5. Moving forward, what would you recommend Kotagal do to sustain the hospital’s improvement efforts?

Case question: Put together an analysis of the Cincinnati Children’s Hospital Medical Center case that addresses the assignment question. Reflect on your own organizations approach to improving quality and please establish the comparison when requested.
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REV: APRIL 25, 2011
ANITA TUCKER
AMY EDMONDSON
Cin
ncinnatti Child
dren’s Hospita
H
al Med
dical Ceenter
Drr. Uma Kotag
gal, Senior Vice
V
Presidentt (SVP) of Qu
uality and Trransformation
n, reflected on
o the
beehiv
ve of improv
vement activiity under way in 2009 at the Cincinnaati Children’ss Hospital Meedical
Centeer (CCHMC). The enthusiaasm was palp
pable. The ho
ospital had seeven strategicc initiatives and 28
officiaal projects ra
anging from a new processs to deal wiith scarce parrking in the hospital garaage to
initiattives to elim
minate adverse drug events. Still, desp
pite the spreead of CCHM
MC’s standarrdized
metho
od for impleementing pro
ocess changess, Kotagal wanted
w
to inccrease the raate and impaact of
impro
ovement. But how was a biig challenge. For instance, she wonderred whether the hospital sh
hould
be driiving the strattegic selection
n of improvem
ment projectss centrally or allowing mottivated indiviiduals
in vaarious work areas to sellect their ow
wn initiativess. Also, shou
uld the orgaanization’s qu
uality
impro
ovement speccialists be emb
bedded in thee medical div
visions underr the supervission of the div
vision
directtor, or work out of the centralized Qu
uality and Transformatio
T
n Departmen
nt? Similarly,, how
much
h formal train
ning was need
ded to accelerate improveement? Thesee questions consumed
c
Ko
otagal,
whosee years of meedical education and experrience did nott reveal any eaasy answers.
Back
kground
CC
CHMC, a no
ot-for-profit, pediatric acaademic med
dical center, was establish
hed in 1883. The
organ
nization had over 40 med
dical divisionss, each headeed by a direcctor who wass a physician
n. The
divisiions encompa
assed physiciaans’ research
h, clinical caree, and education programss. To illustratte, the
Pulmo
onary Divisio
on had 17 facu
ulty memberss for five cliniical programss and the Neo
onatology Div
vision
comprised 45 facu
ulty memberss and the Reg
gional Centerr for Newborn
n Intensive Care
C
(RCNIC)). The
hospital employed
d its physician
ns, which wass unusual. Mo
ost hospitals granted adm
mitting privileg
ges to
physiicians, but lacked formal au
uthority overr them.
Hiistorically, thee hospital had
d three aims: research, education of neew physicianss, and patientt care,
with an
a emphasis on
o research and teaching. However, in 1994, senior management
m
created a rad
dically
new vision:
v
CCHM
MC would be the leader in
n improving children’s heaalth. This meaant a dramaticc shift
in focus to excellen
nce in patient care by imprroving the hosspital’s deliveery systems.
By
y 2009, CCHM
MC had mad
de progress. The organizzation had grrown from a regional ho
ospital
servin
ng greater Ciincinnati’s 2.22 million peo
ople to an intternationally recognized 475-bed
4
faciliity. In
2008, U.S. News and
a
World Reeport ranked the hospital third amon
ng pediatric hospitals.
h
In 2006,
CCHM
MC was awa
arded the “A
American Ho
ospital Associiation-McKessson Quest fo
or Quality Prize,”
P
which
h honored inn
novation in quality
q
and co
ommitment to
o patient caree. It had overr 93,000 emerg
gency
deparrtment visits and
a 27,000 ho
ospital admisssions per yeaar, a substantial increase fro
om 2003. Oveer this
period
d, the numbeer of patientss treated in the
t hospital’ss emergency department increased by
y 11%,
______________________
__________________________________________________________________________________________________
Professo
ors Anita Tucker an
nd Amy Edmondso
on prepared this caase. HBS cases are developed solely as
a the basis for class discussion. Casess are not
intended
d to serve as endorrsements, sources of
o primary data, or illustrations of effeective or ineffectivee management.
ght © 2009, 2010, 2011
2
President and
d Fellows of Harvaard College. To orrder copies or request permission to
o reproduce materiials, call
Copyrig
1-800-5445-7685, write Harv
vard Business Scho
ool Publishing, Bostton, MA 02163, or go to www.hbsp.h
harvard.edu/educaators. This publication may
not be digitized,
d
photocopied, or otherwise reeproduced, posted,, or transmitted, wiithout the permissiion of Harvard Bussiness School.
This document is authorized for use only by Anin Kalladanthyil in Healthcare MBA OM 2018S taught by Paulo Gomes, Florida International University from March 2018 to May 2018.
For the exclusive use of A. Kalladanthyil, 2018.
609-109
Cincinnati Children’s Hospital Medical Center
inpatient admissions increased by 33%, and length of stay simultaneously increased 7%. Net
operating revenue increased 235% from 2006 to 2008, to $66 million on $1.3 billion in revenue. (See
Exhibits 1a and 1b for the hospital’s operating revenues and patient visit data.)
Dr. Frederick Ryckman, a transplant surgeon, clinical director of the Division of Pediatric Surgery,
and VP of System Capacity and Perioperative Operations at CCHMC, had worked at the hospital
since 1982. He recounted, “The philosophy has dramatically changed from when it was a community
hospital. It has truly transformed itself over the last 15 years.”
Delivering care to hospitalized patients was a complex business. Patients entered the hospital
through several routes: the emergency department, planned surgical procedures, or referrals from
physicians. While in the hospital, the care process often shifted patients to different locations. For
example, a patient might enter the hospital through the emergency department for diagnosis and
stabilization, be transferred to the intensive care unit, and then to a medical unit, perhaps with side
trips to radiology or other specialized departments, before discharge. The complexity was further
heightened by the variety of caregivers involved: treatment plans were orchestrated by one or more
physicians and involved pharmacists, nurses, physical therapists, respiratory therapists, dieticians,
and others. Coordinating care across multiple units and professionals required extensive verbal and
written communication. While some aspects of hospital operations were routine and predictable,
most were not, and the care process for an individual patient could change at any time. Finally,
medical knowledge changed frequently, and some diseases were still not well understood.
Overall, the hospital’s work was both varied and complex. Most caregivers provided care for
multiple patients at the same time, which required continual reprioritization as patients’ conditions
changed during the course of a shift. Vigilance was required to prevent medical errors, such as giving
a patient the wrong dose of medication or allowing an infection to develop. Individual patients with
the same medical condition might respond differently to treatments because of inherent variations in
physiology. Further, hospitals kept track of every procedure performed, medication administered,
and supply used, and had to submit detailed reports to payers—whether private insurance
companies, the government, or the patients themselves. Finally, medical research had historically
focused on discovering treatments for diseases, but these were not implemented consistently. In
many settings, patients received treatments based on historical practices rather than proven methods.
The complexity of patient care and the prevalence of system failures created opportunities to improve
the reliability and efficiency of the systems through which care was delivered.
History of Process Improvement at CCHMC1
Kotagal joined CCHMC in 1975 as a fellow in neonatal physiology2 and continued to work as a
neonatologist, eventually becoming director of the Neonatal Intensive Care Unit. By early 1996,
Kotagal had become concerned that, despite the hospital’s emphasis on medical research to discover
new treatments, known best practices might not always be used for current patients. She started
investigating whether patients were receiving the care best supported by clinical evidence.
Together with a team that included primary care physicians from the surrounding community,
Kotagal searched the medical literature for the most effective treatments for bronchiolitis. In past
winters, CCHMC’s intensive care units (ICUs) often became full because primary care physicians
1 This section draws on Charles Kenney, “The Cincinnati Children’s Triumvirate: Uma Kotagal, Jim Anderson, Lee Carter,”
in The Best Practice: How the New Quality Movement Is Transforming Medicine (New York: Public Affairs, 2008).
2 Fellows were physicians in the highest level of postgraduate medical specialty training.
2
This document is authorized for use only by Anin Kalladanthyil in Healthcare MBA OM 2018S taught by Paulo Gomes, Florida International University from March 2018 to May 2018.
For the exclusive use of A. Kalladanthyil, 2018.
Cincinnati Children’s Hospital Medical Center
609-109
referred patients with bronchiolitis to the hospital for complex respiratory treatments. To its surprise,
the team discovered that the most effective treatments could be performed in primary care
physicians’ offices and patients’ homes. Seeking to avoid unnecessary procedures, the team changed
the recommended guidelines for primary care physicians, reducing hospitalizations while
simultaneously providing better care. The team went on to develop evidence-based guidelines for 11
other common conditions. Use of these guidelines dramatically reduced hospitalizations.
Later in 1996, Kotagal’s quest for improvement was bolstered by the arrival of Jim Anderson as
CEO and Lee Carter as chairman of the board. Although a long-time CCHMC board member,
Anderson was an unusual choice for CEO because he was a practicing attorney not a physician. He
was also well versed in quality improvement methods historically used by manufacturing firms.
Carter, a firm believer in focusing on patient care, supported transparency about improvement
opportunities. Carter articulated his vision for CCHMC as “We will be the best at getting better.”
With two strong allies, Kotagal continued investigating other medical conditions that might benefit
from an evidence-based approach. Not everyone in the organization, however, immediately accepted
her passion for evidence-based medicine. The chief financial officer and SVP of Finance, Scott
Hamlin, recalled his early encounters with Kotagal:
Dr. Kotagal informed me that much of our protocol for liver transplant was not
scientifically proven to impact outcomes for the patients. My response was, “We make a
margin on every one of those treatments you want to discontinue. Your plan would reduce the
amount of money we make on liver transplants.”
In 2001, as part of the organization’s strategic planning process, Kotagal, Anderson, and Carter
listened to a report from the head of radiology about the quality of outpatient care. Although
clinicians strived to do their best for patients, the work pressure kept them from engaging in
spontaneous improvement efforts when they encountered process problems. Kotagal recalled:
He reported back saying, “We have very talented physicians, but a system that is broken
and full of workarounds. We think we need to fix the system.” Jim could barely contain his
enthusiasm. He had come from the industrial sector and thought that most managers would
get fired for the performance that CCHMC was turning in. He was delighted that there was a
group of senior clinicians saying, “Fix the system.”
Anderson captured this energy in the strategic planning effort. Instead of setting typical financial
goals such as growing revenues by 15%, the new strategic plan called for a dramatic improvement in
the delivery of care. Strategic initiatives included incorporating systematic approaches to quality,
service, and process improvement into their management systems and developing scorecards to
measure the performance of their delivery system and patient care. Anderson also convinced Kotagal
to leave her position in the neonatal ICU to lead CCHMC’s improvement efforts. Kotagal recounted
the daunting task. “The weight of the new strategic plan to dramatically improve the system fell on
my shoulders. I thought, ‘Okay, that’s great, but how?’”
Building Momentum: The “Pursuing Perfection” Grant
In early 2002, with the backing of Anderson and Carter, Kotagal competed against 200 other
organizations to become one of several winners of a $1.9 million grant funded by the Robert Wood
Johnson Foundation, with technical guidance from the Institute for Healthcare Improvement (IHI).
The grant, “Pursuing Perfection,” was a program to help health-care organizations transform the
quality of their care from good to perfect by implementing a series of improvement projects.
3
This document is authorized for use only by Anin Kalladanthyil in Healthcare MBA OM 2018S taught by Paulo Gomes, Florida International University from March 2018 to May 2018.
For the exclusive use of A. Kalladanthyil, 2018.
609-109
Cincinnati Children’s Hospital Medical Center
Winning the award enabled Kotagal to take five physicians and one nursing leader to
Intermountain Hospital’s four-week-long training on improvement science. The course had been
developed by Brent James, a physician and statistician who had spent the prior decade using W.
Edwards Deming’s industrial quality improvement techniques in health care. In addition, CCHMC
was able to learn from the other grant-winning hospitals. For example, one of the other hospitals had
achieved 95% reliability in administering antibiotics to surgical patients before their surgery to
prevent surgical site infections (SSIs). Kotagal asked someone from that hospital to teach CCHMC
how to achieve this high level of reliability. As Kotagal explained:
They built a “forcing function” into their operating room process. Patients couldn’t enter
the operating room until they had received their antibiotic. Learning about forcing functions
and how to use them was our biggest breakthrough on process reliability.
Improving Outcomes for Cystic Fibrosis Patients3
The Pursuing Perfection grant required CCHMC to undertake two improvement projects initially.
For the first project, Kotagal worked on developing and implementing treatment protocols with
proven efficacy—what was known as evidence-based medicine. Finding a second project, however,
had not been easy. She ultimately picked cystic fibrosis (CF) because the head of the pulmonary
division (which treated CF patients) was the only division leader who expressed interest in
participating. Another benefit of working on CF was that the Cystic Fibrosis Foundation (CFF), a
national nonprofit organization, collected patient outcome data from CF centers throughout the U.S.,
analyzed it, and provided standardized reports to the centers on their individual and aggregated
performance. CF became a defining project for the hospital because their CF patient outcomes for
lung function skyrocketed from being in the 20th percentile compared to the other CF centers in 2001
to being in the 95th percentile by 2008.
CF was a genetic, chronic disease that caused the body to make thick mucus secretions that
clogged the lungs, resulting in infections that destroyed lung tissue. Most children with cystic fibrosis
were able to participate in most activities and attend school as young children, but their disease
worsened with age. In the 1950s, most patients with CF died before they reached their fifth birthday.
By 2009, treatment advances had increased patient life expectancy to 35 or 40 years. While
medications helped, quality of life and life expectancy greatly relied on daily vigilance in diet and
physical therapies. Therefore, CF treatment centers such as CCHMC worked closely with parents to
help them provide the daily care their children needed.
Transparency Two key outcome measures for CF were lung functioning and nutritional status
as measured by body mass index (BMI). The Pursuing Perfection grant required CCHMC to agree in
advance to disclose their performance to patients. Lee Carter recounted that, when they agreed to
transparency, they were naïve about how difficult it would ultimately prove to be.
In reviewing our data from the CFF, we learned that our patients’ lung functioning was at
the 20th percentile, and our BMI results were below average compared to other centers. We
knew that we would have to tell the families what our performance was, but we did not know
the courage such transparency was going to require.
3 For more information about CCHMC’s and Minnesota’s cystic fibrosis performance as well as the Cystic Fibrosis Foundation,
see Atul Gawande, Better: A Surgeon’s Notes on Performance (New York: Henry Holt, 2007), pp. 201–230.
4
This document is authorized for use only by Anin Kalladanthyil in Healthcare MBA OM 2018S taught by Paulo Gomes, Florida International University from March 2018 to May 2018.
For the exclusive use of A. Kalladanthyil, 2018.
Cincinnati Children’s Hospital Medical Center
609-109
The performance of the CF Center was much worse than CCHMC leadership had expected. Like
many large research hospitals, CCHMC had believed itself among the best hospitals in the country,
despite having little data with which to make comparisons. Clear evidence of their mediocre
performance convinced clinicians to change practices that, despite beliefs to the contrary, had been
ineffective. Jim Anderson recalled:
We talked with one of the CF doctors who had been at this for 30 years. By the fourth or
fifth rendition of the data he finally accepted that the way they had been treating CF patients
was yielding poor outcomes. He said, “We have been wrong.” And he was close to tears. He
realized that they had been doing things that got their patients to the 20th percentile when they
thought they were at the top.
CCHMC’s CF physicians informed all of their patients’ parents of the hospital’s performance on
lung functioning and nutritional status. Despite the fact that there were three other CF clinics within
a 100-mile radius of Cincinnati, everyone kept their children in CCHMC’s CF clinic. After much
discussion of how to best incorporate the patients’ perspective into their improvement efforts, the CF
team decided to invite 20 parents to participate directly as full-fledged team members. Seventeen
agreed. One such parent, Kim Cook, recalled her response.
Our numbers were not good at all. But I think we all reacted in the opposite way to what
the staff thought we would. They thought we would be angry. But we respected them on a
new level. They were being totally honest. They were saying, “We want to be number one, and
we want you to help us get there.” I was so motivated. I thought, “We are going to do it. We
are going to get there!” I think their nervousness went away after we reacted that way.
The parents and clinicians were committed to working together to improve CCHMC’s outcomes.
They wanted to use a “positive deviance” approach of identifying the CF centers with the best
performance and replicating what they did to achieve superior performance. CCHMC asked the CFF
for the names of the top five centers. It took several months for CFF to comply with this request
because they had not previously ranked the centers. They first analyzed several years of data to
identify consistently high performing centers. After identifying the top performers, CFF obtained
permission from those centers to share the information with CCHMC. Kotagal recalled, “Once CFF
revealed the top five hospitals in the country, we visited Minnesota and some others and talked with
the remaining ones on the phone.4 We learned a lot that we applied.”
In 2006, CFF made all CF centers’ data available to the public on their website. Bruce Marshall,
vice president of clinical affairs at CFF and leader of the CFF quality improvement initiative, recal …
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