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Quality and Accountability: Why We Can’t Have One without the Other

  • Publication: Studer Group
  • Release Date: August 30, 2012

Quality has always mattered. Delivering top-notch clinical quality day after day and striving to get better and better at doing so, have always been our industry’s main goals. After all, patient care isn’t just another product or service. We’re talking about saving human lives, and we have a human responsibility to do our best work.

But keeping this moral imperative at the forefront has suddenly become a lot more challenging. Changes are shaking up our industry, pulling our attention first this way, then that way. How do we stay focused on our overall goal of providing the best care to the patient without feeling like we’re jumping from one quality initiative to the next—especially as we’re being held accountable for results in a more rigorous and quantifiable way than before?

A New Definition of Quality

First, we need to think about quality in a broader way. At Studer Group, a Huron solution, we define quality as the cumulative impact of all that happens to a patient while in an organization’s care. This includes the care provided as well as the outcomes achieved. Patient perception of care results, safety metrics, and the presence of hospital-acquired conditions (HACs) and preventable readmissions are all measures that help define quality of care. 

When the Centers for Medicare & Medicaid Services (CMS) released the Value-Based Purchasing (VBP) Program, the quality metrics included the patient experience or perception of quality care (HCAHPS) and the process of care measures. CMS combined these in the same Value-Based Purchasing “bucket”—declaring that, together, these indicators represent quality care.  

There is a proven link between patient perception of care and clinical quality care – these outcomes go hand in hand. To cite one example, it’s been proven that as HCAHPS percentile ranking results in the “responsiveness” question increase, vascular catheter-associated infections, pressure ulcers (stage 3/4), and manifestations of poor glycemic control decrease.

Patient perception of care is also linked to preventable readmissions. A study published in the American Journal of Managed Care found that “higher overall patient satisfaction and satisfaction with discharge planning are associated with lower 30-day risk-standardized readmission rates after adjusting for clinical quality.” (“Relationship Between Patient Satisfaction with Inpatient Care and Hospital Readmission Within 30 Days,” William Boulding, PhD, et. al, Am J Manag Care. 2011;17(1):41-48)

When all staff members are taught to be responsive to patient needs, outcomes will improve in all quality areas. And because patients don’t make distinctions between clinical care providers and non-clinical employees, their perception of care will improve across the board, and this leads to better HCAHPS results.

So how does a hospital get to the point that it’s providing “high-quality” care in all areas…always? How does it ensure that it has consistent responsiveness of care and has hardwired evidence-based care and processes throughout the entire organization?

The answer requires a laser-focus on creating a highly reliable culture

Holding People Accountable Gets Consistent, Sustainable Results

Leaders often know what tactics will improve quality in specific areas. They may see quick results when these tactics are implemented. Consistency and sustainability are the real challenges. It’s one thing to get isolated (and short-lived) surges of improved quality. It’s quite another to make sure the behaviors that create them are hardwired across the organization and that the improvements last over time.

For example, organizations that have implemented comprehensive hand-hygiene compliance programs—including unit-based initiatives, marketing campaigns, and leader evaluations complete with accountability measures—have achieved dramatic decreases in various hospital-acquired infection rates.

In order to sustain these improvements, leaders must verify that everyone is practicing the correct behaviors with every patient encounter. This approach not only requires everyone in the organization to be passionate about providing the highest levels of quality care to the patient, it also requires alignment in goals and accountability.


The bottom line is that culture drives quality. And, if you don’t have accountability in place, you won’t have the foundation necessary to achieve and sustain high-level quality outcomes.


Quality Is Everyone’s Job

To create and sustain improvements achieved, leaders have to make sure everyone is practicing the right behaviors with every patient, every time. This requires everyone in the organization—from senior leaders to middle managers to physicians to frontline care givers to ancillary service providers—to be passionate about working together to accomplish great things for the patient. But passion isn’t enough: They also need to be aligned in goals and accountability.

Everyone needs to execute the behaviors proven to get great quality outcomes. Critical to the execution of these behaviors is ensuring that all involved fully understand the why. And, everyone must be held accountable for the results. That means defining the behaviors desired, engaging staff by thoroughly explaining why, and then ensuring compliance through accountability.

Being able to create this kind of culture requires that an organization has the right focus and structure. Everyone needs to be focused on aligned outcomes, and the organization needs to be structured in a way that supports that focus.

What Does an Accountable Culture Look Like?

Have you ever been inside a hospital where everything feels focused on providing the absolute best care for the patient? Processes and procedures happen in a smooth and organized fashion. Employees come across as competent, caring, and positive. Patients seem less anxious and more confident than they do in other hospitals.

That’s the result of a culture where leaders are fully accountable to results—and it doesn’t just happen. It is deliberately created from the top down and is usually based on a framework that gets goals, behaviors, and processes aligned. Studer Group’s Evidence-Based LeadershipSM (EBL) framework is one such example. As an organization begins to implement this framework, an accountable culture evolves, strengthens, and grows. It happens simultaneously and it happens organically.

Here are some of the characteristics of an accountable organization:

  • The organization is aligned from top to bottom. Everyone knows the mission, and actionable goals are set up to support it organization-wide. These goals are cascaded from level to level through the organization so all are working together to achieve the same outcomes.
  • People know the why behind everything they do. If they’re asked to make a change, they are told exactly how it will benefit the patient. Knowing the why forces them to make the behavior a “must-do.” Once they understand their personal role in the patient’s outcome, their values won’t allow them not to do it.
  • Leaders are well trained and able to cascade that training to their staff. Even the best clinicians don’t automatically have the skills to lead. Organizations that consistently provide great quality care also provide leadership training.
  • Everyone practices specific behaviors proven to get results. Whether it’s Rounding for Outcomes, AIDET®, Post-Visit Calls, or so forth, leaders make an effort to standardize behaviors so that all employees and patients get a consistent experience. These behaviors—which are proven to make patients more active participants in their own care and to reduce anxiety—are validated and rewarded in order to ensure they’ll be repeated until they are hardwired throughout the organization.
  • People are held accountable for their performance. High-quality, high-reliability organizations use evaluation systems that are based on objective, weighted performance metrics that are aligned with the overall goals of the organization. What’s more, low performers aren’t tolerated—the organizations have an effective system in place for moving performance up or low performers out.
  • Processes are standardized across the organization. Whether it’s hand hygiene practices or call light responses, everyone in every department is trained to do it the same way. Doctors, nurses, cleaning staff—all employees follow the same procedures.
  • The organization is geared to innovate. People at all levels understand the need to constantly improve and strive for ever-greater efficiency and cost savings. The willingness and even the thirst to change is built into the culture. This has always been an important aspect of being a great healthcare organization, but it’s even more critical in the environment where the bar will continue to be raised. 

The Power of Purpose and Human Responsibility

Earlier, we mentioned the importance of knowing the why. Let’s briefly come back to it: As an organization seeks to enhance accountability and drive a quality culture, there is nothing more critical than being able to help every staff member connect back to the purpose, the why. It’s this ability that makes continuous transformation possible.

Connecting staff to purpose requires more than just making the vague, overarching statement: “Do this; it’s better for the patient.” It’s about saying, for instance, “As a member of the housekeeping staff, you reduce infections and impact the healing of the patients when you follow the protocols to sanitize the patient rooms.” Staff need to be able to see the direct impact they have on patient care.

People who work in healthcare have a strong sense not just of professional responsibility but of human responsibility. Our mission is to provide the best possible care for patients, and when we understand that the changes we’re being asked to make result in better outcomes for patients, our values won’t allow us not to make them.

About the Author: Debbie Ritchie joined Studer Group in 2006 as Chief Operations Officer and stepped into the role of President in 2016. Under Debbie’s leadership, Studer Group was recognized as a 2010 Malcolm Baldrige National Quality Award recipient. She is devoted to making healthcare better and throughout her more than ten years as an executive leader at Studer Group, she has consistently offered executive-level coaching and built professional connections, demonstrating her commitment to the success of the organizations we serve.

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