Hospital describes how it became
top performer in CMS demonstration
Memorial Hospital Pembroke features a cardiac care unit, an emergency department, a hospice unit, an intensive care unit, an outpatient department and a respiratory special care unit. The hospital also features a Memory Center, Sleep Disorders Center and Wound Healing Center. This 301-bed facility is centrally located in South Broward County and has been operated by Memorial Healthcare System since 1995. www.mhs.net.
Situation:
In the first year of the CMS/Premier Healthcare Quality Incentive Demonstration Project (HQID), Memorial Hospital Pembroke in Pembroke Pines, Fla., finished a disappointing sixth decile for acute myocardial infarction (AMI), seventh decile for heart failure and eighth decile for community-acquired pneumonia. By year two the hospital had improved its results substantially: second decile for AMI and third decile for both pneumonia and heart failure.
Solution:
Quality is not just a job for the quality and risk departments. Achieving results requires will at all levels, especially at top leadership levels. Hospital leaders play an essential role in ensuring the quality and safety of care for patients.
The will must be backed up by a good implementation plan:
- Use trained personnel who know the indicators to do concurrent review, then hold reviewers accountable for the indicators being met.
- Hold leadership and staff accountable.
- Investigate variances and “near misses” fully and implement changes from what is learned quickly.
- Meet weekly.
- Never take your eye off the ball.
- Lead by making others powerful. Remember, the conductor of an orchestra doesn’t make a sound.
In year three it all came together and Memorial Hospital Pembroke became one of the HQID leaders in three of five clinical areas for which it was eligible, finishing in either the first or second deciles for three measures.
Results:
In year three it all came together and Memorial Hospital Pembroke became one of the HQID leaders in three of five clinical areas for which it was eligible, finishing in either the first or second deciles for three measures.
"The organization’s will was very important; that was the board and
hospital leadership getting on board 100 percent. The ideas came from Premier
and others – we’re looking for the best in the world. Then it’s just a matter of
how you carry it out day in and day out at the bedside. We found that’s the
biggest challenge of the three. Taking those good ideas and making them work.
Not people dependent, but as part of the way the work gets done each day."
Nicole Auffret, RN, MS, LHRM, CPHQ,
Director of Quality and Patient Safety
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