A Board-Driven Quality Program

Meritus Health, Hagerstown MD

Many hospitals and healthcare systems yearn for a “Board-Driven Quality Program.” Meritus Health, an independent hospital in western Maryland, actually made it happen, and they are realizing the significant benefits of their considered effort.

It all began with a Board Strategy Retreat that included all Board members, senior hospital management and senior medical leadership. Given a choice among “Board Driven,” “Physician Driven,” and “Management Driven” the 80+ people in attendance opted almost unanimously for “Board Driven.”

Their first significant action – while at the Retreat – was to set a standard VERY high: elevate Quality-related metrics (eg Core Measures, Hospital Acquired Conditions, Harm, Readmissions, Falls with Injury, The Patient Experience (HCAHPS), and the like) from “below to about average” in the State of Maryland to “Top Decile.”

In order to achieve this significant improvement, the Board understood they needed a Strategy for Quality Management that outlined the key priorities and focus areas, organizational responsibilities and accountabilities, policy/process/procedure changes, infrastructure (especially information technology), and improvements to organizational culture (both for the hospital as well as for the medical staff). This Strategy, in keeping with the original tenets of the goal-setting process at the Retreat, was developed in a collaborative session that included Board members, physicians, and hospital leaders.

Improving The Patient Experience is the overarching focus area in the journey to Top Decile, supported by three so-called Strategic Vectors:

• Clinical Excellence: Meritus Health will be a provider of excellent care across the continuum with the patient and the family at the center.
• Patient Safety: Zero preventable patient harm.
• Population Health: Meritus Health will relentlessly improve and promote the health and wellness of every person in our service region.

Those who created the strategy understood that in order to achieve the visions for the Strategic Vectors there would be required improvements to six significant “Foundational Enablers:” Physician Engagement, Technology, Just Culture, Continuous Improvement, Data Powered & Transparent, Workforce Alignment & Development.

The Board Quality & Patient Safety Committee meets monthly to review/approve management and physician plans for improvement, and, of course, review progress against specific goals, objectives and milestones.

Specific improvements during the first six months of focused effort include the following:

• Core Measure Fall-outs (or, Opportunities for Improvement) reduced from ~50 per month to less than 5 per month
• Harm Index reduced from 6-7 per month to 1-0 per month (yes, Zero is possible!)
• Hospital Acquired Condition ranking improved from worst in the State to #7 (Top Quartile).