With the advent of public reporting and increased public accountability for quality, members of the PH&S Board of Directors and senior managers concluded in August 2004 that a quality strategic plan was needed. The scope of the changes brought on by public reporting and Pay-For-Performance (P4P) was considered potentially transformational.

The Board undertook a nine-month, full-scale strategic planning effort focused on quality and safety. Three scenarios were developed, varying in assumptions about the number of national measures implemented, the degree of national alignment, the significance of P4P, and the eventual influence on healthcare consumers and markets. The planning group selected what was considered the most likely scenario, predicting the development of a large set of national quality measures leading to P4P, but limited direct consumer action.

The IOM Six Aims were adopted as the overarching set of principles for the PH&S Quality Strategic Plan. A quality vision statement – best care and services for every patient, every time – was developed, with measures of success defined. The two key strategies of achieving 90th Percentile on national quality measures and eliminating preventable deaths and injuries were directly linked to the vision measures of success.

The Quality Strategic Plan has provided leadership with a clear set of quality goals, directions, and messages to enact and drive across PH&S. Dashboard measures, performance objectives, and other action plans are tied to the Plan priorities. Management has clearly articulated that quality is the top strategic priority of PH&S.

The development of metrics is a key focus. While the dashboard contains the Hospital Quality Alliance (HQA) clinical measure sets, leadership needed a more concise set of measures to use in managing the improvement work. In November 2005, the Board adopted a version of the Centers for Medicare & Medicaid Services (CMS) Appropriate Care Measure (ACM), encompassing 18 HQA measures. Goals were established for this measure (termed the Clinical Quality Index) to drive improvements. Also known as an “All or None” measure, the Index is readily understood: Did every patient receive each treatment for which he was eligible? This measure links directly with the vision statement, emphasizing reliability in clinical care. The challenge is in evolving from a project-oriented approach, which results in achieving 80th percentile performance, to a culture-wide integrated systems approach, which calls for the 90th percentile and no-preventable-deaths goals.

One year after adopting the ACM, PH&S understands the transformation, focus, and time these changes will take. The lessons learned include: governance can be a strategic catalyst; strategic planning for quality can create focus on long-range implications and engage leaders at all levels; leaders must see a quality strategy as central to business needs; quality strategy must go beyond national measures to set the broader framework for initiatives and performance across all care processes; and management systems must evolve to include a focus on prioritizing improvement opportunities, setting benchmarks, and measuring execution.

Mercy Health Partners (MHP), an integrated health system in Cincinnati, embarked in 2004 on a partnership with its physicians to incorporate these goals in a deliberate way throughout its five hospitals and outpatient sites. The result was an comprehensive strategic plan focused on safety, quality, and clinical transformation. Dr. Randolph believes that its successful implementation is due to five factors.

The first factor is committed leadership with an emphasis on: mission-driven decision making; quality as a core function on equal footing with financials; and progress reporting to promote accountability. System objectives for quality and safety are set annually by the Regional Board and its parent company, Catholic Healthcare Partners (CHP), in alignment with the strategic plan. MHP’s leaders are incentivized to both target and stretch goals. Progress towards goals is reported at every organizational level up to the MHP Board through a dashboard. In addition, the CEO shares his goals publicly with all managers and provides quarterly updates.

The second success factor is system-wide alignment of strategic initiatives into one overarching strategy – that is, integration of quality into every aspect of operations. Behaviors promoting quality are embedded in operations and include evidence-based medicine (EBM); simplified, standardized processes; and elimination of non-value-added processes.

Active physician involvement is the third factor. MHP is focusing on its physician relationships, and a newly-formed 22-member Physicians Council guides strategies and policies for implementing EBM across the MHP system. MHP supports the Physicians Council by providing staff, resources, and redesigns of care processes. Thus, clinical excellence is clinically, rather than administratively, driven.

A robust information system infrastructure focused on quality and safety is the fourth success factor. Systems that support that framework include; digitized radiography; emergency department tracking boards; bar-coded medication administration (unit-dose packaged); smart infusion pump technologies; integrated electronic medical records in physician offices; a citywide simulation center for team training on patient safety; computerized physician order entry; data mining for regular reports of progress on key quality indicators; and full integration with the regional health information organization.

The final success factor is a strong focus on the entire continuum of care. MHP’s goal is the transformation from episodic care to supportive care, realizing that the most difficult cases are not necessarily the medically complex ones, but cases that involve chronic-care patients who have multiple non-medical issues and require management across the continuum. This focus is particularly misaligned with reimbursement mechanisms focused on procedures and episodic illness, rather than on maintaining people at their optimum level of health. However, MHP has been able to demonstrate decreased resource utilization and improved outcomes for people living with chronic illness as a result of its efforts.

In recent years, TriHealth leadership felt the need to transform its organization. TriHealth had experienced fast growth, but lacked integration. Leadership wanted to improve its quality and become transparent by reporting the quality measures. Following a financial turnaround, it also wanted to be able to measure growth and success, to manage both leading and lagging measures (that is, the ones that were not achieving desired goals), and to improve data integrity and accessibility.

Mr. Prout indicated that strategy was important in transforming the organization, but so was the ability to understand how that strategy impacts every aspect of the business. To that end, in 2005 the Board and Mr. Prout decided to implement a business management system using a balanced scorecard to achieve a better alignment between strategy and daily activities, to improve the business review process, and to better communicate strategy and performance throughout the organization. This scorecard ensured a “balanced” focus on quality and service, customers and community, and workforce development.

The scorecard consists of multiple layers of “cascaded” balanced scorecards, which will ultimately align the entire organization to the key top-level strategic objectives and performance measures. The top-level scorecard has been cascaded into scorecards at each hospital, and into other corporate business units and clinical service lines. After each scorecard is built, a model of monthly systematic business reviews is implemented at each level to support exception-oriented, root-cause thinking. The benefits of the balanced scorecard system include the ability to: communicate strategy to all organizational levels; provide alignment and "drill-down" visibility into strategic objectives, metrics, and problem areas; ensure that resources get applied appropriately; and drive accountability and results.

Mr. Prout described the keys to success as: top-level leadership that drives the process; management buy-in at all levels; processes that ensure data accuracy and timeliness; commitment to monthly business reviews; linkages to the strategic planning and budget processes; accountability for performance at all levels; and proactive change/cultural transformation management. During the course of this initiative, MHP leadership has learned to: standardize language to ensure consistency and reliability; devote sufficient, appropriate staff resources; expect data conflicts and involve the IT team early; prioritize corporate initiatives; use scorecards as communications tools; find internal champions and leverage them; and build in rewards and recognition for good performance.