The Rise of Quality Improvement at Stanford
Photo caption: Ann Weinacker, MD (left), Interim Chief Quality Officer, and Lisa Freeman, Interim Vice President of Quality, Patient Safety and Clinical Effectiveness, lead Stanford Health Care's quality efforts.
US News & World Report ranked Stanford as one of the top 10 hospitals in the nation in 2017, placing it ninth, up from 14th just a year ago. Hospital Compare, which looks at medical data on Medicare patients, awarded Stanford four stars. These outstanding marks reflect the level of care that Stanford strives to deliver. But at the same time, a scoring system that uses more current patient data saw Stanford drop in key quality measures such as mortality and hospital-acquired infections. Vizient—formerly known as the University HealthSystem Consortium—ranked Stanford 71st out of 107 similar hospitals, down from Stanford’s ranking of 42 last year.
“Stanford always strives to provide the highest quality care in a very safe environment for our patients,” said Ann Weinacker, MD, Interim Chief Quality Officer. “As we look at each of these ranking systems, we see opportunities to improve the value of the care we deliver.”
Over the past five years Stanford has launched a lean management system to reduce waste and inefficiency. It created quality improvement training courses to give employees at every level the tools they need to conduct improvement work in their own areas. It developed high value care teams to reduce the variability of surgical care and recovery. It launched C-I-CARE to improve the patient experience. It created Unit Based Medical Directors partnering with Patient Care Managers to lead quality studies. This all-out approach set the foundation for the more targeted work being conducted today.
“We have been painting quality with a broad brush,” said Weinacker. “The Vizient report focuses our efforts, and forces us to pay attention to areas where we need to improve. It uses the most current data, which makes it the most actionable measure to follow.”
How are we going to improve?
Today, the quality effort is a targeted assault at every level of the organization. It is led by Weinacker and Lisa Freeman, Interim Vice President of Quality, Patient Safety and Clinical Effectiveness, under the direction of Chief Medical Officer Norm Rizk, MD. At the highest level, President and CEO David Entwistle has partnered with Lloyd Minor, Dean of the School of Medicine (SOM) and Christopher Dawes, President of Stanford Children’s Hospital. These three leaders formed the Safety, Quality and Value Committee to enhance the improvement capability of their respective clinical and administrative staff. At the departmental level, the SHC quality team has deployed specialists, invested resources and provided data to help inpatient units, outpatient clinics and every SOM department in leading efforts to improve the value and safety of the care they deliver.
“In a much more tangible, measurable way, we are engaging faculty from the department chairs to the front-line clinicians and unit-based medical directors and their patient care managers in achieving both departmental level goals and unit-based goals in achieving quality,” said Freeman.
Every department was given a standardized list of quality improvement opportunities from which to develop plans. These efforts target key measures set by SHC and SOM leadership—observed to expected mortality, length of stay, cost and the patient experience—measures that are equally important to patients and their families.
Already, these efforts are paying off. High value care teams in colorectal, pancreatic, spine and gyn-onc surgery have begun to reduce variability of care and length of stay by creating new Enhanced Recovery After Surgery (ERAS) care pathways that are patient-centered, evidence-based, integrated and multidisciplinary. The goal of these efforts is to reduce a patient’s surgical stress response, optimize physiologic function and facilitate recovery.
A second system-wide quality effort involves improving Stanford’s accuracy in documenting the complexity of its patient population. This effort will help improve the “observed to expected mortality rates” measure, in which Stanford currently ranks below the national average.
Hospital-acquired infections is another area identified for improvement. A team in the E2 ICU has significantly reduced the rate of catheter-associated urinary tract infections by considering alternatives to catheterization and managing the length of time patients are catheterized. Their efforts have proven so successful that new protocols are being implemented hospital-wide.
What do the rankings mean?
US New & World Report, which ranked Stanford ninth among top hospitals in the US, analyzes data from nearly 5,000 medical centers and survey responses from more than 30,000 physicians. It ranks hospitals in 16 specialties from cancer to urology, and looks at survival rates, patient safety, hospital structure, specialty staff and hospital reputation. Hospital Compare uses Medicare patient data on 57 different quality measures. Vizient looks at multiple domains—survival, safety, patient experience, effectiveness, efficiency and equity—and benchmarks Stanford’s performance against other similar institutions.
While all three of these ranking systems look at similar quality measures, they differ in the weight they give to each measure, and in some of the categories they analyze. For example, US News’ ranking relies heavily on hospital structure and reputation, two factors that are not part of the Vizient ranking system. Vizient, instead, attributes more than half of its score to patient safety and mortality.
For the Stanford quality team, the Vizient ranking has become its best instructor. “It shines a light on areas we need to improve,” said Weinacker. “That is why our quality improvement efforts are guided by these relevant data, and target measures where we score lower than the national average – such as mortality and hospital-acquired infections. These are all very concrete, actionable data highlighting things that we can change.”