Cooper’s Quality and Patient Safety Department consists of clinical and non-clinical team members; quality outcomes managers, clinical effectiveness managers, a patient safety manager, data abstractors, a data base coordinator, a health economist, and an administrative assistant. The department is under the direct leadership of Nancy Davies-Hathen, AVP, Quality and Clinical Effectiveness. The majority of the team is comprised of individuals with extensive nursing backgrounds. The breadth and depth of their experience includes bedside patient care, data management, data entry, and analysis. These attributes ensure a team well qualified to drive organizational improvements and meet state and federal regulatory reporting requirements.
Cooper’s quality team uses a multidisciplinary approach to provide unique contributions to the health care continuum. The team applies a systematic methodology and incorporates evidence-based improvement principles, and has a shared goal of identifying opportunities to improve patient care delivery and the quality of care provided at Cooper. The imperative to achieve quality improvement and cost containment is resulting in healthcare organizations making better use of existing health information. Healthcare delivery is often inefficient and uncoordinated, thereby wasting resources and potentially leading to patient safety issues (Berwick & Hackbarth, 2012; Institute of Medicine, 2001; Osborn, et al., 2016).
Clinical data, coupled with administrative data, strengthens data systems and offers the greatest opportunity to achieve improved cost-effectiveness and quality outcomes that translate into improved public rankings (Jordan et al., 2007). The organization’s quality outcomes data are disclosed through public reporting requirements established by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (TJC), as well as state regulatory governing bodies.
Members of the quality team who have changed from bedside to quality roles still rely extensively on their nursing knowledge and processes. These systematic processes are the core of nursing practice that ensures delivery of compassionate and quality patient care and focuses on key communication to inform colleagues about specific opportunities in systems and processes. The fundamental principles and skill set of critical thinking, patient centered care, evidence based practice recommendations, and nursing intuition support the ability to identify and close gaps between our current system and our ideal system. Additionally, the outcomes managers have specialized clinical experiences in the institutes that they support.
Deep dives into the data analytics, from a clinical standpoint, allow for identification of gaps in care, and thus opportunities for improvement. Clinical team members partner with non-clinical team members for further data analysis to identify contributing variables, outliers, as well as the trending of performance over time. The combination of quantitative data, qualitative data, and clinical narrative allow for the best decision making to drive clinical effectiveness projects.
Cooper is on the High Reliability Organization (HRO) journey and members of our quality team are trainers in HRO principles and behaviors for employees across the organization. These principles and behaviors support and serve as the foundation for all initiatives designed to improve safety, clinical effectiveness, publicly reported data, Event and Activity Reporting System (EARS) reviews, mortality reviews, the quality portion of the physician compensation plan, and responses to quality of care concerns from insurance carriers. The core nursing fundamentals remain rooted throughout all of these assignments. Clinical knowledge and experience, coupled with quality data analytics, results in optimum process and patient outcomes across the organization. Cooper’s quality team contributes to the organization by evaluating, informing, and monitoring practices to achieve the best quality of care for our patients.
The Quality Department’s journey began in the fall of 2012, when Cooper’s senior leadership created a vision for a centralized quality model. Planning began with an assessment of organizational quality and concluded that (Quality Improvement QI) activities were isolated within departments. Core functions were identified by leadership and key stakeholders.
Job accountabilities and qualifications were reviewed, and standard job descriptions created. A budget neutral plan was developed for reassignment of decentralized staff to the central QI department. Affected staff were informed of the new quality model and were then transferred to the quality department.
Core competencies were identified and staff were trained in the following areas: Six Sigma Principles knowledge & Manage Variability; Crucial Conversations and Premier Training. Team building activities were designed, including Myers-Briggs sessions so that members of the team could appreciate the different contributions made by the personality profiles representing the team.
The quality department initially focused on alignment of mandatory quality reporting with the institute level leadership and ensured coordination of reporting. The reporting consisted of the traditional core measure reporting. Process mapping was conducted with staff to understand data flow. During this time, stakeholder consensus was that Premier, Inc.’s data warehouse was identified as the benchmarked group for Cooper comparison. Cooper’s patient outcomes data became aligned with publicly reported outcomes via Premier, Inc.’s Quality Advisor data, consisting of coded, publicly available data.
The new model was based on an easily communicated concept, namely the quality staff member serves as the ‘pitcher’ to the institute’s quality resource ‘catcher.’ The quality staff compiles outcomes data from internal/external sources which they then pitch to their partnered catchers who disseminate the data to institute leadership. The expectation was also established that all institutes create QI committees supported by the QI staff.
Institute specific, high level monthly/quarterly dashboards are populated with the ability to drill down and focus on identified defects and trends. The quality staff also assure that there is data coordination between their department and all data producing departments, such as Infection Prevention, Population Health, Patient Safety, the Process Improvement Department, the Medical Staff Office and the Clinical Documentation Improvement Department. The Quality Department has evolved from a focus on regulatory institute alignment to expanded oversight for multiple data sources. The department has been positioned to meet the challenges of regulatory agencies, payers, purchasers of health care and the public.
Cooper’s multi-disciplinary quality staff are focused on data-driven processes, populating over 100 dashboards for institutes and the organization. In addition to institute support, the quality staff continue to provide abstraction and reporting for CMS and TJC’s core measures, which have increasing clinical complexity. The QI staff pull EPIC provider data for CMS’s Merit-based Incentive Payment System metrics. They also prepare the quality dashboard for Cooper’s Accountable Care Organization. Additionally, the QI team work closely with the Medical Staff Office to ensure data availability for On-going Professional Practice Evaluations.
In conclusion, the Quality Department is designed to be a valuable organizational resource, founded on the principles of process improvement through multi-disciplinary teamwork. The department’s goal is to improve patient outcomes by practicing the philosophy of continuous improvement.
References
Berwick, D. M., Hackbarth, A. D., (2012). Eliminating Waste in US Health Care. JAMA, 307(14), 1513-1516. doi:10.1001/jama.2012.362.
Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi:10.17226/10027.
Osborn, R., Squires, D., Doty M. M., Sarnak, D.O., Schneider, E.C., (2016). In New Survey of Eleven Countries, US Adults Still Struggle With Access To And Affordability Of Health Care. Health Affairs, 35(12), 2327-2336. doi: 10.1377/hlthaff.2016.1088.
Pine, M., Jordan, H., Elixhauser, A., Fry, D., Hoaglin, D., Jones, B. Gonzales, J. (2007). Enhancement of claims data to improve risk adjustment of hospital mortality. JAMA, 297(1), 71-76. doi: 10.1001/jama.297.1.71.