Go team! How an empowered frontline staff drives superior outcomes

At Parkview (Ind.) Huntington Hospital, a 36-bed community facility, frontline staff proposed hiring a transitional care nurse to help lower 30-day readmission rates among its most vulnerable patients.

The idea was taken seriously. A nurse who focused exclusively on the transition to post-acute care joined Parkview Huntington in January 2015. Readmissions for patients have been on a steady decline since.

The staff also came up with a plan for the new position. They suggested the transitional care nurse consult with high-risk patients upon discharge to ensure they have all the appropriate support and resources to schedule follow-up appointments with their provider and to take home the necessary medications.

They also recommended the nurse continually check in with patients for 30 days after discharge to make sure they are following their care plan. The patients at heightened risk for 30-day readmission usually suffer from pneumonia, congestive heart failure and chronic obstructive pulmonary disease.

Since the nurse was hired, 30-day readmissions to the hospital have fallen significantly. The 30-day readmission rate for pneumonia patients dropped from 7.8% in 2013 to 4.9% in 2015. For COPD patients, the decline was from 17.26% in 2013 to 11.59% in 2015. Overall, 30-day readmissions at the hospital declined from 7.46% in 2013 to 5.5% in 2015.

The idea to hire a transitional care nurse came out of a “Lean” quality-improvement session that hospital leaders held to empower frontline staff to decrease readmissions in their departments.

“The frontline worker does the work day in and day out,” said Juli Johnson, president of Parkview Huntington Hospital. “The more we have brought them into the decisionmaking process, the more strides we have made.”

Motivating staff to come up with solutions to improve quality and efficiency is one of the key strategies used by Parkview Huntington and other hospitals that made this year's list of 100 Top Hospitals published annually by Truven Health Analytics, IBM Watson Health. But fostering a culture of teamwork and empowerment can present challenges, leaders of even the top hospitals say.

Truven's best-performing hospitals were divided into five categories based on size. The list includes 15 major teaching hospitals (400 or more acute-care beds) and 25 teaching hospitals (200 or more acute-care beds). Among community hospitals, there are 20 large hospitals (250 or more acute-care beds), 20 medium-size hospitals (100-249 acute-care beds) and 20 small hospitals (25-99 acute-care beds). The 100 Top were chosen from 2,740 hospitals across the U.S.

The recognition program is in its 24th year. Truven identifies hospitals that were top performers based on publicly available government data looking at 11 performance measures including lengths of stay, 30-day readmissions, compliance and death rates. The data were from 2012 to 2015, depending on the metric. Those that make the roster have the best performance compared with all hospitals in their category, which establishes the benchmark for comparison.

Inpatient mortality was 23.3% lower and the rate of complications 17.1% lower among all hospitals on the list compared with their peers, according to the Truven analysis. Average length of stay was 9.4% shorter and wait times in the emergency room were 5.5% shorter compared with the benchmark.

If all hospitals surveyed had achieved the same results as the top-ranked hospitals, nearly 89,000 additional inpatient lives could be saved, 61,000 additional patients could be complication-free and more than $5.6 billion could be saved each year, according to Truven.

A majority of the hospitals on Truven's list, 87%, are repeat winners. Several made a return appearance after many years absent from it. For example, Beaumont Hospital-Royal Oak (Mich.), a large teaching hospital, was recognized this year after a 12-year dry spell. North Florida Regional Medical Center, a large community hospital in Gainesville, was recognized after a 13-year absence.

This phenomenon is “what makes a good hospital really good,” said Jean Chenoweth, senior vice president of performance and improvement at Truven. “They floated around below benchmark levels, and then they came back. It shows they are consistently striving.”

Among the hospitals Truven recognized this year, Logan (Utah) Regional Hospital, an Intermountain Healthcare facility, made the list for the seventh time. This is Logan Regional's fifth consecutive year on the list after a 10-year absence.

To improve performance, Logan Regional created a culture dedicated to continuous improvement, CEO Kyle Hansen said. A large part of that culture is encouraging staff to submit ideas that address quality improvement, Hansen said. Every department at Logan Regional has an idea board prominently displayed, listing initiatives by frontline staff as well as its progress or performance.

Staff ideas submitted via the boards have led to various initiatives. They included converting a supply closet into a space to store drugs after staff noticed they were too frequently left out in the open on department floors. “The best ideas come from the people who are dealing directly with the patients,” said Neil Perkes, chief nursing officer at Logan Regional.

But Hansen said there are still kinks to work out. A daily safety huddle implemented a year ago was designed to encourage frontline staff to report issues to managers so they can be addressed quickly. Since the huddles began, serious safety events decreased from 2.7 events per 10,000 patient-days in 2014 to 1.8 events per 10,000 patient-days in 2016.

Despite improvements, Hansen said he isn't convinced everything that occurs on the floor is actually reported out of fear of being chastised. “I'm just not convinced our culture has arrived there yet,” he said. “I think it's done a lot of good, but to feel comfortable raising a concern we need to get to another level.”

University of Colorado Hospital, part of UCHealth in Aurora and on the Truven list for the fourth time, has made it a core mission to give staff the resources, data and encouragement to make changes at the hospital.

Six years ago, the hospital created a 12-month training program for physician and administrative leaders that offered tracks to build various skills including how to build employee engagement, communicate with employees and develop strong teams. The volunteer participants meet every other Tuesday for four hours over the course of a year.

The program also involves applying those skills to design a quality initiative at the hospital. “We didn't want what we were teaching to live and die in a classroom,” said Dr. Jeff Glasheen, chief quality officer. “We apply everything we learn.”

The program inspired frontline staff to initiate change, Glasheen said. “They have the empowerment to solve problems.”

At Adventist Medical Center Hinsdale (Ill.), a teaching hospital recognized by Truven for the first time, staff have been trained to take a proactive approach to caring for patients, said CEO Michael Goebel. This includes nurse rounding on patients every hour to ask if they need assistance, have any pain or are comfortable.

All staff are told to follow the 10-5 rule, which involves making eye contact with every person within 10 feet and saying hello to every person within 5 feet. “Ultimately, it's about putting patients at ease,” Goebel said.

The efforts have paid off. Patient-satisfaction scores have improved since it became a strong focus area at the hospital beginning in 2012. According to its Press Ganey scores, Adventist Medical Center Hinsdale scored 74 out of 110 for patient satisfaction in 2016, up from a score of 56 in 2012.

But the effort requires diligence, which can be difficult because the hospital has an array of other quality metrics it's monitoring, Goebel said. “It takes a strategic focus all the time. We can't take our eyes off of it. As soon as we do, it will go down.”