CQI at Suburban Hospital Larry K. McReynolds Clara Maass Health System is composed of a 475-bed community hospital, a 120-bed long-term care facility, a 10-bed subacute care unit, and a visiting nurse agency. It is located in north Newark, New Jersey. The hospital is the largest entity of the health system, having been in existence for 125 years. It is a community-based non-teaching hospital and the medical staff is an older, conservative group, wary of change. The employees typically pride themselves on being part of their local hospital, but have recently become disturbed by the changes occurring. The introduction of managed care into the local marketplace has contributed to growing unease among the hospital administration given the service changes that must occur in the immediate future. Some of the key factors causing this concern include:

1. The county in which Clara Maass is located has 14 other hospitals, making the county over-bedded by 200 percent.

2. The competitive environment is enabling managed care companies to force hospitals to accept reimbursement rates below their costs.

3. The hospital's average length of stay and average cost per discharge are significantly higher than those of other hospitals in the area.

In an attempt to help bring about some of the needed changes in the organization, administration decided to implement a CQI program. The hospital CQI program had been approved by the board of trustees and had now been in place for almost two years.

The CQI program was implemented through required CQI training for managers, all employees, and as many physicians as possible. Initially, quality action teams (QATs) were chartered to examine operational and clinical issues.

Operational QATs were chartered by the steering committee to address processes and procedures that were high-volume, problem-prone, costly, or likely to have an adverse effect on the patient. Elements predictive of patient satisfaction were also used to determine if a QAT should be chartered.

The patient services department selected the CareMap format for addressing physician and complex patient care issues. CareMaps are multidisciplinary tools that help establish care protocols and delineate expectations about factors such as clinical outcomes and length of stay based on the patient's case type. CareMaps were developed using the primary nurse model, placing the nurse as the responsible party for keeping the patient on the specific CareMap.

To facilitate integration of CQI principles among all employees, managers attend an ongoing workshop. This monthly meeting is designed to provide a non-threatening forum for managers to examine their department processes and outcomes, and to determine the degree of the department's success in meeting customer needs. Ideas from the workshops and suggestions from the QATs and CareMaps process are approved by the steering committee and implemented by the team.

Case Questions

1. Employees have the feeling that eliminating "wasted work" and improving processes is a fancy way of eliminating more jobs. Identify strategies to overcome this impression.

2. Managers feel this is the management philosophy of the week. Identify and describe effective means to overcome this barrier.

3. Physicians see CareMaps as cookbook medicine imposed upon them by the nursing department. Describe ways to get them to buy into CareMaps.

4. Identify organizational strategies that the hospital should adopt to make the institution more viable in the marketplace.