For better outcomes, health systems invest in quality and safety workforce

The COVID-19 pandemic has posed a national challenge for health system staff who work in quality and safety.

These workers are tasked with assessing issues and implementing improvement strategies in a wide range of areas, such as reducing surgical site infections and readmissions, ensuring smooth transitions to post-acute care, and boosting communication between staff and patients.

But some responsibilities have fallen by the wayside during the public health crisis, as quality-focused employees have left organizations or been tapped to help with care delivery. The ensuing gap in expertise could lead to lower quality scores—which affect federal funding—and cause health systems to miss out on potential savings.

“The ability of healthcare organizations to sustain their overall performance and clinical care quality, safety and efficiency has been tested by the degree of turnover and short staffing,” said Dr. Read Pierce, chief of the hospital medicine division and associate chair for faculty development and well-being at Dell Medical School at the University of Texas at Austin.

To strengthen quality efforts, health systems are using data and external frameworks to identify organizational areas for improvement; creating systems that better support quality management; and investing resources into employees’ ongoing professional development.

One major step toward supporting quality work is identifying existing gaps in proficiency levels among staff members, said Stephanie Mercado, CEO and executive director of the National Association for Healthcare Quality.

The organization’s Healthcare Quality Competency Framework defines eight “domains” as necessary for a high-functioning quality program. In a nationwide assessment published this month of more than 2,500 healthcare professionals with quality and safety responsibilities, NAHQ discovered that workers generally perform fewer activities, at a less advanced level, in the areas of health data analytics, professional engagement, and quality review and accountability when compared to other domains.

Staff reported middling average proficiency levels when it came to responsibilities regarding performance and process improvement, population health management and care transitions.

But there were some bright spots, in the domains of patient safety; regulatory matters and accreditation; and quality leadership and integration.

“Realizing that the workforce is tilted in three directions at the expense of the others was a big ‘aha moment’ for us in creating this report,” Mercado said.

Organizations must show proficiency in all eight of the domains to achieve high-level quality outcomes, according to Mercado.

“All of those things are what makes healthcare better, and if you’re just doing a few of them, you’re missing the opportunity to take quality to the finish line,” she said.

The results of the assessment demonstrate the need for health systems to focus on the more forward-looking elements of quality work when hiring and training workers, she said. Too often, health systems’ quality programs are developed on the fly, without regard for long-term funding or staffing plans.

“We want to make sure that people are expanding and acting on quality in the broadest context, that we are not isolating quality functions by department, or into clinical and nonclinical silos,” she said.

Many quality workers have learned their responsibilities on the job without any formal training, said Dr. Taryn Kennedy, chief quality officer at Bon Secours Mercy Health, based in Cincinnati.

Bon Secours Mercy participated in NAHQ’s Workforce Accelerator program, which allows organizations to use the association’s competency framework to identify areas where employees need the most support. Upon seeing that its quality departments lacked experience in performance and process improvement, the health system started pairing employees to work on projects in that domain.

“There were a lot of people who wanted to do the work but didn’t even know where to start,” Kennedy said.

Oakland, California-based Kaiser Permanente budgeted time and funding for its quality workforce to participate in the program.

“We present [the assessment] as a gift, not tied to their remuneration or their annual performance, but rather for each individual to use to better identify how they want to learn and grow,” said Robin Betts, vice president of safety, quality and regulatory services for Kaiser Foundation Health Plan and Hospitals in Northern California.

Using NAHQ’s framework, Kaiser creates internal profiles detailing all the requirements and competencies necessary for specific positions. For example, a specialist focused on quality assurance and quality projects must be able to perform statistical analysis and develop policies and procedures in compliance with accreditation and standards organizations and the government.

The health system offers mentorship opportunities, an advanced safety management training program and a quality professionals fellowship program to help individuals develop necessary capabilities.

To address gaps in organizational competency, health systems can establish a chain of command and split up responsibilities more efficiently.

Before its leaders began putting resources toward revamping its quality program, Alameda Health System was in a tough spot. In 2020, the San Francisco Bay Area public health system received low hospital safety grades from the Leapfrog Group and five condition-level findings from the Joint Commission accrediting body, leading to a preliminary denial of accreditation and palpable tensions among staff.

Nearly 3,500 employees went on strike in October of that year, citing underfunding, unsafe conditions and worker shortages. In turn, Alameda County supervisors called on the health system’s board of trustees to resign, with five members departing; the system’s former CEO submitted his resignation toward the end of 2020.

“These were many of the elements that led me to consider an exit myself, wondering whether this was the right place for me,” said Dr. Taft Bhuket, chief of gastroenterology and hepatology, who was serving on the board of trustees at the time. Now board president, Bhuket said, “It was the darkest moment I’ve ever felt in any single healthcare organization.”

Bhuket—and Alameda Health System—found relief when new leadership came in at the beginning of 2021. In addition to rebuilding trust and increasing employee engagement, the executives made it a goal to construct a quality division that combined central governance with greater support for front-line quality workers.

The system established a core quality team, along with committees in various departments that help manage quality concerns and communicate them to the board of trustees, Bhuket said.

“We’ve been very thoughtful about building a quality division, putting the right people in the right seats on the right bus,” he said. “We’ve tried to provide the tools to the quality team with which they can measure things and create an infrastructure for them to do their job.”

A particularly useful tool for Bhuket is the Midas Quality Management Monitor. Produced by Houston-based symplr, the software platform uses reports from clinicians to provide data on areas for intervention, analyze treatment outcomes and identify opportunities for improvement. Distributing responsibilities to caregivers and automating data production through Midas has streamlined work for the quality team and reduced much of their burden, Bhuket said.

We’ve been very thoughtful about building a quality division, putting the right people in the right seats on the right bus.”

Dr. Taft Bhuket, chief of gastroenterology and hepatology and board president at Alameda Health System

Still, the volume of potential quality defects—such as customer service complaints, patient reports of painful blood draws and prescription errors—can be overwhelming for the core quality officers in charge of addressing the issues.

To keep the process manageable, system leaders encourage individual teams to meet monthly and brainstorm ways to address staff-reported safety and quality events themselves, identifying areas for assistance if necessary.

Alameda Health is seeing results: It was able to move from D and F hospital safety grades in 2020 from Leapfrog to a B in 2022. It also began passing Joint Commission surveys with no condition-level findings; the accrediting body commended the health system on its efforts to ingrain equity in patient safety. Staff members also have expressed feeling more invested in creating a safe work environment.

But Bhuket said the system is still figuring out whether its mechanisms, committees and processes are serving its goal of becoming a highest-quality organization.

“It’s sort of like you’re building the airplane while you’re flying,” he said.

In addition to establishing an effective structure, empowering workers with professional development opportunities and the necessary resources to excel in their roles are important ways for health systems to sustain their quality teams, said Dell Medical School’s Pierce.

“The well-being of the people doing that work is just as important as the work they’re doing every day that informs metrics, outcomes and compliance with processes and regulatory standards,” he said.

At Chicago-based Northwestern Memorial HealthCare, every employee has a $1,000 budget to spend on career development, which can include professional organization memberships, continuing education or other expenditures. Workers focused on quality can put the funding toward a mandatory Certified Professional in Healthcare Quality certification to demonstrate their competencies in the field, said Cynthia Barnard, the system’s vice president of quality.

 

Good quality is cheaper, period. If we do it right the first time, it’s an investment in our future.”

Tami Minnier, chief quality and operational excellence officer and senior vice president of the health services division at UPMC

At UPMC, headquartered in Pittsburgh, thousands of employees have attended Wolff Learning Academy, an educational resource provided by the health system offering introductory courses, training sessions and mentored projects to help individuals grow their quality skills.

Support from health system leaders in the form of collaboration and necessary funding is crucial in helping quality employees succeed, said Tami Minnier, chief quality and operational excellence officer and senior vice president of the health services division at UPMC.

Quickly adapting to feedback is another major component. UPMC recently had to scale back an educational program created for its clinical care coordination team after hearing from team members that the training was overwhelming, according to Minnier.

To make the project more manageable, the health system broke up key subjects into shorter videos and set up a centralized call center for questions.

Investing resources toward quality improvement can lead to lower expenses down the line.

In her early days as a chief nursing officer at UPMC Shadyside, Minnier said she persuaded the hospital president to fund two quality-focused positions dedicated to process improvement.

Minnier said she helped save the hospital $600,000 in the first year by restructuring emergency department processes and creating an admissions team to save nurses time and reduce unnecessary inpatient tests.

She also reduced nurse overtime through changing documentation requirements and creating more efficient supply distribution and discharge processes.

Success means “understanding the connection between quality work and the actual overall long-term financial outcomes for your organization,” Minnier said. “Good quality is cheaper, period. If we do it right the first time, it’s an investment in our future.”

Health systems can also measure their progress through higher scores on national quality assessments, improved patient safety outcomes, and positive feedback from employees about infrastructure effectiveness.

Kaiser Permanente created predictive algorithms to assess how strategies are working. Quality teams monitor the tools and measure factors such as delays in treatment, central line infections or adverse maternal health outcomes, using the information to provide front-line staff with real-time information about care gaps.

In turn, to ensure quality teams’ data accuracy and consistent performance, groups of in-house Kaiser experts regularly conduct reliability testing and provide feedback.

Betts said the efforts resulted in reductions in inpatient mortality rates, intensive-care unit transfers and lengths of stay across the health system, along with improvements in staff engagement survey scores.

“Investing in people and processes dedicated to quality and patient safety accomplishes several things,” said a spokesperson for the National Committee for Quality Assurance, an accreditation organization. “In the short run, it alerts care teams to care gaps and helps them investigate patient-harm events and near misses. In the long run, it helps improve health equity. That’s because many quality teams are embedded in community health teams that improve care transitions and population health.”

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