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- Mile Bluff Medical Center -

How to Make Healthcare Quality Improvement a Cultural Habit

Building a passion for healthcare quality improvement into your organization’s culture is no easy task. But it is vital to your success, not only with regulatory bodies like CMS and The Joint Commission, but in the greater pursuit for better patient outcomes and improved patient safety.

We spoke to industry veteran Pat Stubbs—who has worked at Mile Bluff Medical Center in south-central Wisconsin for an impressive 47 years—about what it takes to get your clinicians to embrace quality improvement and all the processes and data that come with it. We quickly learned that it takes a lot of patience and education, so make sure you have a provider champion who’s ready to go along for the ride with you.

What role does your IT team play in Mile Bluff’s quality efforts?

Pat: Historically, our IT department has managed our electronic clinical quality measures (eCQMs) for the hospital. I have 10 people on my IT team, and four of them are dedicated to our EHR and our eCQMs. IT works in partnership with the quality department to maximize reporting for our clinical practices. Currently, the quality department manages quality more for our clinics. We have a goal to have the quality department manage all quality data by having systems or partners in place to obtain needed information efficiently and accurately.

You were there for the very beginning of meaningful use and eCQM piloting in 2013. What were some of your very first challenges back then?

Pat: We are a small community hospital, and it really came down to: do we have the right tools and the right people? For example, we could have used SQL reports in our EHR to fulfill our requirements, but we didn't have a report writer at the time. We were fortunate to find Medisolv which was the perfect solution for our team.

Of course, then the next challenge was really understanding the measures and mapping them out in our EHR. We weren’t always collecting everything that we needed. We were fortunate to have Medisolv to walk us through it from the very beginning. But then again—that challenge never really goes away, does it? Even now, with the latest iteration of our EHR, it’s actually gotten a little bit more complex!

Over the decade, you’ve built a robust internal culture up around these measures. What has it taken to get your clinicians on board?

Pat: That was another early challenge. When we first started with eCQMs, our fallouts were often due to the fact that our nurses and providers simply weren’t used to documenting a measure. The quality of our care was there, but learning to adapt our efforts around the measures required a change in workflows and mindsets.

One of our first moves was to make eCQM-related queries required fields in our EHR. We tried to make it so that our clinicians couldn't skip the data element. You can't do that in every case, but we do it whenever possible.

But the most effective tool has been education. A lot of education! Over time, our providers and nurses have gotten used to the fact that there are certain things we need to do for regulatory purposes, and they've gotten much better about doing it.

What does clinician education look like at Mile Bluff?

Pat: We’re monitoring our measures on a continual basis and giving constant feedback to our providers. By keeping it top of mind, quality becomes a habit. We all know that the same things are being addressed with each patient, each time, and that leads to better outcomes for every patient.

We also have a PA who serves as our liaison with our providers. If there are any changes in documentation or what we're recording, it’s his role to educate our providers. It seems like providers are more willing to accept that information from their peers rather than the IT department, so having him as part of our team has been a big success.

Speaking of successes, what are some of the ways in which your hospital’s “quality habit” has translated into better results?

Pat: For us, success is not just about measure performance but also how it's making a difference in patient care. One example of that is our VTE [Venous Thromboembolism] Prophylaxis measure. We're doing a good job of making sure that it is consistently addressed when a patient goes home because we have actively monitored it for several years. I believe that we're doing a better service for the patients because we know that it’s getting addressed with every discharge.

Another good example is with our e-prescribing objective measures. Our performance has definitely changed a lot over the last few years in that almost all of our providers e-prescribe, which I view as a definite improvement. So many people with a paper script never go pick them up. We’re making it easier for more patients to follow through on their treatment plans now.

On a different note, Mile Bluff is a bit of a rarity in that you’re a small community hospital that has continued to grow and thrive without having to rely on a larger health system. In what ways have your quality improvement efforts helped you keep pace and remain independent?

Pat: We are fiercely independent by choice. We pride ourselves on the fact that we strive to make the right decisions based on our community's patient population.

There is a lot that goes into that, but certainly a major part of that is being in control of your own EHR and your own data.

If we had gone under a major health system, we most likely would have gone under their EHR, and our data would have been absorbed into their data. Any changes in our care would be decided by a larger organization that doesn’t know what our needs are here locally.

When you own your data, you can make better decisions of your patients. And making sure we have the right data tools, like Medisolv, certainly helps us stay in control of our data.

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