Building a Transformational Quality Programme

By Cynthia L Deyling, MD, Chief Quality Officer, Cleveland Clinic, Cleveland, Ohio

The need for transformative change in healthcare has never been greater. We face pressures from regulators, payers, and patients to provide safe, high-quality, affordable and accessible care. Every healthcare organisation is trying to respond to this change, though the results vary. We seek to change processes, meet goals, and enhance culture. But, we face a paradox: the outcomes we strive for rely on excellent teamwork and collaboration, but our structures are steeped in silos and fragmentation. Transforming healthcare requires altering how we work. Let me share our journey. We realised that an organisational model was needed to support the highest quality care across our integrated care model. At Cleveland Clinic, we established a specific function, called Clinical Transformation, to coordinate efforts around safety, quality, patient experience, and continuous improvement.

Our charge was to support the integration of our health system, ensure collaboration, and provide consistent tools to make it easy for caregivers and leaders to interact with subject matter experts. These centralised resources support our regional hospitals and clinical institutes to drive quality outcomes and serve our patients. 

Nursing partners and administrative support are catalyst to build local capacity for improvement. Patients are also an important partner in this work — inviting, listening and acting on their input helps us achieve better, quality outcomes.

While building this structure, we know that the resources are finite. Prioritisation is critical. To determine our priorities and measure progress, our work is carefully aligned to a Strategic Agenda Management process. This process engages stakeholders from across our health system in reviewing our mission — care of the sick, investigation into their problems, and education of those who serve — and establishing specific goals and priorities that define our work as an organisation. Safety and Quality goals are instrumental in this structure, and help prioritise where and how Clinical Transformation resources work. 

These goals and targets are created with our stakeholders from across the system, including our academic main campus and regional hospitals. We engage clinicians, administrators, quality professionals, and patients to help us define and set our priorities and our agenda. While we review comparative benchmarks and publicly reported measures, our goals must ultimately remain true to our mission.

Monitoring our progress and identifying performance gaps are essential. As such, area specific scorecards and dashboards were developed to measure progress and hold local leadership accountable to their metrics. Through monthly operating reviews with executive leadership, we can gauge progress, celebrate successes, and identify and remove barriers to success. Transparency of the dashboards across institutes, hospitals, providers and departments, allows us to readily identify high performing areas and share best practices. And a healthy competition certainly provides motivation to continuously improve.

High reliability principles are also critical toward achieving our goals. We have partnered with the Joint Commission to master the three components of high reliability: leadership commitment, safety culture, and robust process improvement.  As leaders, we must commit to zero harm, which is reinforced through our strategic agenda, leadership meetings, and local venues. Our goals are aligned with these concepts and tied to aspirational targets for safety and harm events. Our safety culture is built on the premise that any caregiver can speak up and report safety concerns and our engagement survey results indicates this is working. Equally important to strengthening our safety culture is supporting our leaders through training and skill building. Finally, we use data-driven problem solving to drive quality and performance improvement. Developing an internal improvement model and deploying various tools, such as Lean and Six Sigma, to our frontline clinical and administrative teams are a few examples. Above all, we recognise that improvement efforts must be driven by our frontline – those that are closest to the work, know best how to improve the processes. As our high reliability practices broaden and evolve, we continue see encouraging results in our outcomes, and there’s a noticeable correlation between safety culture, caregiver engagement, and clinical outcomes.

Driving this culture requires involvement throughout the organisation, including our most senior leaders. Fortunately, our CEO and board members are committed to quality and safety. This commitment extends to our Board of Directors who uphold a responsibility for quality at Cleveland Clinic by actively participating in leadership rounding, team simulation training, and are serving on our quality committees.

Sustaining a high reliability culture requires constant attention and recognition. Be mindful of the importance to celebrate success with quality and safety events, e-mails, letters, and awards. A brief, handwritten thank you note sends a powerful message. Engaging and igniting your caregivers will bring endless benefits to your patients, their families and each other.   

To Summarise  
Set specific goals and targets and empower your frontline caregivers to drive improvement to reduce unnecessary variation. Ensure leadership is accountable to results and to culture. Leadership, the CEO, board members, physicians and all caregivers need to be engaged and focused on what adds value to your organisation; and remember the value in rewarding and recognising success.