Two Barriers to Hospital Quality Improvement and How to Overcome Them
Hospitals today face more pressure than ever to improve the quality of care they provide. The rising number of medical errors-- now a leading cause of death and injury in the United States 1—and a growing reliance on performance measures for hospital accreditation and reimbursement have pushed quality to the top of the health care agenda. This shift was triggered in part by the Institute of Medicine’s 2000 publication, “To Err Is Human: Building a Safer Health System,” which found that over half the adverse events in the health care field arise from preventable errors.2 Preventing those errors, the IOM concluded, would require hospitals to systematically design safety into processes of care.
As hospital administrators have responded by developing quality improvement programs, many have encountered entrenched barriers. Two commonly encountered barriers are:
- Compartmentalized department structure
- Clinician resistance to behavioral change
How can hospitals overcome these barriers and make demonstrable improvements in quality of care?
Compartmentalized Department Structure
Hospitals are exceedingly complex, housing up to 50 specialties and subspecialties. Many operate as a collection of balkanized departments, each with their own cultures and loyalties. When retrieving data from various departments, quality administrators typically find themselves swamped with data in incompatible formats, including some in paper form. “We’re data-rich but information-poor,” says Debbie McQuay, director of quality improvement at Citizens Memorial Hospital, an IHM member in Bolivar, MO. "There's so much data coming at you that it’s hard to know what you need to analyze first.”
Because the data are so hard to retrieve and analyze, problems with quality typically take several months to identify. By the time they are identified, it’s often too late to address those issues meaningfully. According to Barb Rudolph of the Leapfrog Group, a patient advocacy organization, “patient safety depends on systems working together to provide quality care, not on units or departments operating as closed entities. Insularity, along with the "siloed" data systems you find in most care facilities, creates an environment that puts some patients at risk.”
Constrained by balkanization, many hospitals adopt piece-meal approaches to quality that produce sub-optimal results, or even failure, according to a 2006 study in the International Journal of Healthcare Quality Assurance.3 Bolstering that conclusion is a recent survey sponsored by the Agency for Health Care Research and Quality (AHRQ)4, which found that among hospital departments that monitor care-associated infections, only half report those measures to the hospital’s patient safety reporting systems. “This shows how [infection measures] don’t make it to a place where they can be comprehensively evaluated,“ says William Munier, MD, acting director of the AHRQ's Center for Quality Improvement and Patient Safety.
Clinician Resistance to Behavioral Change
On a different front, clinicians are often significantly resistant to quality reforms. The challenge here is twofold. First, many physicians view reforms as imposed threats to their own autonomy. Motivating physicians to comply with evidence-based best practices can be problematic if it goes against the way ‘they have always done things.” Secondly, many clinicians are not trained to properly use the hospital’s health care information system (HCIS). Most HCIS’s in use today are cumbersome. They are often isolated from where care gets delivered, so “what usually happens is that someone hand-writes an order and someone else enters it electronically. That creates a huge opportunity for error,” says Barb Rudolph of the Leapfrog Group. In such cases, training can be problematic, because physicians may not be motivated to get up to speed on systems that they rarely use.
In both of these situations, top-down support from the hospital’s chief administrators is crucial. Hospital leadership has traditionally stayed out of clinical matters to focus more on finance and operations, but with quality reporting influencing payment and consumer choices, administrators have no option but to participate in quality more directly. “The CEO and the board have to be involved,” says Barb Rudolph of the Leapfrog Group. “Anything that comes from below isn't going to work. Teams have to be held accountable for the improvement that needs to take place, and this really requires you to re-engineer the organization. I’m the old days, you’d never see quality or safety on a board of director’s agenda; it wouldn’t rise to that level. But now that's changing.”
How IHM Can Help
IHM’s mission is to help its member hospitals meet their quality reporting and improvement goals. They take a two-pronged approach to assist with the two most commonly encountered barriers to quality improvement. First, the Automated Information Extraction System (AIES) works around compartmentalized data systems to present unified, meaningful reports to quality improvement departments, physicians and the hospital leadership. AIES retrieves data automatically from the hospital's Meditech HCIS, analyzes it, and reports back with a user-friendly, web-based interface. There is no need for running applications on-site or for staff training. James Keegan, MD, vice president of clinical quality at Rapid City Regional Hospital, says that AIES “frees up resources; IHM pulls quality data out of our Meditech system so we don't have clinicians wasting time extracting that data manually.”
Second, the Physician Quality Management System (PQMS) supplies feedback on a physician by physician basis. When the data is right there in black and white, physicians are more easily motivated to improve their compliance with quality measures and to become properly trained in electronic medical recordkeeping. “It helps us promote a culture of quality,” says Debbie McQuay, director of quality improvement at Citizens Memorial Hospital. “IHM's reports supply valuable feedback to the hospital's physicians. By comparing how their measures compare to national benchmarks, or to that of their colleagues, physicians become educated about their own performance, which is crucial to the hospital's quality improvement efforts.”
For more information about IHM's services and how we can help your hospital achieve its quality goals, please visit us online at www.healthmetrics.org .
References
1. HealthGrades, Inc. research group. “Third Annual Patient Safety in American Hospitals' Study.” Available at www.Healthgrades.com
2. Kohn, Linda T, Janet M Corrigan, and Molla S Donaldson, eds. To Err is Human Building a Safer Health System. Washington DC: National Academy Press, 2000.
3. Miller PM, et al. An empirical investigation of quality improvement initiatives in for-profit and not-for-profit hospitals: Environmental, competitive, and outcome concerns. International Journal of Health Care Quality Assurance. 2006;19:539-550.
4. Lucian L, et al. Five years after “To Err is Human”: what have we learned? JAMA. 2005;293:2384-2390.