Quality Improvement: Challenge and Promise
In a recent review of 185 clinical journal articles on the effects of quality improvement (QI), University of Michigan researchers Jeffrey Alexander and Larry Hearld concluded that most QI efforts would benefit from systems theory, and that today’s narrow focus on medical aspects ignores organizational context, cost effectiveness, and value added to the patient or organization.
For a large inner-city healthcare network like Einstein-Montefiore, truly transformational quality improvement can be a challenge. Its physicians are increasingly faced with issues like teeming emergency departments, skyrocketing patient volumes (Department of Medicine admissions alone rose from 18,000 to 37,000 between 2000 and 2008), and sicker patients with more comorbidities (nearly 25% of hospitalized patients present with diabetes, and liver disease and cardiovascular conditions closely follow).
"When it comes to issues like safety and quality, we have historically relied on our front-line people—doctors, PAs, nurses, and social workers—rather than the systems engineers and process people that other industries have,” said Jeffrey Weiss, the Montefiore Medical Director. “Learning from our own experiences and from other industries, we have added greater process analysis to our improvement efforts, expediting and streamlining progress while maintaining our core strength—focus and attention to the overall patient experience."
Quality improvement is pervasive throughout the Einstein-Montefiore network, as shown in its recently published strategic plan that includes goals of developing a seamless delivery system with superior access, quality, safety, and patient satisfaction; and of building a culture of high performance, motivation, and fulfillment. “I think of QI as a staple to everything we do, whether it’s resident education, patient care, efficiency, length of stay, ancillary service, customer service, or staffing and retention,” said John Loehner, Service Chief of the Moses Division. “We try to look at everything through QI glasses.”
Einstein-Montefiore Department of Medicine’s current QI initiatives include changing the outcomes of chronic heart failure, diabetes, AIDS, and cardiac complications; improving performance through training for medical practitioners; patient satisfaction by changing physician communications and practice patterns; building external recognition; peer review; and community health.
The Physician’s Role
The Department of Medicine has made a significant investment in quality improvement, particularly in hiring and fostering physician leaders who can translate knowledge of better care into practice and transform its delivery systems.
Associate Director of Quality Calie Santana, hired in 2008, helps coordinate and evaluate Medicine-related QI efforts throughout the network. Santana sees one of her roles as promoting a strong, well-organized system that enables quality of care. “I try to step back and look at the interaction between patients, providers, support staff, administrators, and other parties involved,” she said.
Infectious disease specialist Belinda Ostrowsky, also hired in 2008, directs a multifaceted stewardship program to advise practicing physicians throughout the Montefiore network on the judicious use of antibiotics and antimicrobial agents. “Our real work now is to design a program that truly meets our patients’ needs, which means well-matched dosing that preserves the effectiveness of the drugs we have available,” she said. “We want to make sure that we are providing the best possible clinical care.”
Physician participation can provide a more comprehensive, system-oriented perspective to QI initiatives. On the other hand, there are challenges. “It’s a tough job for every manager, figuring out how to motivate people to become invested in particular project or process. In an institution as large as Einstein-Montefiore, there will always be variability,” Loehner said. “We are fortunate to have a number of interested, engaged, motivated attendings who are invested in directing and overseeing various QI projects. This goes a long way in maintaining a high quality of service and operations.”
Opening communication lines between different levels of the hospital hierarchy is one of Loehner’s key duties. Through regular meetings with hospitalists, chiefs, PAs, housestaff and nurses throughout the hospital, he keeps tabs on the institutional culture and determines effective motivators. “My job is really about being out on the floors so that people are more inclined to fill me in on bottlenecks to patient care and other quality issues,” he said. “When physicians and PAs are happy, it pays forward. They communicate well with nurses and patients, starting a wave that allows people to go above and beyond the call of duty.”
From Micro to Macro: Creating Systems of Improvement
In his role as Chief Quality Officer, Dr. Rohit Bhalla works with Department of Medicine physicians to think critically about improvement initiatives, and ways to transform care while understanding provider and system constraints. “The physicians’ role is critical—they improve care and save lives. But most physicians think of saving lives one patient at a time,” said Bhalla. “At a systems level, we can improve care in volumes.”
“It’s a major work in progress,” agreed Weiss. “Throughout the department people are doing great work, but figuring out how to collaborate and integrate their efforts into a regulated, proactive quality apparatus is another challenge.”
A Hopeful Vision
Amidst the hurdles, further intensified by limited funding and the pressure to successfully sustain the initiatives once they are launched, each leader’s outlook is unfailingly positive.
“Maintaining quality improvement on a day-to-day basis requires thoughtful, mature oversight, and I am fortunate to have phenomenal people to assist me in directing the attendings, housestaff, and hospitalists,” Loehner said. “They have provided vital mentorship, especially for our newer staff, who in turn have injected tremendous energy. All of this combined—the interest, investment, and motivation—has gone a long way in maintaining our quality of service and operations.
“People often tell me how much better it is to work here now, how much easier it is to get things done,” said Weiss. “It inspires me to think about how all of the little cogs together have created a culture of quality and safety, and in a relatively short period of time.”
“Making our physicians part of our solution has allowed us to reinvent healthcare with a different view, and we are still discovering new ways to raise the bar on quality improvement,” Bhalla said.
I think the current quality landscape creates great opportunity for physician leadership,” said Santana. “As we narrow the gap between what needs changing and how to change it, new areas of scholarly inquiry are opening. I am excited to figure out how endeavors that have succeeded elsewhere can be tailored to work for Einstein-Montefiore.”