the Dana-Farber Cancer Institute in Boston. This teaching hospital administered the wrong dosage of chemotherapeutic drugs to a patient, resulting in that patient's death and a subsequent scandal that played out in the local press. Dana-Farber's new CEO implemented a quality improvement system that focused particularly on improving communication among healthcare professionals — especially between nurses and physicians. The resulting improvements significantly reduced Dana-Farber's morbidity and mortality statistics (Dana Farber, 2005).

Tenet Healthcare

As with the Commonwealth Fund model, a scandal prompted a management change and a renewed focus on patient quality care at Tenet Healthcare, a for-profit healthcare system based in Santa Barbara, California. Tenet's facility in Redlands, California, was found to have performed open-heart surgeries and cardiac catheterizations far out of proportion to patient need or community demographics — as many as 17,000 angioplasties in a community of fewer than 100,000 people. The resulting scandal demonstrated that Tenet's focus on profitability had come at the expense of quality.

Tenet implemented a quality improvement program in three steps: (1) replacing management with a new CEO and top management team, (2) appointing a senior physician with system-wide responsibility for quality improvement, and (3) beginning to evaluate management and physician teams in each hospital and region by quality measures, in addition to the previously tracked financial outcomes (Tenet, 2003).

On a broad basis, Tenet's quality improvement program focused on four initiatives:

• Ensuring patient safety and reporting results
• Supporting physician excellence
• Improving the practice, resourcing, and leadership of nursing
• Facilitating patient flow and care delivery to create operational efficiency (Tenet, 2003)

Cleveland Clinic Stroke Improvement Plan

Ischemic stroke affects over 700,000 Americans per year. Although the benefits of tPA (tissue plasminogen activator) have been demonstrated in a number of double-blinded clinical trials, adoption of tPA for ischemic stroke treatment has been slow, resulting in preventable patient deaths. Part of the reason for the slow uptake has been concern that some patients may suffer intracranial hemorrhage, potentially worsening their condition.

The Cleveland Clinic implemented a program to increase tPA use in order to improve patient outcomes (Katzan, 2003). It created a quality improvement program that set goals and monitored progress in stroke treatment and tPA administration. Most importantly, the Cleveland Clinic created a "dashboard" showing how all nine hospitals in its system were adhering to tPA administration guidelines and comparing results to national and regional statistics.

The results were reported in the discussion section of the relevant journal article: two years after the initial Cleveland audit, the rate of symptomatic intracranial hemorrhage with intravenous tPA dropped from 13.4% to 6.4% across the nine Cleveland Clinic Health System hospitals. During the same period, the rate of three specified protocol deviations declined from 33% to 17%, and the intravenous tPA usage rate increased from 1.8% to 2.7% among all patients with ischemic stroke.

Treatment of CHF Patients

Patients with congestive heart failure (CHF) tend to have poor compliance with medical prescriptions, which can lead to more frequent hospitalizations and negatively affect morbidity and mortality in this population. ACE inhibitors are among the drugs shown to improve the course of CHF. A Canadian study (Weil, 2001) found that only 23% of CHF patients who were candidates for ACE inhibitor treatment were actually receiving it; moreover, the doses prescribed were often below the levels shown to be effective in clinical trials.

While the Canadian retrospective study encouraged better administration of CHF medications, some U.S. centers have taken active steps. The Primary Care Physicians Group in Pittsburgh implemented a patient quality program to improve medication compliance for CHF patients (Civitarese, 1999). The program included the following steps:

• All patients with CHF were assessed for left ventricular function.
• Patients in the target group who would benefit from ACE inhibitor therapy were prescribed the medication.
• Nurses and in-home professionals followed up with patients to ensure compliance.

The results were measured as the number of patients admitted to the hospital with CHF and systolic dysfunction, with significant reductions observed following implementation.