Employee culture and patient care played equal roles in the turnaround tale of a medical center in Washington state, says the CMO who helped it find a new, winning way.
In October 2012, Multicare Health System of Tacoma, Washington, purchased a hospital in the nearby city of Auburn. Auburn Regional Medical Center ranked in the bottom quartile of several of the state hospital association’s measurements of quality: falls with injury, hospital-acquired infections, readmission and core measures.
Those outcomes weren’t surprising to me as I walked through that hospital at midnight on Oct. 1 as its first chief medical officer. In part, while rounding that night, I saw each medical unit had two words posted on the dashboards at the nurses’ station: “budget” and “actual.” The dashboards didn’t include other work factors — such as quality, service or throughput — to help teams understand, in a transparent fashion, what actually was happening with care in the hospital.
The hospital has a rich history. Located on the site of an apple orchard, the original hospital was built in 1921, a few years after the construction of the Northern Pacific railyards, to meet the needs of 1,200 railroad workers as well as those who worked in coal mining and lumber.
By 1945, the 46-bed facility was staffed by 13 local doctors and offered services that included a nursery and maternity ward. New X-ray and pathology laboratories were added. And the hospital was noted to be the only building in Auburn at that time with an elevator. Staff no longer had to move patients between floors via a stairwell stretcher.
In 1956, the hospital was purchased by a nonprofit organization. Its original 46 beds were increased to 66, which included a new obstetrics department, newborn nursery and radiology services. A 1973 expansion increased capacity to 90, which improved services in emergency, surgery, women's health and newborn departments. Also, an intensive care unit was added. Two years later, a $3.2 million campaign provided a more-efficient building, which added 30 beds.
A midnight walk through the hospital was an eye-opening experience for the new chief medical officer. He noticed that elements such as quality, service and throughput were missing from the dashboards at the nurses’ station, and teams couldn’t really understand what was happening with the care being offered.
In 1982, a new owner completed construction on a two-story addition that expanded services to include nuclear medicine, ultrasound, MRI and a cardiac catheterization unit. Additions, including a four-story patient care tower and medical office building, continued until MultiCare Health System acquired it.
But even with all of the investments over the years, it was clear from my first day on the job that changes were necessary. And as I talked with medical staff leaders, they agreed.
Changing the Culture
Many times, physicians remarked on the condition of the aging facility and what they perceived as lack of support. Most poignant, within my first year on the team, the peer review committee wanted to establish a code of conduct. In the recent past, medical staff had experienced near-misses and poor outcomes attributed, in part, to behaviors that led to a lack of communication.
This was a key point in our turnaround. Establishing a code of conduct was critical — a process to address behaviors that had included verbal and physical abuse; disruptions of meetings; personal disparagement; impertinent or inappropriate comments in medical records and internal communications; criticism designed to intimidate, threaten or belittle; damaging property; and other behavior that compromised the effectiveness of colleagues.
Wherever such behavior occurred, leaders sought to understand what actually happened. For incidents deemed to have violated the code of conduct, there was a three-step improvement process:
- First, an informal conversation and re-education on the code of conduct.
- Second, a formal discussion that includes a letter and an action plan to prevent a reoccurrence.
- Third, presentation before the medical executive committee, which can lead to sanctions under the medical staff bylaws.
Another measure the medical staff took was enrolling providers into a third-party system known as the Pulse Program. It’s a web-based, anonymous, 360-degree survey that continuously collects feedback from colleagues about an individual’s work habits and behaviors. It’s designed for the health care industry, to help organizations achieve cultural change that leads to improved professionalism and quality of care. For our team, it was an effort to help staff members understand how they were being perceived and see what they could do to change negative perceptions.
It wasn’t about creating a utopia — it was about ensuring patient safety. Some team members previously had been averse to working with others because they expected to experience disruptive behavior, increasing the risk to patient safety. By having difficult conversations, the medical staff helped get the hospital’s turnaround going.
Changing the Care
Meanwhile, hospital leadership focused on several initiatives to improve the care patients received — and, ultimately, overall performance. This work included three areas:
Initiation of safety huddles: At the time of acquisition, I perceived a lack of awareness of safety issues at the hospital — whether it was around staffing, falls, power or other environmental risks.
To overcome that, we established daily morning meetings for hospital leaders to review the previous day’s safety concerns and staffing. Over the years, these sessions became more robust as an electronic health record system was implemented. They now include check-and-act discussions on service, quality and throughput.
These daily huddles were critical for creating transparency about safety concerns and in reinforcing a culture of no harm to our patients — or to each other.
Campaign Zero: Our quality improvement work started to become more formalized, but challenges remained. In 2014, for example, 11 patients acquired catheter-associated urinary tract infections. Upon review, gaps in patient safety and noncompliance with standards were found to be the root causes. Examples included breaks in protocol, inconsistent perineal care and lack of ongoing evaluation of catheter necessity. Our intensive care unit’s average was 15 days for an indwelling Foley catheter; our medical surgical unit’s average was 45 days. Compared nationally, our ICU’s usage was in the 75th percentile, our progressive care unit’s usage was in the 33rd percentile, and our MSU unit’s usage was in the 44th percentile.
What Campaign Zero did was provide focus. Specifically, during the daily safety huddles, we reviewed the number of days since the last fall, pressure ulcer, clostridium difficile infection and CAUTI, and outlined the common causes for these types of harm. For example, we examined whether a CAUTI was the result of insertion technique, perineal care every shift or checking for removal every shift. We added prevention reminders to the dashboards. For CAUTI, this included asking: “Can we remove the Foley?” every day, as well as “Are we using aseptic technique?”, “Are there no dependent loops?” and “Are all Foley bags below the bladder?” This level of detail at the leadership huddle and on the units at shift change was cornerstone work for the hospital.
The ideal patient experience: Where Campaign Zero provided the framework, this step increased accountability. Hospital leaders conducted staff interviews and put the findings into a pamphlet outlining what we should be doing for every patient, every time. This was our Ideal Patient Experience.
Not only was this endorsed by the nursing staff, but similar bundles were endorsed by our support partners, such as the lab, imaging and pharmacy teams. The medical staff endorsed its own bundle as well. This was presented at the medical executive committee and approved. Thereafter, it was posted and mailed to each member of the medical staff.
This bundle included such things as hand hygiene compliance, adherence to infection prevention practices, and ensuring patient safety with appropriate interventions. For the medical staff, a key difference from the other bundles was around handoffs.
Specifically, it states the medical staff will support team members by ensuring important details are shared and communication is accurate by documenting the care provided and in provider-to-provider handoffs.
Successes were celebrated using personal notes sent to staff and physicians. Recipients of these notes were eligible for prizes that include gifts such as food, clothing or tickets to local sporting events. Deviations from the bundle were managed via coaching, progressive guidance for employees, or the code of conduct if it involved a member of the medical staff.
How It Paid Off
One result of this work was a significant reduction in patient harm. Specifically, the number of CAUTIs decreased from 11 in 2014 to four in 2015. Overall, there were six fewer events comparing year to year. Volume adjusted, this equated to 19 fewer patients harmed. The number of Foley catheter device days dropped dramatically as well (see table.)
Internally, it was great to share the results of this work with the teams. Equally important, given the previous performance of the hospital, it was also helpful to receive recognition from external sources.
In October 2015, MultiCare Auburn Medical Center received the Washington State Hospital Association’s Achieving Best Care award — one of only 12 in the state to earn it. Top performers were defined as those achieving the highest scores in reducing patient harm. Scoring was based on the size of the hospital and whether the hospital was in the top 25 percent in comparison to others of similar size. Areas of improvement included CAUTI, central line-associated bloodstream infection, c. difficile, surgical site infection, falls, early elective delivery and venous thromboembolism.
A month earlier, the hospital was recognized as a Top Performer on Key Quality Measures by the Joint Commission — one of 13 hospitals in the state to receive it. This was attributed to the work done to improve care for patients needing care for heart attack, heart failure, pneumonia, surgery and perinatal care. For each of these measures over the course of a year, one’s denominator needed to be greater than 30, the composite measure needed to be greater than or equal to 95 percent, and each accountability measure needed to be greater than or equal to 95 percent.
Such recognition validated the turnaround efforts, but there was one final measure that showed the hospital was on the right trajectory: an increase in medical staff membership. With that came an increase in the number of suspensions — because the medical staff acted upon delinquent records and licensure, among other activities (see table.)
The hospital continues to work on its journey to be a great place to work for providers, and a great place for patients to receive care. And, thanks in large part to the work that was done to implement a code of conduct, establish daily safety huddles, and the campaigns for zero harm and ideal patient experiences, the improvements have been remarkable.
With contributions from Roseanna Bell, RN, and Katie Bellarin, RN.
Chad Krilich, MD, MBA, is the former chief medical officer for Auburn and Covington medical centers of MultiCare Health System, based in Tacoma, Washington. He is now the chief medical officer of St. Joseph Health Sonoma County, based in Santa Rosa, California.