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Example Cases

Valuable lessons can be learned from the following organisations:

Heart of England NHS Foundation Trust, United Kingdom
Healthcare scorecard helps improve practices

The Heart of England NHS Foundation Trust hospital developed comprehensive systems for monitoring healthcare performance in certain key areas. The hospital increased its capacity to provide credible data by gathering information from a number of sources (triangulating) and this improved its accuracy while minimising bias. Scorecards and dashboards that covered the following quality outcomes were implemented and systematically reported to management:
  • your skin matters: tissue viability
  • staying safe: preventing falls
  • keeping nourished: nutrition
  • promoting normal birth: reducing caesarean section rates
  • important choices: end-of-life care
  • fit and well to care: staff wellbeing
  • ready to go, no delays: safe patient discharge. [21]
The scorecards/dashboards offered a visual reference that helped hospital staff to review data from a range of sources, and enabled sound evidence-based discussions. This enabled Heart of England to increase transparency and improve practices. Figures 4a, see below, and 4b, see top of next page, provide examples.

Further detailed records of the quality indicators used by the Heart of England hospital system may be found at Quality Indicators.

Novant Health, United States
Project team reduces infection rates

The CEO and senior leaders of Novant Health assumed responsibility personally after a 28-day-old infant died from an invasive methicillin-resistant staphylococcus aureus (MRSA) infection. This resulted in an aggressive hand hygiene campaign being initiated at Novant’s seven hospitals, and outcomes were directly linked to senior leadership compensation. A project team—comprising representatives from nursing, infection control, environmental services and medical affairs—set a goal of 90 per cent hand hygiene compliance over the next three years. Alcohol hand sanitizers were strategically placed within each hospital. Two observers rotated throughout the system’s acute inpatient units to monitor compliance, educate staff, and document the 2,000 hand hygiene observations they made each month. A continuous cycle of education/feedback was initiated, involving:
  • caregivers
  • leadership conferences
  • computer-based training modules
  • infection prevention personnel/nursing unit staff, and
  • a $325,000 promotional effort employing cutouts of cartoon characters stationed around the hospitals to help remind people about hand hygiene. [23]
All hospitals were able to observe the performance of the others in the system. The penalty for failing to reach the 90 per cent target was the forfeiting of end-of-year bonuses (from the director level up). Novant reduced MRSA infection rates by 60 to 70 per cent-down to 0.15 infections per 1,000 patient days. The hand hygiene target was subsequently increased to 95 per cent. Novant Health data similar to the bar graph below, see Figure 5, may be found on the Novant Health website.

Cedars-Sinai Medical Center (CSMC), United States
Lean Six Sigma aims at zero errors

CSMC aimed to achieve zero errors for its Lean Six Sigma projects even when considered not theoretically possible. They likened their “zero errors” philosophy to designing a jet aircraft, where anything less is not acceptable. The following outline CSMC’s successes:
  • Hand washing compliance rates rose from 66% to 95% in 18 months, and remained steady at 98%.
  • Surgical site infection rates per 100 procedures fell from 15.5 to less than 5.
  • Readmissions: 30 day all-cause readmission rates among heart failure patients was reduced by more than 50% within eight months.
  • Ventilator-Associated Pneumonia (VAP) rates fell over a 10-month period to five incidences out of 9,580 ventilator days. No VAP cases occurred anywhere at CSMC for six of those 10 months. This rate was more than 70% below the average for similar hospitals in the National Healthcare Safety Network.
CSMC believed its aggressive goal-setting successes were largely due to leadership at all levels of the organisation. It believed that leadership involved driving change; when people were first committed to change, then established far-reaching goals, success was assured. [24]

Catholic Health Partners (CHP), United States
Organisation structure change improves value

CHP set  itself  the  goal  of  delivering  high  quality services  at  40  per  cent  less  cost. A new  business model focused on improving patient flow. At a chosen location,  the  average  time  from  patient  admission to discharge for all patients was 5.3 days (above the national average of 4.9 days). By eliminating non-value added activities and encouraging collaboration, CHP was able to improve the value in care provided, and significantly shorten the length of stay for patients to 3.9 days. New job roles were created-and standard procedures established-to provide a more predictable patient flow. Since patients spent 30 per cent less time in the hospital, all aspects of patient care became more efficient. Nurses and physicians spent more time with patients, which improved levels of care, experience, and the flow through the hospital. Building a culture of learning and innovation was a key part of the restruc- turing processes. Open discussions enabled staff to learn about problems in the care process; creativity was encouraged to enable staff to tackle issues. New operating models were introduced that provided patient flow visibility from one department to the next; this helped to improve throughput for physicians, patients and employees. A more predictable operation framework enabled physicians to plan their work more effectively. Eliminating waste in the patient flow process led to reduced costs, and the improvement of many other services provided by CHP. [25]

Heartland Health, United States
Continuous Quality Improvement brings excellent financial performance

Heartland Health was experiencing serious patient safety issues, in addition to losing some US $1 million per month. To remedy this situation, Heartland carried out detailed research on Continuous Quality Improvement and visited a number of healthcare organisations across the United States. As a result, Heartland restructured its executive management team, and focused on developing new leadership competencies, establishing benchmarks associated with quality improvement. A multidisciplinary team-based approach was promoted. By doing this, Heartland achieved significant quality improvement results, and excellent financial performance. Consequently, Heartland earned two Missouri State Quality Awards, and a coveted Baldrige National Quality Award. The next two years were the most successful in Heartland’s history. Heartland’s vision incorporated:
  • delivering the best and safest care
  • improving individual health, and
  • improving community health. [26]

AtlantiCare, United States 
Cross functional teams reduce costs significantly

Team-based care for chronically ill patients at the Baldrige Award-winning AtlantiCare helped to reduce hospital and emergency department visits by 40 per cent. In addition, patient experience scores rose, and overall costs were cut by more than 10 per cent. The members of each clinical team included:
  • Health Coaches: each patient was assigned a health coach whose responsibilities included educating patients about their conditions, and helping them make appointments and navigate the system.
  • Physicians: high-performing specialist physicians were assigned a manageable panel of patients. New patients were scheduled hour-long visits.
  • Social Workers and Behavioural Health Providers: the team-based care model recognised that life problems exacerbate health problems.
  • Pharmacists: medication compliance rates were almost 98 per cent.
Teams were  accountable for the Institute of Medicine’s Triple Aim of:
  • improving the health of the population
  • improving patient experience, and
  • reducing the per capita cost of care. [27]

MultiCare Health System, United States 
Environmental sustainability in healthcare

MultiCare Health System tapped into the passion of its staff by creating “green teams” to focus on system-wide efforts for waste, energy and chemicals reduction. In addition, a comprehensive sustainability programme was established to serve the needs of patients, staff and the community, and also to benefit the environment. A consultancy and training organisation was engaged to assist MultiCare meet its goals of:
  • eliminating mercury where possible
  • reducing the quantity and toxicity of healthcare waste
  • minimising the use and exposure to hazardous chemicals
  • reducing healthcare’s environmental footprint through resource conservation
  • integrating sustainable design and building tech- niques, with environmentally sound operational practices to create a true healing environment.

Among the initiatives carried out by MultiCare Health System were the following:
  • Cafeteria: the Nutritional Services department, in conjunction with its suppliers, implemented a number of beneficial environmental sustainability projects.
  • Waste management: MultiCare planned to recycle more than 50 per cent of its solid waste and thereby make substantial savings. Opportunities for improvement were identified and significant potential cost savings gained from improved processes for handling regulated and hazardous waste.
  • Green buildings: MultiCare is building Wash- ington State’s first LEED Silver-certified hospital.


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