HLQAT Hospital Leadership and Quality Assessment Tool

1. HLQATHospital Leadership and Quality Assessment Tool Reed Fraley, Senior VP Ohio Hospital Association April 28, 2011

2. Today’s Objectives • Review and understand the intended outcomes of the OHA project • Describe the process used by the OHA project team • Examine ways to analyze the HLQAT survey data • Discuss interventions being developed as a result of the HLQAT survey • Discuss strategies for engaging board members in actions related to the survey results

3. HLQAT • Hospital Leadership and Quality Assessment Tool • HLQAT is a self-assessment tool to help hospitals identify and improve leadership structures and processes associated with high performance in clinical quality measures

4. HLQAT • What does HLQAT do? • Gauges the effectiveness of your hospital's roadmap for quality • Who created HLQAT? • Study from University of Iowa in 2006 Journal of Patient Safety lined HLQAT to Mortality, Morbidity and Complication rates • Commonwealth Fund & CMS introduced the “tool” and expanded the research • IFMC, ActiveStrategy, DotComments working on “post-Commonwealth” research

5. Perceptions • Serious gaps in perceptions of quality between • Board C Suite  Clinical Managers/Staff • Goal: reconcile perceptions to allow people to address FACTS

6. Role of the Ohio Governance Institute • OHA Governance Institute • How HLQAT fits with the Institute's goals • Why the pilot • What the Governance Institute plans to do with the results

7. OHA Project • Pilot hospitals receive a snapshot of their facility benchmarked against other hospitals locally and nationally on a continuum of leadership attributes correlated with high performance on clinical quality measures • Pilot hospitals receive resources for survey interpretation and action planning • OHA targeted a gap analysis to focus on difference in perceptions between Board, C Suite and Clinical Managers

8. Process used by the OHA project team • Seven pilot hospitals participated in administering the survey to staff: • Board Members • Administration • Clinical Managers

9. Survey process • Taking the survey

10. Survey process • Viewing Results

11. Survey process • Knowledge seeking • Established goals and priorities • Effective communication • Collaboration • Clear roles • Non-punitive culture • Public reporting • Process improvement tools • Adequate resource allocation • QI education • Monitoring and evaluation • Rewards/recognition • 100 questions • 30 minutes • 12 domains

12. Analysis of HLQAT Results • Normalized against the Board perceptions • Used Board perceptions to understand the gaps between the Board and other groups

13. Analysis of the HLQAT survey data

14. Analysis of the HLQAT survey data

15. Domains • OHA Pilot Removed 3 Domains from results: • Monitoring and evaluation of QI progress • QI for all staff • Collaboration across functions and levels

16. What we did next • Collaborative discussion face to face • Graphed data • Compared results between hospitals • Shared individual hospital committee and reporting structures • Shared data reported to committees • Shared frequency of data collection and data distribution

17. Graphed and Compared

18. Committees and Frequency of Reporting • Committees • Quality Committee • Safety Committee • Medical Executive Committee • Board Level • Frequency of Reporting • Ranged from monthly to quarterly

19. Data Shared • All Pilot Hospitals reported at least: • Core measures • Medication Errors • Hospital Acquired Infections • Patient Satisfaction • Sentinel Events • Score Cards

21. Teased it apart • Take away points: • Face to Face meeting as a group was critical • Discussion on what was a priority and why • Discussion on what could be excluded and why • General consensus that every hospital had serious gaps in perception of quality between groups: Board, C Suite, Clinical Managers

23. What we excluded • Removed 3 domains for reporting purposes • Color coded dashboards; prefer control charts

24. Agreed Upon Strategies • Patient Stories • Frequency of Reporting to Board • Communicate same measures to Board and Bedside • Resolution and Feedback Loop • Importance of Patient and Staff Safety Reporting

25. Board Communication • Score Card Big Dots • Measures Commonly Reported • Additional Items Reported • Frequency of Reporting • Patient Stories • Measures Communicated to Board and Bedside? • Resolution Feedback Loop?

26. Put it together

27. Suggested Interventions 1995 2000 2005 2010 1995 2011 2005 2015 2010 2017

28. Strategies for engaging board members • Institute of Healthcare Improvement • Boards on Board, etc. • Quality should be high on Board agenda • Safety & Quality needs to be a priority • Staff safety • Patient safety • Control charts not dashboards • Patient stories: include good as well as bad stories

29. Next Steps • Pilot Boards acceptance • Compare Pilot & HLQAT results • Take second survey • Modify approach • Longitudinal study - correlate required Ohio quality reports with HLQAT surveys • Keep improving !

30. Conclusion • Perception variance great • No uniformity in perception variance among hospitals • Minimal feedback • to staff • on problem resolution efforts • Quality leaders seeking help • Boards & management perceptions vary

31. QUESTIONS