Quality: Challenges from Within

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Many healthcare quality leaders see themselves as being proactive—taking steps quickly to save time, money, and patients' lives. Sometimes, though, they bump up against institutional or cultural roadblocks. In some cases, leadership support is lacking, and in some cases, our survey shows, what is lacking is courage.

In the HealthLeaders Media Industry Survey 2010 of quality leaders, one area that shows a significant change from last year is the growing consensus that handwashing is the single best way to prevent the spread of infection, which jumped from 72% last year to 85% this year. All other methods, which received very little response last year, dropped even more this year: rapid testing on admission (down from 3% last year to 1%); isolation of patients diagnosed with infection (from 4% to 3%); adherence to safe procedure protocol (from 16% to 9%); and aggressive cleaning with solutions (from 3% to under 1%).

This year we asked quality leaders what is behind the failure to achieve compliance in handwashing. The top reason selected: "lack of spine to self-police and report colleagues' violations," cited by nearly 40% of those responding. Lack of leadership to make handwashing a priority was next highest, selected by 29%; another 19% noted lack of adequate penalties, and 12% said lack of convenient access to appropriate supplies was a factor.

Making a dent in this infection control issue requires both leadership combined with teammanship as well, observes Glenn Crotty, Jr., MD, executive vice president of the Charleston (WV) Area Medical Center. CAMC was one of 32 hospitals receiving top performer status in 2009 in the QUEST program, a three-year project developed by the Institute for Healthcare Improvement and Premier to promote safer, cost-efficient care.

Crotty noted that it's easy to get distracted in the hospital environment. "But that's not the issue. It is getting to the human factors piece of distraction: How do you reliably have a system that says: 'Stop. Wash your hands'?" he said. That's where a team approach within the hospital helps individuals easily speak up and say: "'I didn't see you wash your hands . . . You need to wash your hands.'"

Keeping this in mind, workplace culture is exerting influence on the quality environment—but sometimes in the wrong direction. It was seen as a major barrier this year among 22% of those surveyed—up more than 4 points from the year before. However, overall, the trend is more positive. Those saying that workplace culture is no barrier rose 8 points, to 18% from 10%, and those citing it as a moderate barrier declined about 14 points, to 26% from 40%.

Quality leaders, though, were less likely to view workplace culture and morale in as rosy terms as hospital CEOs. For instance, only 18% of quality leaders saw the culture/morale as very strong, compared with 27% of CEOs; 33% of quality leaders thought it was slightly strong compared with 45% of CEOs. As for the observation that culture/morale was very weak, 13% of quality leaders agreed versus 2% of CEOs.

Despite these concerns about culture and cooperation, quality leaders indicate that leadership is not a serious obstacle. Thirty-eight percent said leadership is no barrier to achieving healthcare quality for patients at their organizations, an improvement from last year's 30%. Only 5% said leadership is a major barrier, a drop of about 2 points from last year.

At the two-hospital Poudre Valley Health System, headquartered in Fort Collins, CO, communication, collaboration, and support is viewed as important throughout all levels of the organization by leadership.

At Poudre Valley, a 2008 Baldrige Quality Award winner, "I would say one of the most important things that's happening is that we are working on information exchanges—ways to make what we are doing transparent to the end user and to the patient providers," said the health system's CEO and president, Rulon Stacey, PhD. "We've just got to make sure that everybody knows what everybody else is doing—without violating HIPAA laws."

Janice Simmons

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