The Quality Perspective in a Large Healthcare System: Viewing the Forest and each Tree

Purpose:
In a large healthcare system successful quality improvement impacts process/outcome at the unit level, and provides the big picture at the system level (from tree to forest). This presentation outlines use of unit based teams, NDNQI benchmarks, and tools for all levels of the healthcare team.

Significance:
A solitary global (forest) view of quality cannot provide the important detail of varying patient experiences/outcome at the unit level. Likewise, use of a microscopic view (trees) cannot provide the big picture, and may result in strategic planning and initiatives that miss the quality mark.

Strategy and Implementation:
Our initial challenge was to have consistent unit-level quality monitoring, use of concrete data to show result of action plans, and a systematic tool for reporting unit improvement initiatives. We began with a simple scorecard for nursing at the unit level. Over time, scorecards matured into dynamic tools focused on quality needs of each unit's patient type. Expansion included external benchmarking (NDNQI/NHSN) and incorporation of evidence-based processes. Encouraging staff involvement led to colorful graphics, and unit-based quality teams (led by the unit's physician medical director & nurse manager). Teams use the tools to focus on clinical practice, problem solving, cost initiatives and improving outcomes. Over 56 unit-based scorecards have been developed for teams throughout the system. Super scorecards (aggregated at the system-level) present the global view for support/planning of system-level initiatives, thus providing the perspective of both forest and trees.

Evaluation:
Monitoring of concrete data with use of external benchmarking has enabled unit level teams to take actions which positively impact quality outcomes. Colorful tools at unit, facility, and system level assist to monitor the process and provide organizational perspective sought by system leadership.

Implications for Practice:
It is imperative both at the system and the unit level that acute care be timely, economically savvy, and lead to positive outcomes. A systematic approach for monitoring, benchmarking, and communicating quality data can positively impact outcome at all levels of the organization.