Aiming for “Perfect Care”

Mike ApostolakosIn 2009, URMC recognized the importance of establishing a culture in which continuous improvement is driven by governance and top leadership, embraced at every level in the institution, frequently and accurately monitored, and readily communicated. The Strong Commitment and Highland Promise became our mantras for excellence in all three realms:  quality, safety, and patient-centered care. 

The URMC and Highland Boards now see fostering clinical improvement as their top priority. Issues of quality/safety/patient-centered care now lead monthly board meeting agendas, and clinical leaders are invited to present their responses to difficult challenges.  Two retreats brought board members, administrative leaders and clinical experts together to devise a structure and process that ensures universal participation and accountability. 

Perhaps the greatest boost to the new culture came when URMC joined the University HealthSystem Consortium (UHC), an alliance that compares the quality performance of 107 academic medical centers (including some 220 peer hospitals). Using UHC comparisons, we are not only able to benchmark our performance in real time, but we can learn best practices from those institutions whose efforts are most advanced. UHC tools compare outcomes in even the most complex procedures, providing unprecedented clarity and forming a pathway to measurable, sustainable improvement. 

Mortality has emerged as the single most critical measure, and clinical leaders now monitor the ratio of “observed” (or actual) versus “expected” deaths. In part, through a concerted focus on reducing complications, Strong Memorial Hospital’s observed-to-expected mortality rate has dipped from 1.1 to 0.85 since 2007, and Highland met its target of 0.84 for 2009. In fact, in areas such as treatment for heart attacks, preventing pneumonias, and surgical complications, as well as central line-associated blood stream infections, Strong now consistently meets or exceeds the UHC benchmark within Intensive Care Units (ICUs). Highland’s length-of-stay and readmission rates compare favorably with peers, yet the hospital hopes to achieve further reductions through disease management, discharge planning, and attentive post-discharge care. Meanwhile, faculty and staff at Highland Hospital are helping to lead community-wide efforts to reduce central line and other hospital-acquired infections outside of ICUs. Hand hygiene campaigns at both hospitals raise awareness and promote compliance.     

Tim StevensBoth hospitals continue to introduce and track a host of process measures – steps which have been demonstrated to reduce complications and mortality. Combining a series of simple steps together into a “care bundle,” we can conquer many complications once thought unavoidable, including the leading cause of hospital-related deaths: infections. But these best-practice bundles must be implemented in totality and vigilantly maintained to achieve breakthrough improvements. In other words, our discipline now centers on providing unfailingly “perfect care” to each patient. 

We have adopted a new level of candor and transparency. Weekly reports are circulated to clinical leaders and the URMC Board that chronicle incidents of avoidable complications by unit, such as hospital-acquired infections, pressure ulcers, and serious falls, trended over several weeks. The reports allow us to rapidly spot and address areas of concern and to recognize faculty and staff that are making and sustaining progress. 

Patients have also noticed our more attentive environment, a patient-centeredness not typically found in academic settings known for aggressive, interventional care. Using real-time patient feedback helps improve our compassion, attentiveness, and communication with patients. We now encourage patients and their families to play an active role, and we are teaching providers how to embrace family participation in areas like medication administration, pain control, treatment planning, and family meetings. By encouraging our caregivers to truly connect with patients on their most important concerns, patients are more satisfied and caregivers are rediscovering the very reasons they chose a career in caring. 

Four years ago, Strong’s overall inpatient satisfaction score (as measured by Press Ganey) was in the 17th percentile, compared with other 600-plus bed hospitals. That meant 83 percent of our peer institutions were performing better than we were.
Since then, we’ve seen tremendous improvements. In the last quarter of 2009, URMC set a new high-water mark: For the months of October, November and December, we achieved an average score of 85.7, putting us in the top quarter of the 60 UHC academic medical centers who work with Press Ganey. Meanwhile, overall patient satisfaction at Highland improved from 84 in 2008 (the 39th percentile) to 85.2 in 2009, placing it in the 54th percentile among the 2,500 hospitals that participate in Press Ganey surveys. 

This success can be credited in part to the adoption of hourly rounding by staff – pre-empting patients’ needs before they even arise.

Within the home health care realm, URMC’s licensed home health agency, Visiting Nurse Service (VNS), leaders have set a goal of meeting or exceeding the top 20 benchmarks for at least five of 11 measures in Medicare’s Home Health Compare report card. VNS already exceeds state and national benchmarks for nine of the 11 performance measures, thanks to significant progress in wound care and pain management. Achieving the top 20 goal will not only ensure that VNS is well positioned for Medicare Pay for Performance standards, it will improve the health of our home care patients. To date, VNS has reached that goal in four indicators, up from two in 2008. 

The Highlands at Brighton continued to participate in Advancing Excellence in America’s Nursing Homes, a national quality improvement campaign through the Empire Quality Partnership’s coalition of nursing home associations. Now entering the final phase of this three-year demonstration project, the campaign provides free technical assistance in eight areas of nursing home care, management, transparency, and resident, family, and staff satisfaction. 

In 2009, The Living Center at The Highlands at Pittsford earned its best Department of Health survey in over seven years. The Living Center is also the only nursing home in the area fully accredited by the Commission on Accreditation of Rehabilitation Facilities – Continuing Care Accreditation Commission, the nation’s only accrediting body for continuing care retirement communities.