How to Make Healthcare Quality Improvement a Cultural Habit

Mile Bluff Medical Center, a community hospital in south-central Wisconsin, has successfully integrated healthcare quality improvement into its organizational culture. This case study explores the strategies and practices that have fostered this transformation. 

Background

With a commitment to enhancing patient outcomes and meeting regulatory standards, Mile Bluff recognized the need to embed quality improvement deeply within its operations. Pat Stubbs, an industry veteran with over 47 years at Mile Bluff, has been instrumental in leading these efforts. ​

Challenges

In the early stages of adopting electronic clinical quality measures (eCQMs) during the Meaningful Use initiative in 2013, Mile Bluff faced several challenges:​

• Resource Limitations: As a small community hospital, there was a need to ensure the availability of appropriate tools and skilled personnel. The absence of a dedicated report writer highlighted the necessity for external partnerships. ​

• Measure Comprehension: Understanding and accurately mapping eCQMs within the Electronic Health Record (EHR) system required significant effort. Not all necessary data elements were being collected initially. ​

Strategies Implemented

1. IT and Quality Department Collaboration: A partnership between the IT and quality departments was established to optimize eCQM reporting. The IT team, comprising ten members with four dedicated to the EHR and eCQMs, worked alongside the quality department to enhance data collection and reporting processes. ​

2. External Partnerships: Recognizing internal resource constraints, Mile Bluff collaborated with Medisolv, a quality reporting solutions provider. This partnership offered the necessary tools and expertise to navigate eCQM requirements effectively. ​

3. Comprehensive Education and Training: Emphasis was placed on educating clinicians about quality measures and the importance of accurate data collection. This approach aimed to cultivate a culture where quality improvement is a shared responsibility. ​

4. Provider Champions: Identifying and empowering provider champions within the organization facilitated the dissemination of quality improvement initiatives and encouraged staff engagement. ​

Outcomes

The integration of these strategies led to significant advancements:​

• Enhanced Data Accuracy: Improved understanding and mapping of eCQMs resulted in more precise data collection and reporting. ​

• Cultural Shift: A notable transformation occurred within the organizational culture, with clinicians and staff embracing quality improvement as an integral part of their roles. 

• Regulatory Compliance: The hospital achieved compliance with regulatory bodies such as CMS and The Joint Commission, reflecting the effectiveness of the implemented quality improvement measures. ​

Conclusion

Mile Bluff Medical Center's experience underscores the importance of collaboration, external partnerships, education, and leadership in embedding quality improvement into a healthcare organization's culture. Their journey offers valuable insights for other institutions aiming to enhance patient safety and outcomes through cultural transformation.