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

Introduction

SECTION I: System Alignment for STEEEP Care
Governance
Leadership
Organizational Structures
Alignment, Goal Setting, and Incentives
Financial Leadership
Physician Leadership
Nurse Leadership

SECTION II: Infrastructure and Tools for STEEEP Care
STEEEP Academy: Teaching Rapid-Cycle Improvement for Cultural and Process Change
Applications of Lean to STEEEP Care Improvement
STEEEP Analytics: Creating Data-Driven Improvement
STEEEP Care Operations: Organizational Structure and Approaches
Evaluating Clinical and Financial Outcomes to Determine Best Practices
Driving STEEEP Care Across a Multihospital System
Driving STEEEP Care Across a Physician Provider Network

SECTION III: Achieving STEEEP Care
Safe Care
Clinical Excellence through Effectiveness and Timeliness
Efficient Care
Equitable Care
Patient-centered Care

SECTION IV: STEEEP Care in Practice: Service Lines and Lines of Business
Cardiovascular Services
Emergency Services
Critical Care Services
Oncology Services
Surgical Services
Orthopedic Services
Applications of Quality Improvement Methods to Driving STEEEP Care Through a Health Care Delivery System Owned and Operated Health Care Plan
Engaging STEEEP Care through an Accountable Care Organization
Diabetes Health and Wellness Institute: An Escape Fire Model for STEEEP Care

Conclusion

Biography

David J. Ballard, MD, MSPH, PhD, FACP is senior vice president and chief quality officer for the Baylor Health Care System (BHCS), executive director of the BHCS Institute for Health Care Research and Improvement, and president and founder of the BHCS STEEEP Global Institute. Dr. Ballard is responsible for leading health care quality across BHCS. Under his leadership, BHCS has received many awards for health care quality improvement, including the 2010 Medical Group Preeminence Award of the American Medical Group Association, the 2008 National Quality Healthcare Award of the National Quality Forum, and the 2007 Leapfrog Patient-Centered Care Award.

Associate Editors:

Neil S. Fleming, PhD, ASQ CQE is vice president and chief operating officer of the BHCS STEEEP Global Institute, which capitalizes on the health care system’s successful strategies, tactics, and tools in health care quality improvement to enable other health care organizations to improve care while reducing costs. He previously served as the BHCS vice president for health care research for seven years, evaluating clinical and financial outcomes of BHCS initiatives with a major focus on health information technology, work in which he collaborated closely with Dr. Ballard.

Joel T. Allison, MHA, FACHE is president and chief executive officer of BHCS. In this role, his primary responsibility is to lead the organization in attaining its vision "to be trusted as the best place to give and receive safe, compassionate, quality health care." To do so, Mr. Allison continues developing BHCS as a patient-focused health care delivery system and clinical enterprise that emphasizes quality, safe patient care, measurable outcomes and improvement initiatives, as well as continuous medical education and health care research.

Paul B. Convery, MD, MMM served as senior vice president and the first chief medical officer for BHCS from 2006 to July 2013. Under his direction, BHCS was recognized with several important quality awards, including the 2008 National Quality Forum National Quality Healthcare Award and the 2007 Leapfrog Patient-Centered Care Award. Dr. Convery is currently serving as a senior consultant for the BHCS STEEEP Global Institute.

Rosemary Luquire, RN, PhD, NEA-BC, FAAN is senior vice president and chief nursing officer for BHCS. She joined BHCS as senior vice president and corporate chief nursing officer in 2007, the first nurse to serve in that organizational capacity. She is responsible for overseeing both strategic and operational issues that impact nursing practice and patient care across sixteen facilities.

The stewardship and focus of Baylor Health Care System (BHCS) documented in Achieving STEEEP Health Care provides the multi-dimensional journey to sustainable quality improvement needed to address America’s health system challenges. Under the clear direction of its board and senior leaders, BHCS has firmly addressed the vital components of culture, knowledge, teamwork, alignment of incentives, and change expectations to advance BHCS towards its vision. Embedding the Institute for Health Care Research and Improvement under the direction of BHCS Senior Vice President and Chief Quality Officer, Dr. David Ballard and his team have provided the bench strength to implement and attain such needed change. Vision driving change to better care, an important read and roadmap to follow.
—Arja P. Adair, Jr., MBA, President and Chief Executive Officer, Colorado Foundation for Medical Care

Quality of care is the central tenet of the promise that every health care provider makes to the patient. This text is a must for all those who believe that a constant search for better ways to assure and improve quality is an important part of keeping that promise.
—John Agwunobi, MD, Senior Vice President and President of Health and Wellness, Wal-Mart Stores, Inc.

Inspiring, motivational, evidence-based, ‘can do’ blueprint for incorporating quality into the organizational DNA and culture of complex health care systems. Practical tips like making the chief financial officer a quality champion and creating infrastructure for sustaining quality through transforming the professional nurse practice environment make this volume a must-read.
—Linda H. Aiken, PhD, FAAN, FRCN, RN, Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research, University of Pennsylvania

Achieving STEEEP Health Care is a compelling and comprehensive book on improving quality. Baylor Health Care System’s commitment to better health care is unmatched, and in David Ballard they found a person who can not only lead change, but also capture and characterize the key insights that will help the rest of us get on the path to superb care.
—Troyen A. Brennan, MD, MPH, Executive Vice President and Chief Medical Officer, CVS Caremark

The International Society for Quality in Health Care has taken a number of initiatives in its quest to ‘inspire, promote and support continuous improvement in the quality and safety of healthcare worldwide,’ one of which is to seek to enhance the quality of the ‘patient journey’. I was impressed therefore to reference in this excellent publication from Baylor Health Care System to meeting ‘…the needs of the individual patient across the continuum of care.

Achieving STEEEP Health Care comprehensively guides us through the operationalizing of the delivery of safe, efficient, effective, equitable and patient-centered care and as such it provides both a welcome focus and a useful practical guide to all who want the best for those in their care.
—Peter Carter, Chief Executive Officer, International Society for Quality in Health Care

The American health care system is undergoing much needed and dramatic change driven by the need to be more efficient and more effective in delivering high quality and safe care that improves the overall health of the population and does not bankrupt the country in the process. What will this health care system of the future look like? The Baylor Health Care System, which this book outlines in such detail that it could be a cookbook for how to create a future health care system. David Ballard is the architect, STEEEP is the foundation, and this book is a roadmap of how Baylor Health Care System has made the journey to this new destination. Any health care leader faced with this inevitable transformation of their organization will find this book an essential part of their survival guide in the rapidly changing landscape that is the American health care system.
—David Classen, MD, MS, Chief Medical Information Officer, Pascal Metrics Associate Professor of Medicine and Consultant in Infectious Diseases, University of Utah School of Medicine

This book is a ‘must read’ for leaders in health care – the Baylor Health Care System leaders have been wonderful national contributors and a catalytic force in the quality and safety arena. The practical strategies and tactics they put forth will save lives, save money, and create value in the communities we serve.
—Charles Denham, MD, Founder and Chairman, Texas Medical Institute of Technology

'Vision without execution is hallucination,' Thomas A. Edison said. Baylor Health Care System developed a vision and executed it. Ballard and his colleagues have led a terrific transformational process of the health care system in which they work. Achieving STEEEP Health Care documents this process and measures the results in terms of quality improvement and patient safety. This book is a very useful tool for those aiming to lead change, not only in U.S. health care organizations, but also in other health care systems worldwide.
—Carlo Favaretti, MD, MPH, President and Founder, Italian Society of Health Technology Assessment; Former Chief Executive Officer, Udine University Hospital (Italy)

Health care delivery organizations across the United States are struggling to cross the quality chasm in a fiscally sustainable manner. Achieving STEEEP Health Care provides a compelling yet practicable roadmap for doing so, drawing upon the remarkable response of the Baylor Health Care System to the challenge articulated by the Institute of Medicine in 2001. This book is a "must read" for health care system leaders who aspire to thrive in an increasingly accountable health care world.
—Rebecca L. Harrington, Co-Founder and President, The Leadership Institute

Dr. Ballard and his colleagues strongly make the point that the journey to health care excellence requires a committed transformation of leadership, operations, and every aspect of the enterprise. Best care is not the result of a stand alone 'initiative.'
—Ziad Haydar, MD, MBA, Senior Vice President and Chief Medical Officer, Ascension Health

While the journey may be STEEEP, Dr. Ballard’s accomplishments demonstrate that higher quality is attainable. The roadmap provides inspiration to all those dedicated to achieving a better health care system.
—Trent Haywood, MD, JD, Chief Medical Officer, Blue Cross and Blue Shield Association

Transforming health care delivery in a large health system like Baylor Health Care System is no mean feat. In this book, David Ballard and his team spell out their journey over the past decade to achieve such change based on STEEEP as a practical approach to high-quality care in its broadest sense. This book is a great basis for those less advanced on such a journey, and will accelerate the travels of those who read it.
—J. Michael Henderson, MD, Chief Quality Officer, Cleveland Clinic

Enhancing and ensuring the quality of healthcare delivery in the 21^st century is the principle obligation of all health care executives and providers. Achieving STEEEP Health Care will greatly assist leaders in fulfilling that critical obligation.
—Ira J. Isaacson, MD, MBA, Senior Vice President/Partner, Phillips, DiPisa, & Associates

At the heart of quality improvement lies Deming’s idea of fundamental knowledge—the concept that there is a difference between theory and reality. Theory is always an abstraction. Reality is the devil lurking in the details, down in the mud and weeds. Said another way, some talk about it; a relatively few actually do it.

You hold in your hands the detailed journey map of a group who has done it, with elegance and flair. It tracks the transformation as theory becomes functional reality. Those seeking to move to the safety of the high ground in an increasingly difficult health care delivery world will find it valuable beyond compare.
—Brent James, MD, MStat, Chief Quality Officer, Executive Director, Institute for Health Care Delivery Research, Intermountain Healthcare

All too often, case studies of health care organizations that are actively involved in transforming their delivery of care focus on only a single element of that transformation, as if it were the "magic bullet" that could solve all problems. By contrast, Ballard and his colleagues have set forth a comprehensive look at the multiple initiatives—from simple to quite complex—that are enabling the Baylor Health Care System to play a leading role in transforming health care in the US. Every leader who aspires to achieve safe, timely, effective, efficient, equitable, patient-centered care should read and learn from this book.
—William F. Jessee, MD, FACMPE, Senior Vice President and Senior Advisor, Integrated Healthcare Strategies

This book provides a lens into one organization’s journey to safe, timely, effective, efficient, equitable and patient-centered care. Full of insights, strategies, lessons and resources, this is an important read for any health care organization striving for improvement.
—Maulik Joshi, DrPH, President, Health Research & Educational Trust, Senior Vice President of Research, American Hospital Association

This book represents a tremendous contribution by a highly respected organization that is fully grounded in the challenges and opportunities of American medicine. Table I.1 alone is worth many times the price of any book—it is essentially a playbook for forward looking, progressive organizations, and one that meets them were they currently are, and takes them forward. David Ballard and Baylor Health Care System’s national leadership reach a new level with this book’s publication.
—Thomas H. Lee, MD, Chief Medical Officer, Press Ganey Associates, Inc.

In this monograph, Dr. David Ballard and colleagues describe how they have embedded the basic dimensions of the Institute of Medicine framework for quality (i.e., safe, timely, effective, efficient, equitable and patient-centered care), into a practical set of tools used by the Baylor Health Care System—but applicable to any other health care system in the country—into day-to-day operations designed to improve care. They describe the essential components that make their system work, including leadership commitment, use of standardized measurement and quality improvement tools, care coordination across the continuum and the creation of a safety culture. As a health care professional for 35 years, but also a stage IV cancer patient for the last 2 years, I can only hope all health care professionals read and take to heart the advice contained in this book.
—Jerod M. Loeb, PhD, Executive Vice President, Division of Healthcare Quality Evaluation, The Joint Commission

This book will find a permanent place within quick reach of anyone working to implement clinical quality and safety improvement in the real world. It is filled with in-the-trenches wisdom on topics ranging from effective leadership at the top to getting the details right in the front lines of care.
—Michael L. Millenson, President, Health Quality Advisors LLC and author of Demanding Medical Excellence: Doctors and Accountability in the Information Age

Achieving STEEEP Health Care describes Baylor Health Care System’s bold experiment to align teams, evidence, systems, and a culture of caring in the unwavering pursuit of higher value health care. The result is a continuously learning health care system poised, along with new partners, to tackle one of the most urgent and significant challenges confronting our nation—optimizing the health of populations while maximizing on increasingly finite resources. The valuable lessons from Baylor Health Care System’s journey accelerate the capacity of health systems in all communities to assume a leadership role in addressing this challenge.
—Mary D. Naylor, PhD, FAAN, RN, Marian S. Ware Professor in Gerontology, Director of New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing

In today’s health care world of swirling, conflicting reform pressures and 24/7 information overload, a book has to exceed a very high bar to merit executive attention. David Ballard and colleague’s Achieving STEEEP Health Care clears that bar with truly exceptional room to spare. This is the book that will explain why physician leadership is essential and possible, and how it can effectively align complex organizations and the larger health system culture to the triple aim vision of better care, better health, and lower cost. It represents a major contribution to the science of performance improvement precisely because it explains how it was institutionalized in a large and diverse Dallas, Texas institution in the last 14 years. This is the story of how American health care can reform and sustain itself, if it but will.
—Len M. Nichols, PhD, Director, Center for Health Policy Research and Ethics, Professor of Health Policy, College of Health and Human Services, George Mason University

Achieving STEEEP Health Care presents not only a roadmap but also a how-to manual for health systems striving to achieve the Triple Aim. Within these pages, those interested in improving America’s health care will learn how to transform the elements of the Institute of Medicine’s ideal state of American health care into action. This book should be read by all health care leaders on their journey to safe, quality health care.
—Robert W. Pryor, MD, MBA, CPE, FAAP, FCCM, FCCP, President and Chief Executive Officer, Scott & White Healthcare

Baylor Health Care System has been at the forefront of quality in health care for many years. Dr. Ballard and his colleagues, by describing the approach used at Baylor, have created a useful blueprint for others in health care that should speed their journey in quality improvement.
—David B. Pryor, MD, Executive Vice President, Ascension Health, President and Chief Executive Officer, Ascension Clinical Holdings

Like a basic scientist who takes a discovery from the bench to the bedside, Ballard and his colleagues at the Baylor Health Care System (BHCS) have taken quality improvement from hypothesis-testing to application in a large delivery system. Their description of the historical context of quality improvement at BHCS and "lessons learned" is especially authentic for health care CEOs who attempt to walk the tightrope of performance improvement without a net. At the VCU Health System, we have used the STEEEP^® acronym for years in our own journey toward quality improvement. The experience at BHCS, as described in [this book], is both illuminating and sobering – this is a race without a finish line. Continuous improvement is the only option.
—Sheldon M. Retchin, MD, MSPH, Senior Vice President for Health Sciences, Virginia Commonwealth University, Chief Executive Officer, VCU Health System

This book, by the Baylor Health Care System enterprise, should be a bellwether mark for our industry, as Baylor is living where health care needs to be in the near future. We must find a way to engage the industry to focus on quality and safety as the way to control costs and to effectively lower hospital expenses; rather than working on quality as separate from costs. This is an example of one system's approach and other models will follow. A great body of work, from a strong national example of high quality care.
—Dan Stultz, MD, FACP, FACHE, President and Chief Executive Officer, Texas Hospital Association

The Institute of Medicine’s six aims provide a sound framework for those dedicated to transforming the care we deliver to our patients and communities. David Ballard and his colleagues describe a remarkable journey operationalizing this framework across all six dimensions in a complex, growing health system. Their story is both instructive and inspirational. This book, with its detailed descriptions of approaches, lessons learned, and real-life examples, is a must-read for health care leaders and quality professionals.
—Gary Yates, MD, President, Healthcare Performance Improvement, LLC, Former Senior Vice President and Chief Medical Officer, Sentara Healthcare