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Achieving STEEEP Health Care: Baylor Health Care System's Quality Improvement Journey

2013 Edition, September 26, 2013

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Active, Most Current

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ISBN: 978-1-4665-6537-1
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Product Details:

  • Revision: 2013 Edition, September 26, 2013
  • Published Date: September 26, 2013
  • Status: Active, Most Current
  • Document Language: English
  • Published By: CRC Press (CRC)
  • Page Count: 288
  • ANSI Approved: No
  • DoD Adopted: No

Description / Abstract:


This book describes practical strategies and tactics Baylor Health Care System (BHCS) has used to operationalize the delivery of safe, timely, effective, efficient, equitable, patient-centered (STEEEP) care. BHCS has been committed to the delivery of high-quality health care since the organization was founded as Texas Baptist Memorial Sanitarium in 1903. My focus, since joining BHCS as the organization's first chief quality officer in 1999 and founding the Institute for Health Care Research and Improvement,1,2 has been the development and implementation of strategies to improve health care quality across the system and the communities served by BHCS.

The origins of this book, as well as my health care quality improvement efforts, date back to the late 1970s, when I was an undergraduate economics student as a Morehead Scholar at the University of North Carolina at Chapel Hill (UNC) and developed a tool to detect inappropriate hospital admissions for the North Carolina Memorial Hospital Utilization Review Committee. In the 1980s, as a doctoral student in the UNC Schools of Medicine and Public Health, I collaborated with my faculty advisor and mentor, Ed Wagner, to characterize and develop interventions to improve the process and outcomes of medical care in the management of hypertension,3–5 and then went on to shape, with Denis Cortese, the Chair of the Mayo Clinical Practice Committee, Mayo Clinic's health care quality improvement strategies and tactics.6 The latterengagement included leading Mayo's participation in the Working Group of the Appropriateness Project of the Academic Medical Center Consortium, which was ahead of its time in terms of trying to address the overuse of care.7–10

In the 1990s, I served as president of the Kerr L. White Institute for Health Services Research, which focused on population-based health care quality and efficiency research. The institute included among its member organizations five state-level health care quality improvement organizations11 (then called peer-review organizations (PROs)) created by Congress in 1984 to monitor the cost and quality of care received by Medicare beneficiaries. To do this, the Health Care Financing Administration engaged the PROs through a series of contracts. One of these contracts initiated the Health Care Quality Improvement Program in 1990 as an application of the principles of continuous quality improvement. My work with these five PROs provided me with valuable insight into leading quality improvement efforts and creating infrastructure to support quality improvement on a large scale.12–21

When I joined BHCS in 1999, I recognized that it was a complex organization and would require strong infrastructure, robust measurement tactics, leadership alignment, and other elements to enhance the delivery of high-quality health care. Around the time of my arrival at BHCS, the organization renewed its focus on organizational development. In early 2000, the chair of the BHCS Board of Trustees established an ad hoc committee, which I chaired, to develop the BHCS strategic plan to focus its efforts on the organization's goal "to deliver the best and safest care available, focusing on wellness, prevention, early detection, acute and subacute care, and supported at every point by education, research, and improvement."1

During this time, the Institute for Healthcare Improvement was seeking proposals for its Pursuing Perfection Initiative, which challenged hospitals and physician organizations to improve patient outcomes dramatically by "pursuing perfection" in all major care processes.22 As BHCS developed a proposal for the initiative, we considered our approaches to health care quality improvement and realized we needed effective ways to communicate our quality improvement goals and strategies to internal stakeholders (employees) as well as external stakeholders and potential partners. As the Institute of Medicine (IOM) was then developing its report "Crossing the Quality Chasm,"23 we considered the six IOM dimensions of high-quality health care (safety, timeliness, effectiveness, efficiency, equity, and patient centeredness) and their relationship to the transition of a state of ideal health care delivery. My BHCS colleague, John Anderson (then BHCS senior vice president for Clinical Integration), and I imagined the analogy of climbing a mountain and the acronym STEEEP was born.2 Embracing the elements of STEEEP care lent BHCS the IOM's authority to convey to internal and external stakeholders the importance of improving health care quality, and also helped align our work with national health care priorities.

Meanwhile, the health care quality improvement strategic committee— especially committee member Bill Aston, who was then chair of the Baylor University Medical Center Board of Trustees—recognized that BHCS had a history of linking leader compensation to financial performance and suggested the organization extend that focus on performance to other areas.24 Over the next several years, BHCS modified its performance award program to include the areas of People (employee retention); Quality (hospital-standardized inpatient mortality ratio, readmissions, and delivery of evidence-based processes of care); and Service (patient satisfaction) as well as Finance. Although many health care organizations have a culture that precludes linking compensation to performance, BHCS was able to implement a robust approach to designing incentives linked to quality improvement goals. Currently, BHCS has approximately 20,000 employees, all with their own goals in the areas of People, Quality, Service, and Finance, and annual performance reviews and associated annual merit compensation changes are based, in part, on the extent to which they have achieved these goals.

As an organization, BHCS recognized that, to build a culture of qualityimprovement that would extend to all its employees, a core group of leaders would need an in-depth understanding of quality improvement methods, tools, and language. From 2001 through 2003, BHCS sent 40 quality leaders to the Intermountain Healthcare mini-Advanced Training Program course led by Brent James.25 James shared his educational templates with BHCS, and we adapted them, with his approval, to provide BHCS-based examples relevant to our employees. Over the past decade, more than 1,500 BHCS physicians and nursing and administrative leaders have received health care quality improvement training through the resulting "ABC Baylor" course (now, the STEEEP Academy), either in its full form or in one of the tailored adaptations designed to meet the specific needs of certain group leaders (e.g., those who needed a "Fast Track" course).26,27

BHCS leaders understood that, in addition to the STEEEP Academy training and the incentives provided by linking leader compensation to clinical quality performance, the organization would need structures to support a commitment to quality improvement. When I led quality efforts at the Mayo Clinic, I was impressed by how clinical, financial, and operational leaders came together through the Mayo Clinical Practice Committee to address approaches to high-quality health care delivery.28 Over time at BHCS, we have crafted an approach that brings these leaders to a common table through the STEEEP Governance Council (SGC), which promotes improvement efforts that encompass and achieve synergy across all domains of STEEEP care. The SGC structure has enabled BHCS to apply clinical, financial, and operational frames of reference to organizational decisions about health care initiatives.

As our STEEEP journey evolves, many of these decisions will focus on the shift from volume-based to population-based health care. Berwick et al.29 described the "Triple Aim" of health care delivery systems that seek to improve the overall health of populations while reducing costs: (1) improve the patient care experience (including quality, access, and reliability); (2) improve the health of populations; and (3) reduce the per capita cost of health care. The Triple Aim has become the organizing framework for the U.S. National Quality Strategy called for under the 2010 Patient Protection and Affordable Care Act30 and for public and private health organizations around the world, including BHCS. Despite the acknowledged need for population-based care, tensions can arise when health care delivery organizations must make decisions that represent the right thing to do for patients, but that pose problems for organizational financial performance over the short term (e.g., the elimination of clinically unnecessary and/or inappropriate cardiovascular procedures31). One current challenge BHCS faces involves its efforts to refocus its contracts with payers from volume-based to population-based care delivery. This is a particularly complicated task in the Dallas–Fort Worth Metroplex, which is less mature in terms of its focus on population health and the total cost of care than many other markets in the United States.

BHCS is addressing the shift toward population-based health care through several large-scale initiatives, including the founding of its accountable care organization, the Baylor Quality Alliance32,33 and the formation of the Diabetes Health and Wellness Institute, both described in this book. BHCS is also broadening its quality improvement focus to address overuse of care, defined as the provision of health services for which the potential risks outweigh the potential benefits,23 and to promote more widespread use of effective care. Such strategies will enable the system to more effectively and efficiently use scarce resources to optimize the health of a given population. In addition, BHCS enjoys collegial relationships with health care delivery systems in Texas that have historically had a strong population focus, such as Scott & White Healthcare, which has had a health care plan since 1982 and an impressive, more recent history in applying Lean thinking, culture, and tools to improve care. These strengths and strategies will help to support BHCS during the next segment of its quality journey, when, like many other health care delivery organizations, it will need to transition its work from volume-based to population-based care, and use health care resources as efficiently as possible.