This case study first appeared in the report Hospital Quality Improvement: Strategies and Lessons From U.S. Hospitals by Sharon Silow-Carroll, M.B.A., M.S.W, Tanya Alteras, M.P.P., and Jack A. Meyer, Ph.D., Health Management Associates.

Setting

Rankin Medical Center (RMC) in Brandon, Mississippi, is a small community hospital with about 90 active acute care beds and serving five rural and suburban counties. In 1997, RMC was converted from a county-owned facility to a member of a for-profit health system, Health Management Associates, Inc (HMA). RMC is not officially a teaching hospital, but does have some residents in a few specialties. Its patient mix is 51 percent Medicare, 12 percent Medicaid, 26 percent commercial, and 9 percent self-pay.

We selected RMC because our analysis of Medicare data over 2002–2004 (the "study period") identified RMC as among 100 hospitals showing greatest improvement in a quality measure based on risk-adjusted mortality, morbidity, and complication rates. RMC displayed marked improvement on a steady basis over the study period, suggesting a true trend as opposed to a one-year aberration. Also, selection of RMC provided diversity among our case study sites by including a small, non-urban southern hospital that is a member of a large, for-profit health system.

Impetus for Quality focus

Change in Leadership
The event that seemed to spark RMC's efforts in quality improvement was a change in executive leadership during the first year of the 2002–2004 study period. In 2002, RMC named a new CEO who had a strong commitment to quality improvement. He communicated to the staff a new vision in which customer service was the top priority, and he approved resources, programs, and activities (described below) that instilled a culture of customer service and quality.

Acquisition by For-Profit Health System
Preceding the new CEO, the 1997 purchase by a for-profit hospital chain (HMA) was the first turning point for RMC. The new ownership brought new resources and equipment to the hospital, and a process of sharing best practices with other member hospitals. HMA also selected RMC's new CEO, who had worked as COO at another HMA hospital and CEO for another for-profit health care organization.

National Awareness of Widespread Medical Errors
The Institute of Medicine's report, To Err Is Human: Building a Safer Health System (2000), prompted a national awareness of widespread medical errors in hospitals, and helped promote a greater consciousness of safety issues at RMC just prior to the study period.

Actions to Improve Quality: Organizational and Structural Changes

New QI Expertise and Expansion of Activities
Soon after the arrival of the new CEO, the administration and director of quality/risk management decided that the QI department needed more staff with a background in clinical pathways and evidence-based medicine. In 2002, RMC hired a performance improvement coordinator (PIC) who met this description.

The new PIC became very involved in patient and staff education. She helped develop clinical pathways and improve educational materials given to patients, using reputable outside sources recommended by CMS, the National Patient Safety Foundation, and JCAHO. Along with the hospital's Education Department, she coordinated education to clinical staff on best practices in safety measures such as how to reduce errors and prevent infections. The PIC also became involved in the state's quality improvement organization, working collaboratively and sharing best practices with other hospitals in the region and state.

Reflecting the important role of quality at the institution, the director of quality/risk management (DQM) reports directly to the CEO. Since 2000, the DQM has been included in Administrative Council meetings along with the top leadership of the hospital, thus enhancing the stature and effectiveness of QI.

The Quality Steering Council and the QI Process
RMC's Quality Steering Council is considered a driving force for QI. It is composed of hospital leadership from the medical staff, administration (including the CEO, DQM, and others), Advisory Board, and nursing staff. When a problem is identified, either through a physician voicing a concern or the QI department identifying a deficiency based on hospital data, the Council uses a numeric ranking tool to decide how to handle the issue (Figure 2. Prioritization Grid). If the tool, which was adapted from industries outside of health care, indicates that the problem warrants closer investigation, the Council engages in the FOCUS-PDCA Model, a nine-step process guide to quality improvement (also adapted from other industries):

• Find a process improvement opportunity;
• Organize a team who understands the process;
• Clarify the current knowledge of the process;
• Uncover the root cause of variation/poor outcome;
• Start the Plan-Do-Check-Act (PDCA) cycle:
• Plan the process improvement;
• Do the improvement, data collection, and analysis;
• Check the results and lessons learned; and
• Act by adopting, adjusting, or abandoning the change.

If warranted, an interdisciplinary performance improvement (PI) team is identified by the Council or one of eight medical staff committees to address the problem. The PI team consists of individuals most involved in and affected by the particular problem. RMC has found that staff members buy into the process if they are represented in discussions, devise a solution together, and then implement and test their own recommendations. A team addressing medication errors, for example, includes a pharmacist, nurse managers, and line nursing staff. Also, the DQM or PIC participates in every PI team to help guide the process.

PI projects undertaken by the hospital have included the following:

• Zero Medication Error Program—commitment to reduce medication errors by 50 percent over five years;
• Fall Prevention Program—development of reader-friendly guide to patients for reducing risk of falling in the hospital and at home;
• Restraint Reduction—comparison and tracking the effects of alternatives to patient restraints, such as using "sitters" to watch at-risk patients, engaging patients in tasks and activities, and other strategies;
• Mystery Shopper Program—in addition to patient satisfaction surveys, some patients are selected at random at the beginning of their stay and asked to keep their eyes and ears open to whether staff were helpful to them and their families.

It is important to note that while this general QI process preceded the current CEO and the study period, it is viewed by many interviewees as having become much more effective after 2002. With the new CEO's quality-oriented vision and open door policy (described below), physicians and other staff began to feel more confident that sharing quality concerns with the administration would be taken seriously and acted upon. This appeared to make a major impact on the effectiveness of the process.

Resources and Health Information Technology
As noted above, RMC was able to obtain state-of-the-art imaging and diagnostic equipment after it was acquired by a for-profit health system a few years prior to the study period. Access to more resources and better tools, along with general support from the parent health system, are believed to have contributed to better patient care and safety. Indeed, RMC must report on and strive to meet quality and financial performance goals as a member of the health system. This requirement has contributed to the culture of quality.

With support from the health system, RMC made major improvements to the physical plant beginning in 2002. The new CEO believed that quality begins with a clean and physically appealing facility, which creates an expectation of quality throughout the organization. In 2003, RMC obtained new software that enabled medication orders to be sent to and received in the Pharmacy Department via e-mail. This led to a reduction in medical errors related to order transcription. Also, the hospital acquired imaging and lab programs that gave physicians access from their offices to a patient's lab and X-ray results as well as transcripts of reports from other physicians.

Open Door Policy, Keeping Employees Happy
As noted above, the commitment of the CEO who came in 2002 was instrumental in elevating performance improvement to a new level. The CEO immediately implemented an “open door policy,” encouraging physicians to drop by to voice complaints or concerns, which are often brought to the Quality Steering Council. This policy greatly enhanced communication with physicians, leading the CEO to spend the majority of each day on quality issues.

The CEO maintains that achieving a warm and friendly atmosphere, the key to customer service, translates into higher quality and can be achieved only if employees are happy. He is dedicated to treating employees well, and listening to and addressing their concerns.

Keeping Performance on the Front Burner
Creating a culture of quality requires continuous reminders—through new employee orientation, ongoing staff education, a quality-focused newsletter, posting of outcomes, quality improvement fairs, reports, and other means. As the DQM put it, "we need to keep quality on the front burner."

MONITORING RESULTS

A quality review nurse conducts concurrent chart reviews, examines "external" indicators such as Core Measures, and tracks a variety of "internal" measures related to PI team initiatives. RMC has tracked, for example, transport time for AMI patients, the number of emergency department patients who return with the same symptoms, and the time for getting an EKG for patients with chest pain. During the study period, the hospital noted improvement in many areas, including a reduction in patient falls and infection rates, decrease of door-to-drug time for antibiotic administration, and increase in pneumonia vaccination for eligible patients. In 2004, the last year of the study period, RMC received a State Quality Award from Mississippi's QIO.

Follow-up and monitoring of PI team initiatives are the responsibility of the team members assigned to a project, with results sent to the Quality Steering Council, Medical Executive Committee, and the Advisory Board. New solutions and procedures that are proved successful are communicated up to executive committees and down to staff through managers. Because RMC is a small hospital, changes in one department are quickly adopted by others. If improvements are not seen, the team revises its action plan and goes back to work until the problem is fixed. Some teams stay together for a short period, while others, such as those addressing patient falls and medication errors, are maintained over the long run.

In addition to PI team initiatives, each department sets annual quality-related goals. If a goal is not met, efforts to meet it continue for the following year and are reported to the Quality Steering Council. Performance in reaching goals is part of annual evaluation and compensation review for employees.

CHALLENGES AND OBSTACLES

Physician and Nurse Resistance
When new QI strategies were introduced at the start of the study period, many physicians, including medical staff leaders, resisted the recommended medical pathways as "cookbook medicine." RMC addressed this problem largely through peer-to-peer education. Physician champions of QI were identified and recruited to talk with their peers and persuade them that evidence-based medicine does improve results.

There also was some resistance by nurses who had “no time” for additional quality-related activities. In response, RMC got the nurses involved in the QI process and problem-solving, and showed them that such changes could actually make a difference in patient safety. It was also important not to burden the nurses with paperwork. Over time, these efforts resulted in most nurses and physicians viewing performance improvement as part of their daily routine.

During the study period, RMC began to prepare for new accreditation reporting requirements on Core Measures to JCAHO. This process inspired both nurses and physicians, who took pride in their work and wanted the hospital to compare favorably to others.

Financial Implications

According to hospital representatives, improvements in quality have resulted in successful physician recruitment and the addition of new services. The hospital's image has steadily improved in the community it serves. This in turn has attracted patients who in the past might have chosen other hospitals for their care.

Lessons

Emphasize Transparency and Celebrate Success
Interviewees deemed it important to recognize and remind personnel that the hospital is not perfect, and that there continues to be areas in need of improvement. Keeping the staff involved in decision-making and aware of progress contributed to better results.

Indeed, QI leaders at RMC emphasize the importance of celebrating successes. Showing staff where they had been on particular measures and how far they've come—through reports, posters, and QI fairs with games, food, and prizes—has effectively nurtured a culture of quality. Physicians, who are typically described as competitive, are particularly motivated by comparisons with others.

Public Policy Can Help
Public policies viewed as helpful to QI efforts include reports that document and publicize quality problems (e.g., IOM reports) and public reporting of quality data (e.g., new Medicare requirements) that will eventually help consumers make good choices.

Acknowledgments

The authors would like to thank the following individuals at Rankin Medical Center who generously offered their time and insights for this case study: Rhonda Parker, performance improvement coordinator; Davis A. Richards III, CEO; and Margaret Stubblefield, director of quality/risk management.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.