Quality, consistently

In health care, particularly within hospitals, the concept of “quality” has become vogue. Enloe Medical Center holds an annual Quality Summit, at which it sets out its Quality Initiatives. Feather River Hospital has undergone a Quest for Excellence based on precepts and standards of the Malcolm Baldrige National Quality Award. Oroville Hospital, too, has quality measures, albeit without a flashy label.

The medical field is full of terminology that can strike patients as inaccessible jargon. “Throughput” and “boarding” sound like something you might read in a computer manual or hear over the loudspeaker at an airport, unless you know they refer to patients moving through the hospital.

So what does “quality” really mean? Stated simply, quality initiatives (and variations on the name) boil down to making hospitals safer and more efficient. They are new procedures, based on the latest research, adopted by doctors, nurses and support staff.

The push for quality can be traced to a 1999 report from the Institute of Medicine, titled “To Err Is Human,” that determined 100,000 patients died each year from mistakes made in hospitals.

“Now we have a lot of agencies interested in patient safety because of this issue,” explained Dr. Matthew Fine, chief medical officer and director of patient safety at Oroville Hospital. “And because we can do something about it.”

What they are doing, and how they decide to do it, is what the CN&R asked of Butte County’s three largest hospitals.

Enloe Medical Center

In 2009, Mike Wiltermood, Enloe’s chief operating officer, took the reins as chief executive officer, and his management team began diagnosing the health of the hospital.

“We saw that we needed to take a fresh approach with new eyes on how we were providing some of the care,” said Dr. Marcia Nelson, vice president of medical affairs. “We knew … it had to be a concerted effort of the whole organization.”

From this sprang the idea for annual Quality Summits, where members of various departments could coordinate their efforts toward creating Quality Initiatives—overarching changes in procedure designed in consultation with doctors and nurses.

The first year, Enloe focused on reducing the risks of pneumonias associated with ventilators and infections associated with urinary catheters; intensifying treatment of sepsis, a potentially fatal bloodstream infection; expanding the use of surgical checklists in operating rooms; and decreasing the chance a hospitalized patient develops blood clots.

Over the past year, Enloe ramped up screening for antibiotic-resistant bacteria (i.e., MRSA), streamlined registration processes in the emergency room, and set 39 weeks as the threshold for elective delivery of newborns when medical conditions do not call for an earlier birth.

Over the next year, Enloe will work on reducing the number of patients who need to be readmitted within weeks of leaving the hospital; updating treatment orders; more quickly mobilizing trauma surgery teams; and more quickly transferring patients between wards as well as discharging them: aka “Improve throughput: zero boarding.”

The changes, said Nelson, also have made an impact on the bottom line.

“We didn’t have the culture that really emphasized finding, where appropriate, the one best way to treat something,” Nelson said of the hospital’s change in perspective. “It was very much left to individual decision. As we had enough physicians learning about the value of standardizing care and attending [national] conferences, it was the moment we knew we could do much better and that the tools were out there.”

Feather River Hospital

In Paradise, as in Chico, medical professionals look to the latest research and recommendations from organizations such as the Institute for Healthcare Improvement. Feather River Hospital also draws inspiration from the Baldrige Model, promoted for a variety of industries by the National Institute of Standards and Technology (which gives out the Baldrige Award). It offers objective means for measuring performance.

In 2003, Feather River administrators and physicians attended a Baldrige conference in Washington, D.C. “It was an eye-opener,” said Gloria Santos, vice president of patient-care services. “We saw some organizations do some amazing things that raised employee and customer satisfaction and loyalty, and exceeded their financial goals. In terms of health care, we saw some things that we all nationally need to improve upon, because the payers”—the government and insurance companies—“demand that.”

Feather River integrated the Baldrige Model into its strategic planning and undertook its Quest for Excellence. That broad push includes patient safety and service, but also spiritual and holistic care, since Feather River is a religious-affiliated institution, part of Adventist Health.

On the clinical side, the input of doctors and nurses influences where the hospital concentrates improvement efforts. Some happen to match Enloe’s, such as reducing ventilator-associated pneumonias and decreasing hospital-acquired infections. Feather River also has increased support for discharged patients and revised its process of medication reconciliation by tracking every medicine a patient takes, even if not administered in the hospital.

“It’s not, ‘You’re out of our door, you’re done,’” said Maureen Wisener, assistant vice president of communication. “We’re still wanting to make sure a patient’s needs are met.”

Oroville Hospital

Matthew Fine has a concise summation of the Oroville approach to quality improvement: “We look at what we need to fix.” The role he, as a physician/administrator, plays requires a bit more explanation. “I try to deconstruct what we’re doing, take apart all the processes in the hospital, and try to put them back together so we can do things not only safer but also more efficiently.”

As in the neighboring hospitals, administrators consult with the medical staff and refer to practices at other medical centers before making changes. However, Fine explained, Oroville Hospital is careful not to “add extra layers to patient safety” and risk having bureaucracy compound the problems of inefficiency and errors.

One of the first measures Fine and his colleagues took was to improve medication reconciliation. Electronic medical records (EMRs) have increased the precision with which the hospital can monitor patients’ prescriptions, for instance.

Other measures include proactive tracking of patients receiving anticoagulation treatments, preventing blood clots with low doses of anticoagulants after surgery, and putting new emphasis on rapidly responding to strokes.

While getting a diverse group of practitioners to agree on a particular course of action can be challenging, as Fine acknowledged, now there is widespread acceptance of quality measures, and colleagues frequently come to him with new ideas.

“The only hard part,” he said, “is there are so many things we can approach.”