Rising up: C-suite relies on chief quality officers through pandemic

Over the past two years, chief quality officers were thrust from often-underfunded and non-revenue-generating safety improvement work to driving how their hospitals would handle a significant healthcare crisis.

Quality departments—and their leaders—became stars. Hospital C-suites suddenly leaned on quality and safety infrastructure in a way they hadn’t before, because chief quality officers are trained to experiment, observe the results and make changes quickly.

Hospitals needed those skills, and safety officers coached operational heads to implement high-stakes transformations during the pandemic, including quickly shifting all care to virtual settings and setting up large-scale vaccine clinics in parking lots and hospital lobbies.

“In some ways, (the pandemic) actually accelerated my leadership journey, and in other ways, I think it’s hampered it, because I couldn’t turn my attention to some of the (quality and safety) things because I’ve been the chief COVID-19 face for the past two years,” said Dr. David Priest, chief safety, quality and epidemiology officer at Winston-Salem, North Carolina-based Novant Health. “Before, all my time could be totally focused on safety and quality, but COVID-19 is this layer over everything.”

Analysis and action

Quality officers are trained to effect change. They analyze a large amount of patient and clinician data to suss out which departments are providing ineffective care or harming patients. Then they play a careful dance of gaining physician and nurse buy-in to alter practices.

As the pandemic started, New Jersey-based CarePoint Health’s Bayonne Medical Center faced the common problem of having very limited information on which COVID-19 treatments were effective. The hospital’s director of quality resources, Mary Jo O’Donnell, used in-house data to determine treatment efficacy, and reviewed where safety events were increasing or decreasing.

While her responsibilities shifted, O’Donnell still had to oversee visits from accreditation agencies and regulators. She said she grew as a leader delegating some of the responsibilities for these visits to others and growing comfortable in leaning on her colleagues.

“We were raised as quality professionals, especially when it comes to regulatory visits, to be that point person, and we became very adept at doing that,” O’Donnell said. “But it changed so much with COVID-19—it took a while for me to realize that no one person could do everything. I was part of a team.”

But as hospitals’ quality teams became more important, the staff’s usual work took a hit. Central line-associated bloodstream infections in U.S. hospitals had decreased by over 30% in the five years before the pandemic. In the second quarter of 2020, these infections increased by 28%.

Officials at Novant Health and CarePoint Health said they saw varying degrees of regression in several quality measures. At Boise, Idaho-based St. Luke’s Health System, catheter-associated urinary tract infections, patient falls and mortality rates increased. COVID-19 factored into the quality metrics due to patient acuity and changes to care.

Patients overall were sicker and less able to get up to use the bathroom, which meant nurses had to place more catheters, and for longer periods of time—setting the stage for more catheter-associated urinary tract infections.

St. Luke’s had to rely heavily on travel nurses, who weren’t trained in the system’s specific procedures in cleaning and maintaining catheters, and how long they should be left in. COVID-19 patients had to be isolated in individual rooms, with fewer checks from nurses to minimize exposure.

“We realized that even when you have to make such dramatic and frequent changes to workflows and staff, you can’t forget the basics because they will come back to haunt you,” said Dr. Bart Hill, St. Luke’s vice president and chief quality officer.

UW Health in Madison, Wisconsin, saw one-third of its annual expected central line infections occur in November alone. Workers also dealt with a much higher volume of patients than usual, and they had to cut corners. Most hospitals provide nurses with step-by-step instructions on how to insert a line to ensure there are no mistakes. But staff had far more tasks than they could accomplish.

“The staff said, ‘I know that if I scrub the (central line) hub for a little bit less, it’s probably OK, but not OK all the time. But you know, that’s the shortcut that I’m taking so I can take care of these other things that seem to be more important,’ ” said UW Health Chief Quality Officer Dr. Jeff Pothof.

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A holding pattern

Quality improvement projects also dried up. RWJBarnabas Health in New Jersey was almost three years into training 35,000 employees in high reliability, a system in which employees bring up potential safety issues to their manager immediately without fear of reprisal. But that work halted as front-line workers faced overwhelming challenges and the quality team pivoted to pandemic issues. For instance, the health system’s vice president of quality was suddenly tasked with reporting a deluge of COVID-19 data to federal and state agencies. Other quality staff had to pick up patient screening and food service work. The system saw sepsis rates increase and patient satisfaction scores fall.

“When you’ve got those kinds of numbers, all you’re trying to do is keep the wheels on the bus,” said Dr. John Bonamo, executive vice president and chief medical and quality officer at RWJBarnabas. “Sometimes trying new improvement projects is distracting because they have to learn new ways to do things. When you’re under that kind of stress, it’s no time to do that.”

Two years later, RWJBarnabas is restarting its shift to a proactive rather than reactive culture. As omicron fades, quality officers are reviewing how COVID-19-forced innovations and efficiencies to find new paths for safety.

Dr. LeWanza Harris, vice president of quality and regulatory affairs at eight-hospital Mount Sinai Health System in New York, reconfigured the execution strategy for the organization’s annual 10 safety goals of the year.

In the past, each hospital chose how to implement system-wide improvement goals without a coordinated effort. They utilized the same data team resources, but in different, inefficient ways, she said. Now, Harris is creating one system-wide, multidisciplinary committee that creates one quality-improvement strategy for each goal. Every hospital has one person within the group to deploy methods at their home facility, along with a quality improvement specialist.

“I see it as a best practice to come up with a system-wide approach to address issues like what we had to do during COVID-19,” Harris said. “That has been a silver lining for a lot of institutions: to know that yeah, we can do it this other way.”

At UW Health in Wisconsin, the C-suite has gained greater knowledge of what Pothof and his quality team are capable of. Recently, they’ve been tasked with a project to move the organization onto a list of top hospitals, which traditionally would have fallen to a marketing or business strategy team. But behind the ranking is their expected-to-observed mortality rate, which involves better patient documentation to account for comorbidities and other factors. That kind of work closely mirrors risk adjustment for readmission scores and other quality metrics.

“This pandemic might have elevated quality and safety to a point where (executives) are maybe more invested, because I think people will start to connect the dots,” Pothof said. “From a typical CFO budget sheet, you’re this big expanse because you’ve got all these people, but you’re not actually bringing in revenue. But I think they saw what happened during the pandemic, and that quality and safety are the folks who have the skill set to lead us to (strategic work).”