We all want to be part of an organization that embodies excellence. And as a physician leader, you are a key to achieving that outcome. Nothing satisfies a board more than recognition as a Top 100 Hospital.

top-qualityA few years into my tenure as VPMA, our CEO left to take a new position, and the COO, after a search that included internal and external interviews, was chosen to lead the organization. Shortly after his appointment, he and the board made it clear that the executive team was to focus on demonstrating excellence and quality in all aspects of patient care. And we were going to achieve recognition by all pertinent outside quality bench-marking organizations.

The executive team focused on implementing appropriate measurement tools, participating in regional and national quality initiatives, and working in a concerted effort to improve performance measures, including mortality rates, length of stay, readmission rates and patient satisfaction as measured by HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems).

But there were obvious challenges in that assignment, not the least of which are answering these two questions:

  • How do we define quality?
  • How do we measure quality?

We can spend all day arguing about whether our care is excellent, compassionate, safe, cost-effective or world-class. But the quality leader needs to create a program that can demonstrate quality to the board, CEO and other constituents. The program must include the reporting of metrics that can be directly linked back to agreed-upon measures of quality of care.

It sounds like an overwhelming task. But with the appropriate allocation of staff and other resources, the challenge can be met. It can be done by breaking the process into its components and attacking each one individually.

We studied outside bench-marking awards to help us define and organize our quality efforts. Since we were all interested in identifying and promoting quality for our patients, we thought, why not do it in a way that aligns with external measures of excellence?

Truven Top 100

The Truven Corporation defines, measures and publishes a set of performance goals for hospitals and health systems. And it annually publishes a list of the organizations that receive its Top 100 Award. During my tenure, our hospital received the award six times.

There are other types of similar designations by other companies.. We liked using the Top 100 construct as a way to define excellence at our hospital because it was focused on overall excellence that included financial as well as quality and length of stay. But its components are highly weighted towards quality measures. And those measures are often under the direct purview of a physician executive (Chief Medical Officer or Chief Quality Officer).

The Measures

Here are the 10 domains that Truven uses to assess a hospital’s performance, and assign Top 100 Hospital designation:

  • Risk Adjusted Mortality Rate
  • Risk Adjusted Complication Rate
  • Risk Adjusted Patient Safety Index
    • Based on accepted measures of preventable harm
  • Core Measures Score
    • Based on recognized performance measures
  • 30 Day Mortality Rate
  • 30 Day Readmission Rate
  • Severity Adjusted Average Length of Say
  • Patient Satisfaction (measured by HCAHPS)
    • Based on patients’ perception of quality
  • Case Mix and Wage Adjusted Expense per Discharge
  • Operating Profit Margin

In an organization in which the Directors of Quality, Patient Safety and Care Management (or Case/Utilization Management) report to the CMO or CQO, he/she would be directly responsible for the measurement and management of seven of the ten measures.

The CFO (Chief Financial Officer) is responsible for measuring, managing and reporting the financial measures. But those measures are heavily dependent upon successfully providing appropriate evidence-based care while minimizing complications and shortening hospital stays. The Patient Care and Ancillary Divisions are integral to accomplishing those goals.

Seven Steps to a Top 100 Hospital

As the CMO or CQO,  here are the steps to using this model:

  1. Define the components of each of the first eight Top 100 Metrics.
    • For example, how is mortality defined? What diagnoses are included? Are there certain patient types that are excluded? How are Core Measures reported. How are the 30 Day Mortality and Readmission Rates defined?
  2. Educate all involved management and leadership staff in the measures and their sub-components.
  3. Identify tools to measure each of the components.
    • These could be electronic databases, manual extractions, or data that are already collected and submitted to CMS and other tracking organizations.
  4. Report each of the measures to an appropriate committee on a monthly basis.
    • These might be the Quality Committee, Safety Committee, Length of Stay Committee, etc., for review and action if needed.
  5. Create temporary teams led by knowledgeable clinical leaders to address any areas in which performance falls below  benchmarks.
  6. Create a dashboard that summarizes all of the metrics.
  7. Present the dashboard to the senior executive team and the board of trustees at least quarterly and be prepared to present action plans for failing measures.
    • This will serve to keep all stakeholders informed AND to create an additional sense of urgency to continually improve performance.

These are the general steps followed in our organization that led to consistently achieving improvements in quality and recognition as a Top 100 Hospital. You can lead your organization to do the same by following this plan.

If this seems overly simplistic, let me know in the comments.