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Building a Culture of Quality and Safety at Yale New Haven Health · Becker’s Healthcare Podcast

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1:00
- Hello, everyone, and welcome to the Becker's Healthcare
1:03
- Clinical Leadership Podcast.
1:05
- I'm Mackenzie Bean, associate vice president and managing
1:08
- editor of Becker's Hospital Review.
1:11
- Today, I'm so thrilled to be joined by
1:13
- doctor Kate Halpern, who is president of Yale
1:16
- New Haven Hospital and executive vice president for
1:19
- Yale New Haven Health,
1:20
- as well as doctor Deborah Rhodes, who is
1:23
- chief quality officer and professor of medicine at
1:25
- Yale Medicine
1:27
- and Yale New Haven Health System.
1:29
- Doctor Halper and doctor Rhodes, thank you both
1:31
- so much for joining us on the podcast
1:33
- today.
1:34
- Delight. Thanks for having us.
1:36
- So I know I'm, talking with you both
1:39
- a few weeks after CMS released its updated
1:42
- overall hospital star ratings, and Yale New Haven
1:45
- Hospital earned five stars, making it one of
1:48
- the largest hospitals in the country to do
1:50
- so. Congrat congratulations. Such a notable achievement. I'm
1:53
- excited to dive into that more today.
1:56
- I think it's particularly notable as well considering
2:00
- Yale New Haven Hospital is a safety net
2:03
- hospital
2:04
- serving a high Medicaid, high complexity
2:06
- population.
2:08
- What does it actually take to achieve top
2:11
- tier quality outcomes like that
2:13
- in that environment
2:15
- when we know there can be a lot
2:16
- of factors going on there that can affect
2:18
- metrics for for safety net hospitals that might
2:21
- be outside of their control?
2:23
- That's such a great question, but what I
2:25
- would lead with, Mackenzie, is that we are
2:27
- really here
2:28
- for our patients.
2:30
- And what is in our control is how
2:33
- we architect ourselves
2:35
- and choose to respond
2:37
- to some of the external pressures and some
2:39
- of the external factors.
2:41
- And doctor Rhodes and I have been working
2:44
- in tandem,
2:46
- as she has laid out with her team
2:48
- the amazing strategic playbook around quality and patient
2:51
- safety for the health system
2:53
- and for Yale New Haven Hospital.
2:55
- And one of the things we've been embarking
2:57
- on over the last couple of years has
2:59
- really been
3:01
- a cultural change around strengthening the dyad relationship
3:05
- between nurses and physicians at the frontline,
3:09
- and I would actually say triad
3:11
- relationship with our advanced practice providers.
3:14
- The other important thing is that as we've
3:17
- reimagined
3:18
- our senior leadership team, we've become much more
3:22
- forward facing to the front lines with really
3:24
- active leadership rounding
3:26
- and embracing a culture where people can arc
3:29
- up concerns,
3:30
- raise safety issues, and we've got a, an
3:33
- iterative process to manage that. But this is
3:36
- all undergirded by,
3:38
- I think, an incredible set of processes
3:41
- related to the structure, which
3:43
- doctor Rhodes will describe the processes we've put
3:46
- in place and using that as the platform
3:49
- to drive the outcomes.
3:51
- So really on a high level, leaning into
3:54
- dyad and then triad leadership as well as
3:56
- you mentioned
3:57
- and really reimagining the broader senior leadership team.
4:00
- And it sounds like that combined with some
4:02
- of the
4:03
- structural or processes
4:05
- put in place have really been the recipe
4:07
- for success. Doctor Rhodes, can you expand a
4:09
- bit on on the process piece? What have
4:11
- been some of those care delivery or operational
4:14
- changes
4:14
- that have moved the needle on your quality
4:16
- metrics the most?
4:18
- I appreciate you asking a question in that
4:20
- way because I think if you approach quality
4:23
- and safety as an operational
4:25
- change,
4:25
- you've lost people.
4:27
- You have to inspire
4:29
- the staff and reframe what quality and safety
4:33
- means.
4:34
- I think quality and safety
4:36
- had become
4:38
- synonymous with a dry scorecard of reportable metrics
4:43
- that were tracking a relatively
4:45
- small number
4:47
- of adverse outcomes that occur in the hospital.
4:50
- And instead,
4:51
- we wanted to
4:54
- inspire and reframe
4:56
- what quality means to everyone who works in
4:58
- our health system and make it recognizable
5:02
- and meaningful and actionable to them. So the
5:06
- very first thing I did was I named
5:08
- it.
5:09
- I named what we were going to do
5:12
- differently, and I think this is profoundly important.
5:15
- This isn't just quality and safety
5:18
- as we've done it historically.
5:20
- We called this full system quality.
5:23
- It was a comprehensive
5:25
- redesign
5:26
- of performance improvement,
5:29
- not around a small number of dry metrics,
5:32
- but in a way that would touch every
5:35
- patient
5:36
- with every condition
5:38
- in every setting across our health system.
5:41
- So how are we going to do that?
5:43
- We began by building a pyramid,
5:46
- and at the base of that pyramid, we
5:48
- defined
5:49
- roles and responsibilities
5:51
- for everyone who touches the quality and safety
5:54
- and equity of care for our patients. That
5:57
- starts with the board. It includes executive leaders.
6:00
- It includes
6:02
- the dyad leaders to which Kate has
6:05
- referred and really built those what it means
6:08
- to be a dyad partnership.
6:10
- We centralized the quality and safety team. We
6:13
- defined roles and responsibilities
6:15
- for the frontline teams,
6:17
- and we also convened a patient and family
6:20
- advisory council
6:22
- for their input on everything related to the
6:25
- quality, safety, and equity of care that we
6:27
- delivered.
6:29
- Onto that base, that foundational
6:31
- pyramid of responsibility
6:33
- and accountability
6:34
- for quality and safety,
6:36
- we layered new tools
6:39
- and new forms of communication.
6:42
- And that started with
6:44
- standard
6:45
- work.
6:46
- Standard work,
6:48
- standard metrics,
6:49
- standard data sources,
6:51
- standard data definitions,
6:54
- a standard performance improvement methodology,
6:58
- and standard scorecards
7:00
- that were not just one generic scorecard, although
7:03
- they were built around our agreed upon quality
7:06
- priorities,
7:07
- but it drilled it down to the service
7:09
- line and department level. So, again,
7:12
- you have clear accountability
7:14
- for your contribution to the quality, safety, and
7:17
- equity of care that we provide.
7:20
- Then we established a number of new structures
7:24
- around,
7:25
- quality and safety
7:27
- support.
7:28
- So to give you a few examples,
7:31
- we convened
7:33
- safety
7:34
- forward platforms to really take a proactive
7:38
- approach
7:39
- to recurrent safety vulnerabilities
7:42
- in our system, such as medication safety.
7:45
- We established
7:47
- daily management boards and tiered huddles
7:50
- to communicate our quality and safety priorities
7:53
- from the frontline unit based teams all the
7:56
- way up to executive leadership
7:58
- and all the way back down in a
8:00
- day, so so that every day we're convening
8:03
- around those standard quality and safety priorities.
8:07
- We also convened care signature councils to define
8:10
- our best practice standards
8:13
- for every service line and department.
8:15
- So we have 22 of those councils, which
8:18
- really govern
8:19
- quality and safety
8:21
- at that very specific level for every condition
8:24
- for which we provide care.
8:27
- And then we also implemented some new tools
8:30
- that were specifically focused around those key quality
8:34
- metrics
8:35
- for mortality.
8:37
- We introduced an early warning score for our
8:40
- hospital associated
8:41
- infections.
8:42
- We introduced a daily reportable tracker
8:46
- to make sure that we are aware
8:48
- of all the patients that are vulnerable to
8:50
- those infections and the steps we need to
8:52
- take to prevent them. So it was with
8:54
- those standard tools that we layered onto that
8:57
- pyramid of
8:59
- foundational roles and accountability
9:01
- that we really drove this improvement.
9:04
- We identified a common goal. Our goal is
9:07
- to be in the top decile of academic
9:09
- medical centers across the country
9:11
- on every single one of the quality measures.
9:14
- And, again, we defined the ultimate goal, which
9:18
- is to touch every patient
9:20
- or with every condition in every setting
9:23
- across the care that we provide.
9:26
- I appreciate that comprehensive
9:29
- overview. I think it's so helpful to hear.
9:31
- And, you know, I often speak with quality
9:33
- executives, and they talk about the importance of
9:35
- really integrating quality into
9:38
- day to day work and operations. But I
9:40
- think you also make such a great point
9:41
- that it really can't feel like a dry
9:44
- operational
9:45
- focus, but it needs to have be tied
9:48
- to the mission and values and truly be
9:49
- ingrained in an organization. It sounds like you
9:51
- really took that to heart when you're setting
9:53
- that foundation base of your pyramid before you
9:56
- started layering
9:57
- on top of that.
9:59
- I'm curious when did this
10:01
- work begin? How far are you into the
10:03
- journey
10:04
- of building this trying this pyramid and and
10:06
- implementing it across the system?
10:08
- So we began building these,
10:11
- constructs in 2022,
10:14
- recognizing
10:15
- that with a lag in so much of
10:17
- the quality,
10:18
- reporting and performance,
10:20
- we this would this would be a multi
10:22
- year
10:23
- multi tiered strategy.
10:26
- So we are now at last, I think,
10:28
- seeing the fruits of that strategy.
10:31
- Yeah. The fruits of your labor.
10:34
- You lay it out in such a
10:37
- clear and simple way by but I imagine
10:39
- that this level of
10:41
- standardization
10:42
- took a lot of
10:43
- hard work and focus. I'm curious
10:46
- what were one of the biggest obstacles that
10:48
- you
10:49
- faced across the,
10:51
- team and system as you were rolling this
10:52
- out, and how did you overcome it? I
10:54
- think,
10:56
- it's always helpful for executives from other systems
10:59
- to hear those types of lessons if anything
11:01
- comes to mind.
11:02
- So we had two,
11:05
- significant obstacles.
11:07
- The first was that when we started this
11:09
- work, our quality and safety team was not
11:11
- centralized.
11:13
- We had quality and safety,
11:15
- roles
11:17
- embedded in different
11:18
- hospitals,
11:20
- in different departments and service lines,
11:23
- and those teams were not necessarily
11:26
- using the same sources of truth.
11:29
- They were not necessarily honing to the same
11:31
- priorities.
11:32
- And so you sometimes had disparate senses
11:36
- of how we were performing
11:38
- on critical quality measures.
11:41
- By centralizing
11:42
- the quality and safety team and standardizing
11:45
- those roles
11:46
- remember that at that time,
11:49
- the the same role might have an entirely
11:52
- different job description because they the reporting structures
11:55
- were so complex.
11:57
- But by bringing those under one standard reporting
12:00
- structure and standardizing those roles,
12:03
- we were able much more efficiently
12:06
- to move towards those
12:08
- agreed upon quality objectives.
12:11
- The second big obstacle
12:13
- is that we didn't have standard
12:15
- sources of truth.
12:16
- So we really spent a lot of time,
12:19
- and we're still doing this work,
12:22
- standardizing
12:24
- the data definitions
12:25
- and data metrics that we use for the
12:28
- hundreds and hundreds of reportable metrics across the
12:31
- different service lines.
12:33
- It's not just been an an organizational
12:36
- change. It's been an incredible
12:38
- cultural change.
12:40
- It's really been a situation of moving
12:43
- thousands of people,
12:45
- in a in a unified
12:46
- direction towards a single purpose
12:50
- and a and a and a single goal.
12:52
- And I I I can't
12:54
- I can't state,
12:57
- with with greater passion and imperative
13:00
- the leadership that doctor Rhodes' team has provided
13:04
- for the entirety of the system. Focusing for
13:06
- just a moment on Yale New Haven Hospital,
13:09
- there are more than 15,000
13:12
- staff here
13:13
- and thousands of physicians.
13:16
- And so moving that body in a unified
13:19
- way,
13:20
- has been a remarkably
13:23
- great bit of work, and I think,
13:26
- again, it's in part because people have come
13:29
- to understand the purpose
13:31
- of coming together for the greater good of
13:33
- the whole to advance patient safety and to
13:36
- really work to provide the highest level of
13:39
- care quality. And that's from the top
13:43
- of the organization
13:45
- filtered all the way from frontline care, support
13:48
- services,
13:49
- back office.
13:51
- Everybody, I think, is now at a place,
13:53
- and it's taken a couple of years, but
13:55
- everybody's at a place where they really understand
13:58
- now the why,
14:00
- the purpose behind this journey, and what their
14:03
- role is in it. Mhmm. What doctor Halpern
14:06
- is not mentioning is her
14:09
- her role in inspiring this and I do
14:11
- just wanna touch upon it because I think
14:13
- it's so critical.
14:14
- So she
14:17
- leads from
14:20
- a a sense
14:21
- of inspiration
14:23
- and
14:25
- walking the walk
14:27
- every single day. She is out in the
14:29
- hospital
14:30
- every day meeting with people, greeting people,
14:33
- hearing their feedback,
14:36
- asking them questions,
14:37
- learning from them, responding to them, supporting to
14:40
- them, and supporting them. And she has really
14:44
- given this sense that we can do this
14:47
- together. We can
14:50
- achieve
14:51
- these lofty goals together.
14:54
- And I mentioned earlier the importance of new
14:59
- communication
15:00
- forums.
15:00
- She has really developed
15:03
- a meeting
15:04
- structure that nobody wants to miss.
15:07
- And most of the time, everybody wants to
15:10
- miss meetings.
15:11
- But in this case,
15:13
- everybody wants to go to this meeting because
15:16
- it's where
15:17
- things
15:18
- happen. And you walk away from that meeting
15:20
- feeling
15:21
- not only did I get to communicate the
15:24
- key message that we need everyone here to
15:26
- know about quality and safety this month,
15:29
- but I also feel inspired and renewed
15:32
- that we can do this together. And it's
15:35
- that sense of hopefulness
15:38
- and belief in our system
15:40
- that it takes a special kind of leader
15:43
- to catalyze, and
15:45
- she has done that for this hospital.
15:48
- I think
15:49
- that type of
15:51
- alignment and inspiration from a leadership team is
15:53
- just so
15:54
- infectious.
15:56
- Doctor Halper, I'm wondering if you can speak
15:58
- a little bit more to
15:59
- that meeting in terms of the main focus
16:01
- of it,
16:03
- why it's been so successful.
16:05
- I think
16:06
- we've
16:07
- we've changed the meeting to be far more
16:10
- inclusive.
16:11
- And,
16:12
- by the title management meeting, one one would
16:15
- think that isn't something that that you'd want
16:17
- to attend.
16:19
- But what we have done is try to
16:20
- reach out across the spectrum of our two
16:22
- campuses and 1,500
16:24
- beds
16:25
- to include
16:26
- not just the local managers, but system managers
16:29
- as well as physician leaders. And that's a
16:32
- change
16:33
- that, that I made purposefully a number of
16:35
- months ago. And and to see that sort
16:38
- of connection
16:40
- as people are gathering,
16:42
- and, and to hear their stories and to
16:44
- have them
16:45
- communicate, ask questions, and,
16:48
- and offer their input, I think, has given
16:51
- the hospital as a whole, if it were
16:53
- a living, breathing organism,
16:55
- a true sense of self efficacy.
16:57
- And that's the belief that Deb is talking
16:59
- about. I think the team really feels like
17:04
- we can accomplish anything together.
17:07
- And there's nothing more powerful
17:09
- than that. I know this is also a
17:11
- big year for Yale New Haven Hospital celebrating
17:14
- its bicentennial
17:15
- year, which is so amazing.
17:18
- Here's what have the past two hundred years
17:20
- of serving your community and that legacy really
17:23
- taught you all as a leadership team about
17:25
- delivering high quality care for your community community
17:29
- today? How do those lessons show show up
17:31
- in the day to day work?
17:33
- I'll start perhaps, but I do hope doctor
17:35
- Rhodes will will amplify some of my comments.
17:39
- So I guess one could say we've had
17:42
- two hundred years of experience
17:44
- in in working,
17:46
- on behalf of our patients, and
17:48
- I think what that has given us
17:50
- is a true sense of purpose around the
17:52
- deep and abiding commitment we feel to the
17:55
- community we serve
17:57
- and the sense of health equity that we
17:59
- hope to bring to the communities that we
18:01
- serve.
18:03
- We do sit at an interesting intersection
18:06
- as a safety net hospital
18:08
- and a deliverer
18:10
- of some of
18:12
- the highest touch,
18:14
- highest tech, highest complexity
18:16
- quaternary care that is
18:19
- imaginable
18:20
- in in the world, actually.
18:22
- And so I think by
18:24
- by maintaining
18:26
- our vision around community,
18:28
- health equity,
18:30
- and the history that we have here,
18:32
- we're actually
18:33
- serving for the greater root of all. And
18:35
- we're and we're rather than rather than it
18:38
- being diminishing,
18:40
- it's actually
18:41
- strengthening for us. So we're not just coexisting
18:44
- with this dyad. We're actually amplifying the opportunity
18:48
- across the
18:49
- board. Beautifully said.
18:52
- And yet,
18:53
- it is
18:55
- profoundly challenging and ever more challenging
18:58
- to serve the needs of the most vulnerable
19:01
- people in our community
19:03
- in this environment.
19:04
- And so we are
19:06
- trying to become more creative with
19:10
- community resources.
19:12
- Just this morning,
19:14
- we were having a a conversation
19:16
- of how we could align
19:18
- our street medicine team
19:21
- with our addiction medicine team,
19:24
- with other resources in the community
19:27
- to really help
19:28
- unhoused patients with cirrhosis,
19:31
- which we had identified as a key quality
19:34
- opportunity in some of our data analysis just
19:36
- this morning.
19:38
- So it's really about building those partnerships
19:41
- across
19:42
- many partners outside of our health system
19:45
- to support the community as best we can.
19:49
- I I am,
19:51
- every day,
19:52
- just sort of hand to heart
19:55
- about what our clinical providers
19:58
- come up with, how they create and iterate
20:01
- on opportunities for the community. It's it's it's
20:05
- really remarkable. And then
20:07
- when we, as Deb said, work together in
20:10
- partnership
20:10
- with community organizations,
20:13
- that that that power so that's another
20:16
- incredibly important
20:17
- dyad relationship
20:19
- that we do not take for granted, but
20:21
- we feel we've got a very important role
20:24
- in the greater New Haven
20:26
- set of communities
20:27
- and and beyond.
20:30
- And it sounds like you've really built a
20:32
- culture where the entire
20:34
- team at the system
20:36
- understands that and is so dedicated
20:38
- into the work that they're doing.
20:41
- I'm curious
20:41
- reflecting on all of the work that
20:44
- you've done,
20:45
- your five star rating, and where you're going
20:47
- from here.
20:48
- Here's
20:49
- what advice would you have for listeners who
20:52
- are listening to this episode,
20:55
- trying to get their hands around their own
20:56
- quality performance?
20:58
- What are maybe one or two operational
21:00
- moves or pieces of advice you'd, tell them
21:03
- to look at first?
21:05
- I would say first,
21:07
- identify
21:08
- your most compelling
21:11
- quality and safety priorities
21:13
- and hone into those
21:16
- rather than trying to boil the ocean.
21:18
- And, obviously, they need to be expressed
21:21
- in real time data
21:23
- as opposed to performance that may be lagging
21:26
- in some of the CMS and other programs.
21:29
- And then hone in on those top opportunities
21:33
- and priorities,
21:34
- but drill down
21:36
- to the contribution
21:39
- of each individual service line and department
21:42
- to those shared priorities.
21:44
- So that's a really key first step.
21:47
- The second step is
21:49
- standard work and standard metrics. I I cannot
21:53
- emphasize that enough. Your performance can look,
21:57
- stellar or dismal
21:59
- depending on how you define,
22:03
- the source of truth for your data
22:05
- and the way you track it. And being
22:08
- extraordinarily
22:10
- transparent
22:10
- and consistent
22:12
- about those definitions
22:14
- and metrics
22:15
- is critical.
22:17
- Having accountable roles
22:20
- for more than just the quality team
22:23
- is critical.
22:24
- The quality and safety team cannot
22:27
- operationalize
22:28
- quality and safety.
22:30
- We have to work together with every other
22:33
- team
22:34
- to do this,
22:35
- which is so difficult to define
22:38
- who is doing what
22:40
- and who is accountable for what. And many
22:43
- teams
22:44
- and hospitals and systems, including ours to some
22:47
- degree,
22:48
- have shied away
22:50
- from that work
22:52
- of defining
22:53
- roles and accountability. And we have really tried
22:56
- to do that in these last two years
22:59
- with with transparency
23:01
- and fairness.
23:02
- And lastly, I would say
23:05
- communicating
23:06
- performance
23:07
- regularly and consistently,
23:09
- but also
23:11
- humanly
23:12
- with the patient at the center
23:14
- so that these don't become
23:16
- dry numbers.
23:18
- Every time we improve quality and safety,
23:21
- we improve the lives
23:23
- of patients.
23:24
- And if you
23:26
- somehow miss that connection,
23:28
- you will never meaningfully improve quality and safety.
23:32
- So always keeping patients at the center of
23:35
- those metrics.
23:37
- Wonderful.
23:38
- Well, doctor Rhodes, doctor Halpern, I so appreciate
23:42
- you giving us a peek behind the curtain
23:44
- at so much of the
23:46
- care and strategy and focus and hard work
23:48
- that,
23:49
- contributed to your five star rating in this,
23:52
- safety grades update. It really is remarkable to
23:55
- hear about the scale of change management and
23:57
- this cultural transformation that's driving so much quality
24:00
- success for you. So thank you both for
24:02
- joining us on the podcast today and sharing
24:04
- your insights. We so appreciate it.
24:06
- Thank you again. Thank you.