Published in the September 2015 issue of Today’s Hospitalist
HOSPITALISTS are increasingly asked to champion quality initiatives, and some larger programs have even created quality improvement leadership positions. But in smaller groups, quality improvement often takes a back seat to patient care.
Virginia Mason Hospital in Seattle has created a solution that might work for small and large groups alike. The Quality Leader Time (QLT) program was designed by the 25-member group to give hospitalists the resources “including protected time “to propose, design and lead quality improvement projects.
The program, which evolved out of compensation discussions back in 2013, helps hospitalists lead QI projects without having to establish a dedicated QI track or position. That’s critical for smaller and mid-sized programs that can’t devote that level of resources.
“We wanted compensation to be in line with the mission of the hospitalist section, so we proposed dedicating one week a year to quality work,” recalls Evan Coates, MD, section head for Virginia Mason’s hospitalist service. “The consensus was that it was a wise thing to do, but that we needed to put some process around it.”
That process goes like this: In January, during the group’s “open enrollment” period, hospitalists put in for time off. At the same time, group and hospital leadership accept formal applications for quality improvement projects. Hospitalists whose projects are approved receive one week off that year. (Physicians typically work 23 weeks a year in seven-on/seven-off blocks.) While the program schedules a one-week block for physicians to work on projects, they typically complete the work in increments over a period of months.
How the program works
Before the application process begins, the leadership team determines how many weeks of QLT time the program’s budget will permit. It shares that information with the group.
“If we can fund three or five projects, we put in a request for proposals to get the conversation and the thinking going,” Dr. Coates explains. “If we’re looking for a project in a certain area, we let hospitalists know.” During open enrollment, leadership team members also help applicants design their projects so the work can be completed within a year.
For the most part, hospitalists propose the projects themselves. About 50% of the proposals submitted have been approved, he adds. “Some that were not approved in one year ended up being approved the next year after working to further refine the proposal.”
And for one project, two hospitalists were OKed to work on it. “But there should be a good reason for that,” Dr. Coates points out. That particular effort entailed extensive chart review, so “it made sense to have more than one reviewer to improve the validity of the results and to allow us to review more charts.”
The program is also a natural extension, he notes, of the health system’s quality improvement platform, which is called the Virginia Mason Production System. It’s a management method modeled after Toyota’s production system that seeks to continually improve so the final product has zero defects.
“We have a pretty developed system in place because we do a lot of Lean improvement projects,” Dr. Coates says. “If we need to move length of stay on our obs unit, for example, or improve readmission rates, we’ll plan a project to do that.
As for covering open shifts while funded hospitalists take advantage of their QLT week, the group maintains a locums pool. After two years, Dr. Coates estimates that QLT costs about one FTE a year, depending on how many projects each year are approved.
Collaborations and results
Completed projects span a broad range. One hospitalist interested in improving patient experience crafted patient materials to explain hospital medicine and describe what hospitalists do. He then engaged a focus group of former patients to help him design what became an informational brochure that is now handed out to each patient.
Another project created a new acute myocardial infarction (AMI) order set to incorporate the latest evidence-based recommendations, giving hospital medicine a way to contribute to an ongoing QI effort being led by cardiology. The collaboration delivered dramatic results: Performance on AMI defect-free care increased from 77% in 2014 to 93% by early 2015 throughout the hospital.
Another project focused on creating discharge orders. The lead hospitalist studied when orders were completed to gauge the effect of completion time on such factors as length of stay. “The idea was, if you get discharge orders done before noon or 9 a.m., is that meaningful? Does it really mean the patient will leave earlier?” Dr. Coates says. “It’s a controversial topic among hospitalists and administrators.”
For that project, the researcher reviewed patient charts for 100 afternoon discharges to determine which were appropriate and which might have represented unnecessary delays. The net outcome: It may have been possible for 35% of afternoon orders to happen earlier in the day.
“The rest were appropriate. The physician might have been waiting for a stress test result, for example,” Dr. Coates says. “That was really helpful in getting us all on the same page.” The project also became the subject of a research poster presented at the Society of Hospital Medicine’s annual meeting.
Another ongoing project is looking at readmissions, with one hospitalist doing a broad chart review. According to Dr. Coates, “We’ve asked the hospitalist to come out of the project with some recommendations on where we can improve and what work we should take up in the next year.”
Tallying the benefits
Hospitalists give the QLT program top marks because it fosters professional development. Administrators appreciate the program “because it gets hospitalists engaged in QI,” Dr. Coates says. To date, most of the hospitalists have submitted applications, and seven projects have been completed.
And as word of the program has gotten around, it has boosted hospitalist recruiting.
“The people we’re looking for are systems thinkers who are serious about partnering with nurses and others to improve hospital quality,” he says. “We want to have resources available for people to do that, not just to come in, see 16 patients and go home. But we can’t offer a leadership track for all 25 docs, so that’s the role of this program. It lets everybody function at the top of their game as quality leaders, even without a formal track.”
The chief limitation to date in expanding QLT isn’t interest, Dr. Coates explains, but how many projects the program can support at any given time. “If we give doctors a project,” he says, “part of what we owe them as leaders is to work with them, not just leave them out there on their own.”
Bonnie Darves is a freelance health care writer based in Seattle.