Inside Dallas County's "Safety Net"

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In the summer issue of Frontiers of Health Services Management, an American College of Healthcare Executives-published journal that's required reading at UP HQ, Parkland Health & Hospital System's top officials have penned a paper congratulating, um, Parkland for its fine, fine work. Actually, the 7,000-plus-word paper -- titled "The Quest for Quality: Perspectives from the Safety Net" -- is part of a larger series dealing with how health-care providers measure the quality their patients receive -- and Parkland, being "the regional hospital system for the entire North Texas community of 5.7 million people," has had to deal with that subject more than most. And what have Parkland president and chief executive officer Ron J. Anderson, M.D., and his team come up with?

Says the paper, some excerpts from which are after the jump, they've narrowed down the so-called "measurement monster" at Parkland to three things: "an emphasis on quality that is embraced by senior leadership, both clinicians and administrators"; "careful measurement selection"; and "the development of a robust infrastructure for outcomes research." And while that sounds dry and altogether unsexy, the paper is intended to serve as a suggestion box for other hospitals -- none of which likely serve as the principal teaching hospital for the University of Texas Southwestern Medical School and run "a Level A trauma center, a Level 1 burn center and a Level 3 neonatal intensive care center as well as a safety net for the indigent and patients with special needs." How Parkland views Parkland is after the jump. --Robert Wilonsky

SUMMARY

The American healthcare system is in need of fundamental change. With more than a decade of annual forums on quality improvement in healthcare and alarming statistics ranking medical errors among the top 10 causes of death in the United States, hospitals and health systems across the country are responding with a coordinated approach to quality improvement. Parkland Health & Hospital System believes the ideal public hospital system requires three critical components to achieve the Institute of Medicine's quality aims: (1) an emphasis on quality that is embraced by senior leadership, (2) careful measurement selection, and (3) the development of a robust infrastructure for outcomes research. This article describes Parkland's approach to each component and takes a look at selected processes and outcomes.

MORE THAN six years have elapsed since the Institute of Medicine (IOM) issued the first of its landmark reports, To Err is Human: Building a Safer Health System (2000). The report began a national conversation about healthcare quality that grows louder by the day. The report also ushered in a new environment in which financial and regulatory bodies began to look for ways to reimburse providers on the basis of their clinical performance. Hospital and health systems across the country are now beginning to respond, but as Leape and Berwick (2005) have noted, "progress is frustratingly slow." A number of challenges remain. Among those most frequently cited is the lack of a structured, coordinated approach to quality at the level of the hospital system (Leape and Berwick 2005). Parkland Health & Hospital System, one of America's largest publicly owned and managed hospital systems, makes a clear commitment to delivering high-quality healthcare. To achieve the six IOM quality aims of safety, timelines, effectiveness, efficiency, equity, and patient centeredness (IOM 2000), Parkland believes the ideal public hospital system requires three critical components:

1. an emphasis on quality that is embraced by senior leadership, both clinicians and administrators;

2. careful measurement selection; and

3. the development of a robust infrastructure for outcomes research.

This article examines each of these components and describes Parkland's approach to quality.

AN INTRODUCTION TO PARKLAND HEALTH & HOSPITAL SYSTEM

The Parkland Health & Hospital System is a regional hospital system for the entire North Texas community of 5.7 million people (United States Census Bureau 2005). In addition to being the principal teaching hospital for The University of Texas Southwestern Medical School, Parkland is a Level a trauma center, a Level 1 burn center, and a Level 3 neonatal intensive care center as well as a safety net for the indigent and patients with special needs. Parkland has been the busiest hospital in Dallas County for the past 5 years (Parkland Health & Hospital System 2006). Recognizing the need to better address primary care, prevention, and the public health needs of the community, in the late 19805 Parkland created and subsequently expanded an extensive outreach program, including 10 comprehensive community oriented primary care (COPC) sites, a series of prenatal care and women's clinics, a community-based nonprofit health maintenance organization (HMO), the Injury Prevention Center and Homeless Outreach Medical Services, and a series of school-based clinics. It is a highly integrated model using an academic "closed faculty" partnership on campus and a group practice, employed physician model for community medicine.

PARKLAND'S APPROACH TO QUALITY AND OUTCOMES

arkland chose to focus on these three critical components to ensure that quality improvement occurs in an organized systematic manner as part of the overall mission, vision, and strategies of the organization. These three components ensure that quality is a core strategy of the organization, supported and coordinated by the CEO, senior leadership, and the board, who also ensure that the organization not only does things right but that it does the right thing. Careful measurement selection ensures that the organization is doing the right things for the patients and communities they serve. Finally, the quality agenda cannot be achieved without a robust infrastructure for outcomes research. The ability to gather appropriate, meaningful information and to make meaningful decisions from these data is critical to the success of any organization. Improvement can only be judged by the accuracy and availability of what can be measured.

A Senior Leadership Emphasis on Quality Outcomes

The chief executive officer (CEO) of a healthcare system is central to the development of a system that values performance improvement. The CEO is responsible for developing a covenant with the community and nurturing the system's culture of servanthood, cultural competence, stewardship, and value creation. Reinertsen, Pugh, and Nolan (2006, 1) state that "executive review of projects can be a powerful method for channeling leadership attention to quality
initiatives." ...

Parkland's quality improvement efforts and serious approach to data are underscored through a covenant relationship with our community and our patients. This relationship dictates that the best evidence be applied in the care of patients, and it requires an infrastructure that closely monitors and acts upon data to support patient care. Parkland has established measurements to better ensure that quality and safety goals are met. Under the direction of senior leadership, a system is being developed to review quality measures, create measures that are actionable, create a culture that values measurement and improvement, and extend a measurement focus into our work in the community, and in the case of chronic disease, longitudinally. Part of the emphasis is on looking beyond traditional measures of quality. Process measures are important but they are indirect measures of quality; therefore, an emphasis on outcomes is even more important. Further, the Parkland CEO has directed the institution to consider measures that assess how well the organization is meeting the community's needs for prevention and improving health status as well as the patient's perception of his or her experience, whether at the hospital or a neighborhood clinic. Good intentions and measures of public benefits are important, but first we must, above all else, be competent in what we do. We must be perpetual students in a learning organization. Success can breed arrogance and can blind organizations to needed change...

Careful Measurement Selection

Measurement selection reflects institutional priorities, goals, and values...

arkland's quality and outcomes management program is based on making a series of interventions over time to improve performance on specific measures. Two examples of programs are an immunization compliance program and an emergency triage program. The immunization compliance program was first instituted in the COPC system and then migrated to the inpatient setting at the main hospital campus. In 2005, Parkland COPC sites had 43,698 visits for seniors age 65 and older, and 8,456 visits for pediatric patients under the age of 2 years. We identified that important immunizations, such as pneumovax and influenza, were not occurring with the frequency required for this population...

Community efforts

Given that Parkland's patient population is ethnically and linguistically diverse, given that Parkland's employees are likewise ethnically diverse and have skill sets representing many medical specialties, and given that Parkland's providers represent more than 165 different medical specialties, significant barriers exist to providing high-quality, patient-centered, patient-valued care. To break down these barriers Parkland works closely with the community through its COPC system. Parkland developed its COPC program around six key elements: assessment of community needs and assets, community prioritization of healthcare issues, collaboration with community organizations, provision of a community healthcare system, evaluation of patient and community outcomes, and financing (Anderson and Boumbulian 1995). Parkland provides care in both traditional and nontraditional settings. Services are provided through a system of 10 COPC health centers and specialty programs from which care is extended in nontraditional settings, including 23 homeless shelters, 10 schools, a geriatric assessment center, and a senior citizen center via multidisciplinary teams composed of a mix of midlevel practitioners and primary care physicians...

Clinical and access areas

Parkland's community health plan has also achieved significant quality outcomes in both clinical and access areas. Some of the outcomes in managing healthcare for these populations include the following:

* Improved emergency department utilization by establishing a medical home (a medical home is defined as an individual's primary care physician or the clinic where they receive the majority of their primary care) and management of outliers.

* Reduced infant low birth weight rates in the community.

* Enrolled 2,000 children in an asthma disease management program. This program is a public/private partnership with a for-profit disease management company. Fees paid to the private disease management company are contingent upon improved outcomes and quality of care. All of their fees are at risk, meaning that the disease management company is only paid if their outcomes are reached (Boumbulian, Pickens, and Anderson 2004)...

CONCLUSION

We believe healthcare institutions have an extraordinary opportunity. The healthcare environment is poised to reward health systems that deliver high levels of quality. The CEO's message to the organization emphasizes the importance of evidence-based medical care and evidence-based practice. Key components of that message include focusing on demand management and being better stewards of the resources entrusted to our care whether they originate from the taxpayer or the patient and third party. In the spirit of servant leadership, we recognize our interdependence with the community and our need to a focus on prevention and collaborations to influence the social determinants of health. In all of these efforts, including strategic planning, we also recognize the need for strong physician participation. Parkland is putting in place additional structures that ensure accountability for quality whether on the patient wards, in the COPC sites, or in the community-based HMO. The quest for quality must be interwoven into the cultural fabric of the institution. A sincere commitment to greater quality is a wise investment from a marketing perspective, but it is much more. It is an ethical prerequisite for fulfilling a covenant of trust with our community.

The quality agenda cannot be achieved without a robust infrastructure for outcomes research.

Good intentions and measures of public benefits are important, but first we must, above all else, be competent in what we do.

In addition to nationally established measures, hospitals must often develop their own internal metrics.

To really establish outcomes, more sophisticated tools are needed to allow population-based analysis and cohort analysis over time.

Information to calculate measures will need to be rapid, efficient, flexible, and, where possible, automated.

In the spirit of servant leadership, we recognize our interdependence with the community and our need to a focus on prevention and collaborations to influence the social determinants of health.

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