EXECUTIVE SUMMARY
As more hospital-based organizations create the position of chief quality officer, the CIOs in those organizations are finding opportunities to work with these new chief quality officers to leverage clinical IT for exciting new initiatives around improving patient safety, care quality, and clinician effectiveness.
“Joined at the hip.”
That's how Mary Reich Cooper, M.D., J.D., senior vice president and chief quality officer at the four-hospital Lifespan Corp. in Providence, R.I., describes her relationship with senior vice president and CIO Carole Cotter.
“We talk every day. We work very closely on almost every initiative,” Cooper adds. “And the main reason for that is that Carole and her team have done a superlative job of developing an IT infrastructure that is the underpinning of our ability to design for quality initiatives.”
From Cotter's perspective, the creation of a chief quality officer (CQO) position at Lifespan, and Cooper's arrival three years ago, invigorated the organization's quality program. “I now know that I have a strong ally who believes in using technology to achieve our strategic objectives,” she says. “We knew there were financial reasons to be meaningful users, but we also knew that we could focus on meaningful use to improve quality, so we have embraced it as an opportunity to work on standardizing data.”
The position of CQO is relatively new, but is becoming increasingly high-profile, and CQOs' partnerships with IT leaders are leading to impressive efficiency and patient safety improvements.
Health system quality management has changed considerably in the last decade. The scope of quality management activity required to even begin to eliminate harmful medical and clinical errors requires expertise in process improvement, evidence-based care, and informatics, notes Scott Hodson, a principal for Maverick Healthcare Consulting, which has offices in Atlanta and Omaha, Neb. “Hospitals and health systems known for their high quality choose to invest in a full-time CQO to manage the effort,” he adds. “To fulfill their role, it is essential that a close and effective working relationship exist between CQO, CIO, and chief financial officer (CFO).” (Hodson says the CFO should be in the loop because organizations that are unable to quantify the return on their investment in quality management risk having that function being viewed as purely a “cost center,” and they could suffer significant cuts in funding at a time when they are most needed.)
The CQO, CIO, and their staffs must work together on a daily basis to develop, implement, and maintain the technologies that are required to provide caregivers with the information they require, Hodson adds. The information, whether it be in the form of “alerts” such as drug-drug interactions, or out-of-range lab results, or in the form of computerized physician orders or clinical pathways, must be correct and effectively accessible and presented in a manner that is easily used at the point of care.
In addition, now that quality improvement is much more data-driven, chief medical information officers (CMIOs), who often came to an organization to work on the implementation of a clinical information system, are stepping up into these CQO roles, notes Arlene Anschel, senior consultant in the IT practice of Oak Brook, Ill.-based executive search firm Witt/Kiefer. “They see it as a way to continue and realize the value of their initial work to improve patient care outcomes and safety.”
And as Anschel's colleague Linda Hodges, vice president and IT practice leader at Witt/Kieffer, notes, projects involving IT and the CQO “provide a realization to the organization that the investments in automation are worthwhile, and that is a good thing for the CIO.”
THE HUNGER FOR QUALITY DATA
At The Children's Hospital in Aurora, Colo., the close working relationship between Vice President and CIO Mary Anne Leach and CQO Dan Hyman, M.D., is an outgrowth of several business drivers. “The hunger for quality data in research and quality initiatives is expanding rapidly,” Hyman explains. “We have worked hard to embed those data elements from the EHR into the priorities of those groups responsible for our quality infrastructure. We are trying to be supportive of what they need at the local level to be proactive on patient safety. It can't just be central functions steered from IT or my group.” For instance, groups responsible for pulmonary disease have different measures and needs from those responsible for bowel disease. Hyman says the hospital needs the electronic records to provide information to both groups, and have it captured in a way that is consistent with their workflow. “That is the challenging part,” adds Hyman, who came to Children's two years ago in a newly created position of CQO.
IT WORKED WITH US TO CREATE A SCREENSAVER THAT POPS UP WITH REMINDERS FOR THAT SPECIFIC PATIENT, SO IT IS FRONT AND CENTER FOR THE NURSE.-SAMUEL FLANDERS, M.D.
Leach says Hyman has done a great job of creating a quality culture and working with executive committees on understanding the importance of embedding it in the hospital's work.
She and Hyman are working together on a business intelligence platform that they believe will make the quality reporting easier and faster to do. “Right now we are doing some of it with chart abstraction and a lot of hunting and gathering for data,” she says. Less than 5 percent of U.S. hospital systems currently have an enterprise business intelligence program, but Leach and Hyman are convinced they have the organizational readiness and the business drivers in terms of academic research and accountable care organization projects to make the investment.
The two have developed a cross-governance partnership to improve priority-setting for the organization. Hyman sits on the main IT steering committee, the EHR governance group, and the enterprise data warehouse group. Leach also tapped Hyman to be the executive sponsor for meaningful use programs because it really is about clinician utilization of the EHR, and she may ask him to get involved in the hospital's ICD-10 initiative.
“On the flip side, I attend many quality and patient safety council meetings, so we support each other,” Leach says.
“We have IT representatives involved in a number of quality initiatives,” Hyman adds. “We are thinking beyond the availability of data. We are just at the beginning of how the EHR is going to transform how healthcare is delivered.”
Beyond just having all notes available and legible 99.8 percent of the time, Hyman says, “the real impact of the EHR is creating a clinical decision support infrastructure.” In fact, Hyman and Leach recently moved one person from IT to the clinical quality group to help the group develop clinical support tools.
CIO, CQO ON THE SAME PAGE
At Beaumont Hospitals in Royal Oaks, Mich., Samuel Flanders, M.D., senior vice president and chief quality officer, and current Vice President and CIO Subra Sripada started on the same day two years ago, and met at the new-employee orientation. “We bonded right away because both of us were ‘newbies,’” Flanders recalls. But Flanders, who joined Beaumont in a newly created CQO position, also soon learned that Sripada believed that the main reason to do automation projects is to improve quality, “so we were on the same page,” he says.
Both executives stress that gathering and comparing retrospective data is important in terms of helping the three-hospital system measure and prioritize its quality efforts, but they are even more excited about implementing and creating tools to help flag events in real time to prevent errors before they happen, including their ongoing computerized physician order entry (CPOE) implementation.
They describe a recent project that created a nursing dashboard with reminders for nurses. “For certain patients, nurses must give pneumonia shot before they leave,” Flanders explains, but that can be difficult to remember. “IT worked with us to create a screensaver that pops up with reminders for that specific patient, so it is front and center for the nurse. We have found that has had an impact on our numbers in terms of exception tracking.”
The dashboard provides real-time feedback to nurses, Sripada says. “It is proactively feeding nurses' information, and is making a huge difference. It was an idea based on our previous experiences and built in-house.” Flanders is a problem-solver who follows staffers around to better understand issues, such as nursing ergonomics and computer use by emergency room physicians. In many cases he relies on Sripada to help develop automation options.
WE ARE TRANSFORMING THIS ASPECT OF THE CLINICAL ENTERPRISE, BUT IT IS STILL A WORK IN PROGRESS.-MARY REICH COOPER
One current enthusiasm they share is the potential use of iPads by emergency department doctors.
Six months ago, Beaumont began to work on the 15 meaningful use quality measures under the federal American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act. They created a team, led by the CMIO, who reports to Flanders, to build tools to gather the data. “We have two more to finish up,” Sripada says, “but expect to be completely ready to demonstrate it soon.”
Flanders and Sripada also created a multidisciplinary EMR optimization team that includes quality staff, IT employees, as well as nurses and physicians. The team collects suggestions for ways to improve within the EMR the organizational uses, from the Verona, Wis.-based Epic Systems Corp. “We have to connect the dots between those suggestions and our initiatives around quality, safety, and efficiency, and then prioritize and fast-track those efforts,” Sripada says. “This is having a great impact, because physicians can see their ideas being adopted, and they know they are being listened to, which makes them more willing to contribute more ideas.”
THE IMPORTANCE OF PROSELYTIZING
Mary Reich Cooper says one of the challenges involved in taking the position at Lifespan three years ago was that the organization had not had a previous CQO, so she had to establish the role within the organization's strategic framework.
She describes proselytizing the importance of electronic data standardization and reporting as a big part of her job.
Cooper, who previously was CQO at New York Presbyterian Hospital, regularly meets with every clinical department and has set up a quality council structure system-wide. There are quality teams around topics such as infection control, ICU care, emergency department care, and behavioral health.
“That's how we make sure this meets the needs of physicians,” she says. “Just yesterday, I was talking with emergency department staff about meaningful use criteria on tracking medication orders. In a high-paced environment, we have to make sure we have solutions that work for them, and that they have a feeling of empowerment. That's how we were able to roll out nursing documentation at four hospitals in three months-because they felt part of the development of it.”
Cooper and CIO Carole Cotter are both excited about the potential for getting data from structured fields in their Siemens Invision EHR (from the Malvern, Pa.-based Siemens Healthcare) without depending on interventions by abstractors to pull information from charts.
“We have one hospital that has more than 20 full-time-equivalent employees just doing chart abstraction,” Cotter says. “We see freeing them up as a huge opportunity to help with quality projects.”
Cooper predicts that over the next decade, data reporting will move closer to becoming an “almost just-in-time” capability, much the way clinical decision support and closed loop medication administration provide alerts now. “We are transforming this aspect of the clinical enterprise,” she says, “but it is still a work in progress.”
Healthcare Informatics 2010 November;27(11):24-28
