By Elizabeth Gardner

Kenneth Abrams likes to ask job candidates what activities they enjoyed when they were kids. He listens for those that involve group cooperation, whether it's sports or debate or band. “I played soccer, and I find that those team-based activities really enable people to do improvement work,” he says.

Improvement work is how he spends his days as senior vice president of clinical operations for 10-hospital North Shore-Long Island Jewish Health System, Great Neck, N.Y.: trying to cut the incidence of central-line infections, standardizing care in prenatal units and developing a protocol for dealing with sepsis. He's not the only one, either: All of the system's 38,000 employees, from the CEO to the janitorial staff, are expected to share the commitment of making patient care better. They're one giant team; and identifying candidates who can contribute to that team culture is a key part of hiring, he says.

All new hires get a session with President and CEO Michael Dowling on how to be a quality advocate—it's a standing appointment on his calendar every Monday morning. They get another orientation at their home facility, where they learn how the system's philosophy is executed at their site. “Some of them get it the first time around,” Dowling says. “If they don't get it eventually, we don't keep them. You don't just have a job here; you have a responsibility to patients.”

It's that systemwide dedication to quality that helped North Shore-LIJ earn the 17th annual National Quality Healthcare Award, presented by the National Quality Forum in partnership with Modern Healthcare. The organization stood out from a group of 10 strong applicants, NQF President and CEO Janet Corrigan says. “They have a strong commitment to quality and impressive results,” she says. “It's a remarkable organization.”

One of the more remarkable aspects of North Shore-LIJ is that it's an organization at all. Before it was created in a 1997 merger, it was a disparate collection of facilities bound up into two groups: North Shore Health System and Long Island Jewish Medical Center. Its services include not only acute care, but long-term care, hospice and home care. Its service area encompasses urban, suburban and rural areas, and many of its component facilities were originally competitors.

Dowling arrived in 1995 as chief operating officer at North Shore Health System after a varied career that included stints at Blue Cross and Blue Shield, the New York State Health and Human Services Department, academic posts at Fordham and Columbia universities, and jobs in construction and plumbing. He paid his way through college as a dockworker after emigrating from Ireland. (“There is no such thing as a bad job,” he says. “Everything is a good experience and a learning experience.”)

Dowling spent much of his first decade in the organization handling issues connected to the merger. He took over as CEO in 2002. “We didn't just want a collection of entities standing side by side,” he says. “We wanted to have consistent administrative oversight and leadership, share best practices and set the rules of the game so everyone applies the same principles and standardized metrics across the whole system.”

The merged entity operates a corporate university for its employees, the Center for Learning and Innovation, to provide continuing education in management skills. One of its components, the Patient Safety Institute, has patient simulator mannequins that mimic medical scenarios. North Shore-LIJ employees get hands-on practice to polish their skills in taking vital signs, inserting central lines, intubating and performing various procedures.

While the system tracks all the standard core quality indicators, it also takes on specific quality- improvement projects based on its own internal priorities. During the past four years, the system has been working to reduce the number of central-line infections. “Every central-line induced bacteremia is a catastrophe, so this isn't something minor,” says Chief Medical Officer Lawrence Smith, who's been with North Shore-LIJ for five years.

Reducing central-line infections meant adopting a systemwide protocol for inserting and checking them, and following it every time. “The solutions we were asking people to take on were pretty common sense,” Smith says. “If there were doubters, it was because they thought the protocol was too simple to accomplish anything, but the drop in infections was rapid enough to reinforce its effectiveness.” Central-line infection rates systemwide dropped 60.3% between 2004 and 2008, and there was an 8.7% decrease in the number of days patients were on central lines.

While there's systemwide consistency on quality-improvement protocols, Abrams says individual facilities have a lot of latitude in how to execute them—essential in an organization with so many different sizes and types of facilities. For example, in the guidelines being piloted for sepsis, the protocol calls for putting a central line into a patient who's not responding to fluid administration. But it doesn't specify who should handle the procedure—that's up to the hospital.

“In a large tertiary hospital, the ER doc might be the right person, but a community hospital might only have one ER physician,” Abrams says. “They might specify that a surgeon or one of the critical-care docs should put it in.”

Key to North Shore-LIJ's quality improvement are its existing inpatient electronic health-record system and a plan to provide its employed and affiliated physicians with an outpatient EHR. During the next few years, the system will pay 85% of the cost of physician office EHRs (the limit under federal regulations), as long as they agree to full clinical integration with the inpatient EHR. The investment is estimated at about $400 million.

“People keep talking about managing the continuum of care, but it's empty rhetoric unless you have all the providers connected,” Dowling says. “There is no human smart enough to track all the protocols without the help of technology.”

Following are some of the ways North Shore-LIJ met the NQF Quality Award criteria:

Prioritizing goals

North Shore-LIJ has a continuous cycle, called the Quality Prioritization Process, to focus the board, managers and clinical leadership on short- and long-term strategic objectives, and to align quality goals with operational performance. Those quality goals come not only from external sources such as the Joint Commission, CMS and Institute for Healthcare Improvement, but also from assessing the specific needs of its communities and component facilities. Patient advisory councils help assess the effectiveness of services, both overall and in very specific areas such as diabetes in pregnancy and cystic fibrosis.

Some 2009 systemwide goals included improving hospitals' “likely to recommend” scores in patient-satisfaction surveys, reducing risk-adjusted mortality, improving appropriate care scores for acute myocardial infarction, heart failure and pneumonia, reducing 30-day readmissions and improving operating margins. Individual hospitals and departments have additional goals.

Using effective ‘dashboards'

Once the quality priorities have been established, their performance metrics are built into a dashboard to track progress. The dashboard for each goal includes current and three-month-average data, three sets of targets (a threshold or minimum, a goal and a “stretch goal”), and an internal or external benchmark.

The system benchmarks itself with national criteria for excellence, including those from the NQF, Agency for Healthcare Research and Quality, Institute for Safe Medication Practices, National Patient Safety Foundation and Institute of Medicine quality reports. Red and green coding shows at a glance which areas are making adequate progress and which are lagging.

Dashboards are produced at the hospital and system levels, and for each service line and ancillary business unit. They are used by every level of management including frontline caregivers.

Commitment to transparency

North Shore-LIJ works to increase transparency internally and externally. Within the organization, the Physician Activity and Outcome Report provides individualized, risk-adjusted and peer-benchmarked performance reports for system physicians across all specialties. They include measures such as average length of stay, mortality rates and resource utilization, and they reflect compliance with AHRQ's Patient Safety Indicators and CMS Core Measures.

Currently, they are produced twice a year, though there are plans to release them quarterly. They're used by the physicians themselves and also by department chairs and medical directors to discuss physicians' performances and make reappointment decisions. A hand-hygiene project uses video cameras to monitor handwashing behavior and transmit feedback to nurse managers and attending physicians. Hand-hygiene compliance rates are also available to the general public on the system's Web site. Handwashing rates improved by 81% after the system was put in place.

The Web site also publishes quality data or provides links to its information in the federal Hospital Compare database and other sites. It's one of only two health systems in New York to publish its hospital-acquired infection rates.

Data-driven improvement

Quality-improvement projects at North Shore-LIJ start with analysis of internal and external data. An initiative to improve care for heart failure patients began with a multidisciplinary task force that combed the medical literature for data on best practices. The task force, working with subcommittees corresponding to each phase of care, put together flow charts to identify gaps in care and barriers to effective and efficient care.

It then developed algorithms for ideal care and educational materials to train caregivers on the algorithm. The algorithm was put into practice in 2007, and 2008 saw improvements in the system's treatment of heart-failure patients, including reduced mortality, reduced readmissions, reduced length of stay and an increase in the number of patients discharged with home-care services already in place.

Demonstrated results

North Shore-LIJ participates in all mandatory quality reporting initiatives and a number of voluntary ones as well. The system showed improvement on all but one of its composite scores in the CMS Hospital Quality Alliance public reporting program. Its score on the Surgical Care Improvement Project jumped almost four points between 2007 and 2008. Nine of the system's 13 hospitals participate in the CMS Hospital Quality Incentive Demonstration Project, a pay-for-performance demonstration, and all nine received incentive awards. One of its hospitals received the highest monetary award in the project.

When CMS published 30-day readmission rates for the first time in 2008, North Shore-LIJ found that its facilities were performing, at best, right at the national average rate. Those results prompted the system to set a goal of improving readmission rates, and it has added that piece of data to its dashboard to track trends. Likewise, the system's below-average performance on the federal HCAHPS patient-satisfaction survey prompted it to add patient satisfaction to its goal list.

On state-reported measures, the system has significantly lower rates than the New York average on central-line infections and surgical-site infections, and does significantly better on complying with stroke treatment guidelines.

Elizabeth Gardner, a former Modern Healthcare reporter, is a freelance writer based in Riverside, Ill. She can be reached at gardnerem@sbcglobal.net.