Oregon hospital makes significant strides toward 99 percent reliability rate on core quality measures
Salem Hospital Regional Health Services is one of the largest of Oregon's 57 acute care hospitals and operates the busiest emergency department in Oregon. A not-for-profit hospital, licensed for 454 acute-care beds, it is the city's largest private employer with some 4,000 full- and part-time employees. There are 465 physicians on the active medical staff, representing 46 different specialties.
Situation:
The hospital’s board of trustees committed to attaining a 99 percent reliability level on core quality measures for nationally recognized medical conditions and surgical processes – acute myocardial infarction, heart failure, pneumonia and surgical care. Why those particular measures? They are consistent with core measures being reported nationally and they are evidence based.
Solution:
- Chose ClinicalAdvisor® and Quality Measures Reporter® (QMR) to collect, analyze and submit core measures.
- Recruited a new chief medical officer who focused board attention on quality.
- Reconstituted a multi-disciplinary Quality Council that meets monthly.
- Medical staff president-elect made head of council so that when he became president, he would be a quality convert; when he began his tenure, he made the measures and the board’s mandate his focus for two years.
- Designated a core measure work team for each of the measure areas. Each team, in succession, participated in a five-month process known as a 100-day Project to develop plans and take actions toward meeting the goals.
- Leadership cleared barriers, helping teams attain their goals.
- A new chief nursing officer held nursing leaders accountable.
- Team members attended a Premier HQID Top Performer Open House in Escondido, CA, where best practices were shared.
- Engaged Jan McNeilly, a Premier Healthcare Informatics consultant.
- More attended a Premier knowledge-sharing meeting in Newport Beach.
Result:
In two years the hospital made significant strides toward attaining its stated goal for acute myocardial infarction, heart failure, pneumonia and surgical care. Remarkable progress has been made in the past nine months. Sixty percent of the measures are at the 99 percent or better level.
"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."
Dan Grigg, Director
Center for Patient Safety and
Clinical Effectiveness, Salem Hospital
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