QUEST® collaborative helps small
hospital improve core measures
Baptist Memorial Hospital-Union City has been a part of Baptist Memorial Health Care, Memphis, TN, since 1982. The hospital is in the northwest corner of Tennessee just south of the Kentucky border. Recent renovations include addition of a heart catheterization laboratory and updated obstetric facilities. www.baptistonline.org
Situation:
The Premier healthcare alliance’s QUEST® collaborative has been described as “an insurance policy against the effects of healthcare reform.” QUEST goals match up with health reform goals: improve healthcare quality while reducing costs. The Baptist Memorial Hospital – Union City, a QUEST participant for two years, needed to improve its “core measures.”
Solution:
Responding to the challenge, Baptist employees designed processes to ensure reliability and respond positively to “missed opportunities.”
- For each indicator, staff member is assigned primary accountability and a team developed reliability processes.
- Core measures are reviewed concurrently. When an abstractor identifies a “missed opportunity,” processes are examined to determine why there was a failure. Those responsible present to a team of peers what happened and what will be done differently to prevent future occurrences.
- Similar approach is used for indicators for which the medical staff is responsible. A physician is made aware of a “missed opportunity” which goes to the appropriate medical staff department for peer review and becomes part of the credentialing process.
- ALL employees receive ongoing education on the importance of the Department of Health and Human Services’ Hospital Compare website. At mandatory meetings employees learn how to use the website. Baptist data is compared with other area hospitals. The goal is to emphasize how important good scores are because potential patients use Hospital Compare data to choose a hospital.
- Core measure scores are communicated to ALL staff members regularly through quality meetings, e-mails, interdepartmental meetings, and “story boards” posted throughout the hospital.
Results:
Both the mortality rate and the observed to expected ratio have declined.
- Core measure scores have improved dramatically since the hospital began participating in QUEST.
- The hospital’s QUEST baseline all-or-none composite score was 79 percent.
- The most recent data from January to June 2010 [Surgical Care Improvement Project (SCIP) through May] is 98 percent.
"We are successful 1) because we have educated all staff about core measures,
value-based purchasing and Hospital Compare. They have to know that to be
competitive we must have good numbers. It’s all on the Internet. Everybody sees
it. 2) We have senior leadership support. Our CEO comes to all meetings. Staff
tells him when processes fail. That carries more weight than when they tell me.
3) We have built reliability into our processes. And 4) all staff are held
accountable; they all know that core measure compliance means doing the right
thing for our patients. This is shared with everyone."
Teresa Vinson, Chief Quality Officer
Baptist Memorial Hospital-Union City
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