100 Top Hospitals winners cultivate unique cultures that encourage high-quality care

NorthShore University HealthSystem strives for consistency in performance, which can mean extra work early on when trying to improve.

NorthShore, based in Evanston, Ill., doesn't typically pilot a new process at one facility before implementing it across the health system. Instead, new initiatives are enacted simultaneously at its four hospitals in the Chicago area.

"With the piloting approach, adoption can sometimes die and not really produce the results that we want. It's also hard to keep track of numerous pilots," said Dr. Lakshmi Halasyamani, chief quality and transformation officer for the system. "Once we understand the best practices, we are broadly implementing them."

NorthShore has been on the 100 Top Hospitals list 19 times, more than any other hospital.

The broad implementation approach was used when NorthShore worked to improve how it prevents central line-associated bloodstream infections. The system found that bedside nurses weren't consistently monitoring and managing the central lines to prevent the infections. "There was too much variation across the nursing staff in the day-to-day management of the central lines," Halasyamani said.

To tackle this inconsistency, the system decided it would charge the vascular access team with the daily management of central lines at hospitals. The vascular access teams are registered nurses at NorthShore who insert central lines, but they weren't in charge of continuously monitoring them.

Their workflows were changed so the team has the time to check on all patients with central lines at least once per day. They look for signs of infection and make sure the dressing is appropriate. The nurses also monitor whether or not the patient still needs the line. If they decide it's time to take it out, they discuss it with the patient's physician.

Last year, NorthShore averaged one such infection per month; since January, there haven't been any. "We've eliminated a lot of variation," she said.

The health system also strives for consistency with the technology it uses. Leaders found that clinician adoption of new gadgets is low unless it's integrated into its electronic health record system.

That's not to say widespread adoption of new initiatives is easy, though. Halasyamani said she and other leaders spend a lot of time explaining why changes are made.

"You have to make sure you are engaging people in the 'what' and the 'how.' But that process of engagement can be very time-consuming because frequently people have different opinions and you have to create an environment where that can be unearthed," she said.

At Kettering (Ohio) Medical Center, a culture of trust has been created that encourages quality improvement work.

The hospital, which has been on the 100 Top Hospitals list 13 times, shares unblinded clinical outcomes data with physicians on the same service lines so they can compare each other's performance and look for areas to improve.

But the only reason Kettering is able to share this sensitive information so openly with its doctors is because they trust each other, said Brenda Kuhn, chief quality officer of parent Kettering Health Network, which operates eight hospitals.

Kettering leadership has worked hard over the years to ingrain in physicians' minds that comparing performance isn't a tactic to "make someone look bad," rather it's a critical way to improve care for patients, Kuhn said.

"We really want to be a top performer in every aspect, so when you approach work from the standpoint of how do we improve, people are willing to have their data be transparent and they are willing to have those conversations," she said.

Kettering Medical Center also has the opportunity to learn from the other seven hospitals in the system. Every hospital keeps a scorecard, which displays performance on certain metrics like infections and mortality rates. All scorecards are available to every hospital in the system, which allows the hospitals to share best practices, especially when one is performing better than another in a particular service line.

"It allows us to see where our hospitals are doing great, and then say, 'What are you doing that I may not be doing?' We developed a culture of shared learning," Kuhn said.

The hospitals also work together on certain initiatives. For instance, infectious disease prevention work is divided up, with one hospital focusing on surgical site infections while another focuses on catheter-associated urinary tract infections.

"We can make improvement at a faster pace when we are sharing what we are doing," Kuhn said.

Teamwork is how change happens at UCHealth Poudre Valley Hospital in Fort Collins, Colo.

The clinical team at the hospital bands together to develop and implement new processes that will improve patient care. The leaders say that teamwork is a central tenet of their organization to sustain and improve quality care. Poudre Valley has appeared on the 100 Top list 12 times.

"Everything we do is based around the team setting so the people who do the work are involved upfront in the process improvement and quality initiatives," said Kevin Unger, CEO of Poudre Valley Hospital.

The team setting came into play in 2012 when the emergency department was looking for ways to decrease its mortality rate from sepsis. The ED nurses and physicians worked together on a protocol for how they were going to recognize and treat the infection. The team decided to set up an alert in the hospital's EHR system that identifies patients who may have sepsis based on their vital signs. The doctors also agreed that nurses can call for antibiotics and fluids for septic patients without approval from the physician. With sepsis, timing is everything, so they wanted to ensure nurses had the ability to act quickly to treat patients.

As a result of their efforts, the sepsis mortality index at the hospital dropped from 1.19 in 2012 to 0.73 in 2017.

Dr. Diana Breyer, chief quality officer at the hospital, said this kind of improvement was possible because the physicians worked with the nurses to set up a protocol they all supported.

"Having the nurses and the physicians at the table together, it was a huge step. As a team, they agreed that this is what they were going to do," she said.

But it's not always easy for physicians to get behind working together as a team. "There are still some who feel that this move away from autonomy isn't the right one," Breyer said. To combat that, Poudre Valley presents data to its physicians that demonstrate how team-based approaches improve outcomes. "I think the feedback from data is very helpful," she said.

Team-based care can also slow down improvement efforts, Unger admitted. "Being very team-based, sometimes it takes a little longer for these initiatives to come into fruition, so we are working on more rapid improvements and making sure we are getting the right people at the table upfront so we are not wasting people's efforts."