Achieving clinical quality has always been an important component of healthcare delivery, but in an age of quality-based reimbursement and a consumer-oriented business culture, it's more important now than ever.
The problem is that, until recently, there hasn't been a consistent set of standards governing how quality is measured and achieved. That results in a high level of clinical variation, which leads to inefficiencies and gaps in both quality and expense.
The National Association for Healthcare Quality aims to change that. NAHQ recently released a study that aimed to demystify the workforce competencies needed to deliver exceptional quality and outcomes cost-effectively. The resulting Framework for Healthcare Quality Competencies outlines competencies needed by healthcare organizations to meet their their goals.
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Stephanie Mercado, NAHQ's executive director and CEO, hopes the Framework can facilitate competency-based training that eliminates variability -- and does so cost-effectively.
"When I think about competency-based training, I think about a concept relative to healthcare, symptom relief and disease management," said Mercado. "A lot of times things in the market address things in healthcare quality like lowering readmissions, and those would be, from a training perspective, symptom management. The difference is that in competency-based training we're really focused on the disease."
NAHQ's research uncovered the need for consistent standards in quality training, and in eliminating silos in the organization so decision-making can be placed in the context of how it affects multiple areas of care.
"It really came from the perspective that we were looking for constant standards so we can attain consistent outcomes and financial goals across the healthcare system," Mercado said. "We spend almost no time talking about how to reduce variability in how healthcare quality is practiced, and how competencies show up in the workforce. This is an inside-out opportunity to affect healthcare positively. The result will be more consistent and reliable."
The Rhode Island-based Lifespan Health System has been implementing this quality training approach for a number of years and is sold on the central philosophy of reducing variability and improving care.
"The more we can standardize and create expectations for the workforce the more likely we are to improve outcomes," said Lifespan Vice President, Operational Excellence Nidia Williams.
Pennsylvania-based hospital management company Universal Health Services is somewhat newer to the approach, but Ted Donnelly, corporate director, quality, said the quality training framework is a snug fit for his organization.
"It's perfect for us, because we have facilities across multiple states, different regions and backgrounds, so the directors are coming into their roles at various levels," said Donnelly. "This established what the expectations are."
Healthcare quality has evolved along the path of regulatory compliance, Mercado said. The environment was changing, and the quality profession was pushed to adapt. From a variation perspective, NAHQ saw leaders saying they needed more analytics so they would know how to improve; oftentimes these leaders would bring in a data analyst. This was typically done without standard job descriptions and expectations.
The leadership repercussions play out across all disciplines, from regulatory accreditation to population health. It's a lot to manage, and leadership is key. The emergence of new positions, such as chief quality officer, speaks to this trend.
NAHQ's Framework encompasses 486 behavior-based competencies, which leaves little room for guessing when it comes to what's required of the workforce. Once these competencies are defined, the appropriate hiring and training can be engineered.
"Most of the people who ended up in quality did so for any number of reasons, not necessarily because that's what they wanted to do for a living," said Williams, speaking of Lifespan's past. "They had to learn on the job from others, maybe they could find some knowledge and education on their own. But they had no formal prep.
"That was one big need these workforce competencies were able to address," she said. "The responsibilities associated with the field of healthcare quality have expanded, and unless we have something tangible to hold onto, it becomes very difficult to achieve the success and the outcomes we want."
Donnelly said the Framework has reduced variation in areas such as patient transitions out of acute care facilities, thanks in part to " a more efficient use of information that is pertinent to all the stakeholders -- the physician community, department directors. "Those skill sets are not something that is intrinsic or inherent," he said.
'THE ROI IS MASSIVE'
Having competencies in place provides a roadmap, Donnelly said. The milestones on the roadmap are the actual competencies and skills that are needed for a successful healthcare quality program; most organizations need to have these milestones in place.
"Quality leadership integration -- that one I feel very strongly about," he said. "Many directors often feel they're the directors of their quality workforce. They need to think of themselves as organizational leaders. Quality is really one of those umbrellas whereby we provide all care."
Williams said that while there's an initial investment to implement what is now known as the Framework, the return on investment has been massive for Lifespan. When she first came to the company, quality was completely decentralized. It was operating in a silo even though the corporate structure had been in place for a number of years.
Now, all of their quality is centralized, and the organization is spending about $1 million less per year than they were previously.
"The workforce is able to deliver on a level we never were able to before," Williams said. "We provide all the development for the workforce mostly internally. We bring the training to the workforce here."
In addition to that, Williams found Lifespan has accrued about $12 million in savings since centralizing quality. Not only is the workforce efficient, but all of the performance improvement efforts have formal business cases applied to them. The money the organization has saved far outpaced the amount it has spent.
Donnelly is in a similar boat at Universal Health Services. That outfit has addressed several of the facets that are needed for the Framework to be a functional program. It shares methodologies and tools with quality directors, and in the last 14 months a standardized health data analytics tool. Everyone looks at the same information at the same time.
"We are going through the system essentials and making sure we tie it all together," said Donnelly. "Because there's a common platform we're deploying from the corporate office, we're directing leaders to use NAHQ as a starting point. We've established the expectation that NAHQ is, for lack of a better phrase, the source of truth."
Mercado certainly hopes that's the case, and expects that the standardization of the healthcare quality workforce will continue to reap rewards for health systems.
"It's going to be absolutely imperative that we are having the entire healthcare system, and specifically the healthcare quality profession, speaking from one source of truth, and there's a common vocabulary, a common toolset," she said. "There's a lot of starts and stops in the improvement journey, and that's because the workforce has not had a common standard until now."