"The context of the organization is owned by the c-suite. You are responsible for the context of care, meaning the environment, the culture, the behavioral standards, the organizational values," says Gelinas. "The content of care is owned by the caregivers. When it comes to transforming care at the bedside, taking waste out of work, that's what caregivers have to do and that's the content of care."
Gelinas equates c-suite involvement in provision of care decisions as akin to a radiologist trying to do heart surgery. What is far more important is that leaders devote their energies to leadership, cultural transformation, ensuring the organization enforces standards of behavior and codes of conduct, and that the values of the organization are in alignment with its mission.
"The hammer has fallen," says Gelinas. "First we had the tsunami of value-based purchasing and the realization we have to have whole-scale transformation to be successful. After that comes awareness. Now, what is the work that has to be done and where do we start?"
In the old days, if a nursing unit noted its rate of ventilator-associated pneumonia (VAP) was above average, it would start a quality improvement project. The traditional process would involve convening a team, figuring out a strategy, and implementing some tests of the changes. As rates improved, the hospital would celebrate, figure out how to maintain the improvements, and then move on to the next quality improvement project.
"It used to be that we could focus on quality improvement and if we got to a point where we had a 3% reduction in VAP we would be so happy," says Gelinas. "Now with value-based purchasing that's not good enough. Now it's about whole-scale transformation, not incremental improvement, and this difference is what has everyone's attention. Where do we start when we know the game's changed?"
As hospitals scramble to improve HCAHPS and quality outcomes all areas of the hospital are involved. Determining who should be responsible for what is a good first step.