An interview with Alan S. Kliger, MD
Kliger is YNHHS vice president and chief quality officer
What are some of the system's major areas of focus for quality?
YNHHS has two main areas of focus, and they're closely connected: Providing safe care, and enhancing quality and value.
How is patient safety linked to quality?
Safety is a major domain of quality. You can't have high-quality care without it being safe. Studies show that errors made in U.S. hospitals account for 48,000 to 96,000 deaths annually. To eliminate errors, Yale New Haven Health System has joined the Connecticut Hospital Association and other hospitals and health systems in the state on a journey to become high reliability organizations (HROs).
What is a high reliability organization?
HROs are defined as organizations that are able to avoid catastrophes, despite operating in complex, high-risk environments. An aircraft carrier is a good example. You have planes constantly coming in at high speeds, landing on short landing strips on a deck where hundreds of people are working. It's a huge opportunity for catastrophe, but by adopting a series of safety measures and error-prevention techniques, aircraft carriers have virtually no deaths or injuries.
How do high reliability organizations prevent errors?
HROs have several important characteristics: One is a reluctance to simplify. It's easy to say an error occurred because someone didn't know what he or she was doing. HROs understand that in complex situations, multiple factors contribute to errors. A second characteristic is sensitivity to operations. You need to understand what's going on at the ground level, with frontline staff, to change your systems and make them safer.
What other characteristics do HROs share?
HROs are resilient. Errors occur, but unless we're able to understand what happened and bounce back, the next patient is at risk of getting the short shrift because we're preoccupied with our previous mistake. Also, HROs recognize that expertise exists at every level of an organization, so we need to listen to the opinions of everyone, from nursing assistants to attending physicians to housekeeping staff to residents, in order to keep patients safe.
What are some of Yale New Haven Health System's major quality initiatives?
The system has adopted the Institute for Healthcare Improvement's Triple Aim model, which seeks to improve quality in three areas: (1) improving the patient's experience of care, including providing a safe environment, (2) better health for the community and (3) higher-value, lower-cost care. Our high reliability work and efforts to reduce hospital-acquired infections come under the safety umbrella.
How can the system and its delivery networks improve health in our communities?
Through clinical integration. Physicians and other care providers throughout the delivery networks and communities must work together to coordinate people's care, from preventive services through treatment for serious illnesses and beyond. Yale New Haven Health System has created a Clinical Integration department to lead these efforts.
Why is it important to provide higher-value care?
Beyond the benefits to our patients, the amount of reimbursement Yale New Haven Health System receives from the federal government depends in part on our ability to provide lower-cost care, without sacrificing quality. Previously, CMS (Centers for Medicare and Medicaid Services) reimbursed hospitals a set dollar amount for caring for patients on Medicare or Medicaid. With healthcare reform, the government began tying reimbursement amounts to care quality.
How are hospitals' reimbursements calculated under the new system?
Hospitals can get reimbursement bonuses or penalties depending on whether they meet certain core measures — for example, if patients with heart failure received specific treatments. Reimbursements are also tied to readmission rates and mortality rates. Hospitals can be penalized if patients are readmitted within 30 days for certain conditions. Finally, reimbursement is tied to patient satisfaction, as measured by HCAHPS scores.
How do we keep track of how we are doing?
To monitor our progress on safety and quality improvement, YNHHS recently began using a score card that shows how we're doing on core measures; readmission, mortality and infection rates; transitions of care; and serious safety events. This report shows us whether our improvement efforts are yielding results.
Beyond providing excellent patient care and service, how can employees help improve safety and quality?
A culture that supports quality and safety is one that values the experiences and opinions of everyone in the system. Employees are critical to our success, which is why every employee will be trained in key safety habits the Connecticut Hospital Association has identified. One of those safety habits involves encouraging a questioning attitude. This means empowering everyone to speak up when they're not sure if something is right. If you see something, say something.