How the staff at Lapeer Regional Medical Center tapped into their competitive spirit to earn the Premier Award for Quality

American economist Lester Thurow once said, “A competitive world has two possibilities for you. You can lose. Or, if you want to win, you can change.” For the team at the Lapeer Regional Medical Center in Lapeer, Mich, having that competitive spirit has earned it the Premier Award for Quality in the area of pneumonia.

“As an organization, we have a pretty competitive edge about us; I think to be successful in health care today, you have to be competitive,” says Bart Buxton, president and CEO, Lapeer Regional Medical Center. “We recognize that patients have a choice of where they go, and the more value you create, through quality and cost-effectiveness, the more you position yourself for people to choose you for their care.”

Headquartered in San Diego, Premier is a health care alliance of more than 1,500 hospitals and 42,000 other health care sites. Premier Awards for Quality recognize six individual areas. In addition to pneumonia, the five clinical areas are hip and/or knee replacement procedures, coronary artery bypass grafts, heart failure, acute myocardial infarction, and maternal and neonatal care.

This year, Premier evaluated nearly 400 Premier hospitals, measuring performance in clinical quality outcome, clinical process, and use of resources. To ensure fair comparisons, performance is calculated separately for categories of hospitals with similar services.

“We never applied for the award, so obviously someone noticed that we are doing things right,” says Scott Mango, RN, chief nursing officer at Lapeer, who oversees all of patient care services, which includes both nursing and respiratory therapy. “The nurses were excited; they know they are part of something that is important and are part of improving patient care—and that’s why we’re here.”

Part of the Solution
Today’s award-winning team wasn’t in place when Buxton assumed the role of chief executive.

“When I walked in the door of this organization 3 years ago, one of the first things I heard from the community was that we had bad care, that we were not a quality institution,” Buxton says. “So we went about a process to improve it. Our strategic intense statement here is ‘quality care through teamwork.’ ”

To make change happen, Buxton met face-to-face with each department’s staff, including clinicians, and reviewed every key indicator of the facility’s core measures. Communicating his desire not only to meet, but to exceed, national benchmarks for quality, Buxton worked with each unit to put processes in place that would help the hospital reach those goals.

One of the first tasks in that effort was to define the culture of the organization through values. For the first 6 months, a number of different focus groups and several dissemination groups gathered to cement what it was they wanted to be recognized for as a group.

“That was very important for me, because I was new and I wanted to know what the culture was, what the values were, and how they drove the mission and vision of the organization,” says Buxton. “At that time, no one could tell me those things. Now every single person in the hospital can tell you what our values are and how our values drive our mission on a daily basis and get us to our vision.”

Opening Doors
An open line of communication is important to Buxton, who makes rounds of the hospital every day. During this time, he confers with his staff to find out what is going right and what can be improved.

“When I ask people, ‘How’s it going?’ and they say, ‘Good,’ ” says Buxton, “then I ask, ‘What can make it better?’ ”

Rounds also give him the opportunity to review patient charts to make sure the established “pathways”—specific workflows—are being followed.

Specific to pneumonia care, the pathways were established during the department meetings Buxton held shortly after starting as CEO. He asked the principal players to map out the process they believed would deliver care most effectively and most efficiently.

“At the end of the day, the persons who are measured at the highest level, when it comes to patient care, are the doctors. They are the ones who deliver the care, and they are the ones who can always tell you how to do better,” Buxton says. During the meetings, pneumonia care providers detailed how a patient moves through the continuum of care from the moment they are seen for the first time until the day they are discharged. “It literally is a process flow. You look at ways of streamlining processes and at ways of trying to combine care along the continuum, making sure you hit all the key indicators that will allow you to work best practices and evidence-based medicine, and ultimately you deliver a better outcome.”

Which is not to say that once established, the course of action is set in stone. On the contrary, it is designed to be flexible. In cases where improvement is needed, the situation is addressed and remedied promptly.

“The pathways were put in place about 2 years ago, and in that time we’ve built on them. When we see something that can be improved in our current process, the best thing to do is identify the problem and build a solution into the process to change it,” says Mango. “There’s nothing wrong with revising your pathways. We’ve revised them a number of times, and each time it just makes your team that much more solid.”

Mango and other managers assist their staff in any way possible to help everyone hit assigned performance goals. On many occasions, that helping hand comes in the form of ongoing or on-the-job education.

“We are always looking at how we’re doing and where we should be by looking at our scores and by benchmarking regularly,” says Mango. “When we set a certain goal, we publish it and talk about it openly in staff meetings. When necessary, we will work with individuals so they learn about the core measures and pathways and why we’re doing what we’re doing.”

All Together Now
Teamwork is not just a motto at Lapeer; it is a way of life. Everything in the organization is based on the team concept, a vital element in maintaining motivation and giving each individual specific goals to strive to reach. These goals are defined by a set of quality metrics, which are in place for every department.

“All of these are measures identified as best practices, and they are all evidence based,” says Mango. “We have learned what delivers the best outcomes, and these metrics are in place to provide exceptional care for the patients.”

For pneumonia, some of the key measurements are oxygen assessment, completion of a blood culture within 24 hours of arrival, and an appropriate antibiotic selection for all patients. Sets of duties like these are combined and rated as a unit called a bundled indicator.

“A ventilator bundle, for instance, consists of maybe three or four key indicators such as ‘the bed is positioned at 30°’ or ‘the patient is given verbal instruction on an hourly basis,’ ” says Buxton. Other examples include ensuring that the airway mechanisms are suctioned every hour or that tubes are changed routinely. “Each one of those creates a bundled indicator and then you add the scores up. If each metric in your bundle is 100%, then the bundled indicator would be 100%.”

Part of the success of earning high scores—and the subsequent Premier Award—undoubtedly comes from the fact that respiratory therapy was involved in the planning process from the beginning.

“The respiratory department was an equal player when we were developing the pathways for pneumonia. I think one of the things that separates us as a hospital is our RTs have direct input into patient care,”  Mango says. “I value the respiratory therapists’ input on everything we do and consider them as equal players on our team. We don’t look at it as just nursing care or just respiratory care, we look at it as patient care.”

Trickle-Down Effect
Nurses and clinicians are not the only ones cognizant of the bundled indicators.

“Our board is very involved in quality and recognizes its importance. There is a great old adage in health care: that if you take good care of your patients, the bottom line takes care of itself,” says Buxton. “At our board meetings, we don’t even look at financial indicators anymore. Financially, we do very well, but that’s not the focus. The focus is quality care.”

Board members routinely visit the hospital and share their appreciation with the front-line staff for their commitment to the core measures. The existing board is one of the things that sets Lapeer apart from other hospitals, according to Buxton. He believes that its active participation is critical to the success of the hospital, because it helps set the tone for the entire facility.

In screening for new board members—just three of the 10 current members have been on the board since Buxton joined the organization—considerable weight was given to each person’s interest in knowing the hospital’s core measures and indicators.

“I think that’s important at any hospital, because board sets policy; they really set the tone for everything that happens,” says Buxton. “If you have a board and all they care about is finance, then you are going to have a facility that runs that way. If you have a board that focuses on quality first, then you will have a facility that runs that way.”

Making It Happen
For facilities struggling to implement new goals or improve existing processes, Buxton advises first knowing what it is you want to fix.

“We look at how we can change process to get a different outcome. You have got to know what you’re going to change, and you must have measurement capabilities in place to change it,” he says. “The other key indicator is that leadership has to be out and about and has to be focused on quality. You can’t have administrative leadership not driving the process, not owning the process, and not holding people accountable for it.”

That philosophy paid off for Lapeer; and, while receiving the Premier Award is an important milestone, it also provides valuable feedback to the hospital’s employees.

“I think it’s important for the staff to be given this award,” says Buxton. “I can walk around and tell everybody they are doing a great job, but when you are looked at externally and benchmarked against your peers as one of two hospitals of our size to hit that level of excellence—I think that’s a tremendous motivator.”

Dana Hinesly is a contributing writer for RT. For more information, contact [email protected]