talking about a bad surgical outcome used to be a strictly confidential matter that could make even the most stoic surgeon bristle. "It was a big deal to ask an attending surgeon to talk openly about a complication," says former chair of surgery Sean J. Mulvihill, M.D. "There was a lot of fear."
So when Mulvihill announced to the department that they were going to document every complication and adverse outcome, discuss them openly at weekly meetings, and report them to a national database, there was some pushback. To allay the angst, Mulvihill made his intentions perfectly clear: "I told my staff that this wasn't about getting anyone fired. It was about quality improvement."
Mulvihill proved his point by openly discussing his own complications during weekly Morbidity and Mortality (M & M) meetings, and changed the word complication to occurrence. "The tone of the conversation was never punitive," says surgical clinical reviewer Judy Larsen, R.N., who was tasked with the delicate job of collecting and distributing the data to the surgeons and bringing every occurrence to M & M meetings. "It was always educational."
Mulvihill wanted his department to lead the way in establishing greater transparency to improve surgical outcomes. The new protocols were part of joining a pilot program to test the National Surgical Quality Improvement Program (NSQIP) in the private sector. In 2001, University Hospital was one of 18 hospitals to join NSQIP, which was developed by the Department of Veterans Affairs and the American College of Surgeons.
A few key factors helped create buy-in among his staff. The metrics were created and defined by surgeon colleagues. Definitions of outcomes were specific and consistent. The data were impartially analyzed through a central database and risk-adjusted to account for sicker patients. In other words, NSQIP created meaningful data that the faculty trusted. The most persuasive factor, however, was seeing firsthand how the process helped improve patient care.
When NSQIP data showed that the surgery department was a high outlier in postoperative urinary tract infections (UTIs), Rob Glasgow, M.D., section chief of gastrointestinal surgery, led a multidisciplinary team to make procedural changes in catheter management. The next time NSQIP data came out, our surgeons and staff had reduced postoperative UTIs by 75 percent. By NSQIP standards, we went from a 10 (the worst) to a 4 (better than half of the participating hospitals). "This was about real people having better outcomes," says Glasgow, who is now the NSQIP Surgeon Champion. "We had to create a culture of critical appraisal to know where we could improve."
The department took transparency even further by opening its weekly M & M meetings to residents, nurses and students. "It's an excellent teaching opportunity," says Larsen. "And now it's just automatically assumed that when we have an outlier, not just one faculty member but a whole team of people, including residents, will take it on," says Larsen.
The department also expanded the conversation to include issues of professionalism, honest disclosure and positive communication to engender trust in patients. As the move to transparent quality improvement became a fully accepted part of the department's culture, uncertainty and fear were replaced with a common sense of purpose that everyone could embrace. "The essence of quality improvement is something we all buy into," says Mulvihill, who is now the associate vice president for clinical affairs and CEO of the physician group. "At the end of the day, we all want better outcomes. We all want to be proud of what we do."
Ashworth, a board-certified physician in adult psychiatry and child and adolescent psychiatry, had returned to University Neuropsychiatric Hospital (UNI) to help out with the crushing load of patients in the acute child and adolescent unit. He was working time and a half to try to keep up. So the performance meeting and abysmal patient satisfaction scores were a little confusing to him. He was supposed to be the good guy.
What Ashworth didn't realize was how much the culture had changed since he had left five years earlier to work at an outpatient clinic. The transition started with a clear mandate from Lorris Betz, M.D., Ph.D., former senior vice president, to improve the patient experience throughout the system. At an all-staff UNI meeting, he called upon each and every individual, from physicians to housekeepers, to change the patient experience from "good" to "exceptional."
UNI had tried to do this before. The staff was on board but the physicians weren't engaged. The difference this time around was that it was a mandate from the top. At the center of the strategy was a commitment to benchmarking provider performance with total and complete transparency.
"We called out physicians by name and didn't apologize for it," says VanVranken. The facility also created a new standard: all providers were required to improve their patient satisfaction scores to 90th percentile or higher.
At first, there were naysayers. "People felt it was just another marketing thing. They said, ‘Don't tell us how to practice medicine,’ recalls VanVranken. They also felt that the data didn't account for how difficult and sick some of their patients were. But VanVranken paired each doubter with a "physician champion" who had both complicated patients and high satisfaction scores. "Senior leadership gave us the impetus to change," says VanVranken. "We also needed informal peer leaders who could encourage and motivate their colleagues."
With such an impossibly low score, Ashworth could have dismissed the metrics altogether. But instead, he saw it as an opportunity to reevaluate his practices. "I wasn't trained in this culture, so there was a learning curve," says Ashworth. "The culture had gotten it down, and I wanted to find out what others were doing that I wasn't. So I looked at my colleagues who were really in tune with patient satisfaction, and I tried to emulate what they were doing."
Ashworth didn't see the push for provider transparency as an abstract institutional goal. In his mind, it was about creating a positive place for patients, so that if they got sick again, they would be more willing to seek treatment. "We really have only one chance with some of these patients," says Ashworth. "We have to make sure we get it right." And that's precisely what Ashworth began to do. In just one quarter, his patient satisfaction scores rose from the first percentile to the 92nd percentile, and have stayed there.
"I think if you tell physicians, ‘We want to be the best in the world,’ that's something we can all get behind," says Ashworth. "I knew we could do it, and I wanted to be a part of it.&qout; Ashworth has been a great leader, VanVranken says, and has helped bring all of the child psychiatrists into the mid-90th percentile.
As patient satisfaction scores throughout the facility began to rise, staff became obsessive about looking for their scores and their peers’ scores on the unit. "Now, it's really competitive," says VanVranken. "Everyone wants to be the star employee."
Today, UNI enjoys record-high patient satisfaction scores, and the transformation is palpable. "Doctors get tears in their eyes when we talk about patient satisfaction," says VanVranken. "It's like a love fest around here. It's really a team deal. It's the best staff we've ever had."
Let patients grade us and post the scores online, the good, bad and ugly? Are you crazy? This wasn’t the verbatim response of doctors to University of Utah Health Care’s push to publish patient satisfaction data on its Find-A-Doctor website. But it’s pretty close.
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