Becker's Clinical Quality & Infection Control

10 Executive Briefing EXECUTIVE BRIEFING 1 T he value of a quality department is refl ected by its impact on quality and safety outcomes to stop harm upstream and prevent it from reoccurring. In times of budget and workforce reductions, sometimes the quality department's effectiveness is not readily seen for what it is: a monitoring and performance improvement arm of the health system for cost avoidance and achieving top decile performance in healthcare. Irving, Texas-based CHRISTUS Health, one of the largest health systems in the country, took on the challenge of producing a robust quality management function. This initiative sparked a need to align with a validated professional organization to demonstrate how quality management can be strengthened to help the leaders in each hospital support evidence-based care for excellence in quality and safety outcomes. CHRISTUS Health is a Catholic nonprofi t health system with more than 60 hospitals in the U.S. — across Texas, Louisiana and New Mexico — as well as in Mexico, Chile and Colombia. The CHRISTUS health system is comprised of 260 clinics and outpatient centers with eight ambulatory surgery centers. Over the past fi ve years, the health system has embarked on a journey to improve performance and quality, including upskilling and elevating the roles within the quality management department. This journey has included engaging with the National Association for Healthcare Quality (NAHQ). Through this partnership, CHRISTUS Health has adopted NAHQ's industry standards for quality professionals; increased competencies of members of the quality team; and improved performance on multiple metrics. To better understand CHRISTUS Health's quality and safety journey and the critical role that quality professionals play, Becker's Hospital Review spoke with Claire Lauzon-Vallone, RN, vice president of quality and safety at CHRISTUS Health. Ms. Lauzon-Vallone shared insights based on her organization's experience working with NAHQ to transform, upskill and elevate the quality management role in patient care excellence. A need for consistent, organizational quality management standards The quality organization at CHRISTUS Health has been on a "zero- harm" journey using High Reliability Organization Principles for the last fi ve years. At the outset of this journey, standardized system dashboards were built to help quality professionals spend more time infl uencing and improving quality of care versus building their own graphs and tables. These dashboards refl ected performance to national benchmarks. As CHRISTUS' national footprint grew, directors of quality for each hospital asked the system offi ce to establish a standardized job description library, orientation onboarding outlines, recommended department structures with ratios, job-specifi c competencies and professional career ladders in quality that refl ected the multi-factorial role of a quality professional. Engaging with NAHQ Previously, the value of quality professionals at CHRISTUS Health was, in some ways, misunderstood — particularly in how a quality professional brings forth a specifi c skillset that supports leadership in monitoring for variances and providing performance improvement methods to promote quality patient outcomes. This subject matter expertise can assess the organization for quality variances, identify contributing factors and barriers, put an action plan into place and evaluate the effectiveness of the solutions. In the past, this advanced level of quality management expertise was gained through informal methods of "train-the-trainer" or long-term studies in quality management. As CHRISTUS sought to achieve patient care excellence in all publicly reported scorecards, it began a long search for a validated method of assessing and training quality professionals across the enterprise. As part of this initiative, CHRISTUS Health decided to work with NAHQ, as NAHQ delivers the Certifi ed Professional in Healthcare Quality® (CPHQ) credential and represents quality leaders across the U.S. Ms. Lauzon-Vallone noticed NAHQ's website had published a validated program: Workforce Accelerator®. It provided a comprehensive assessment of skills, eight domains of quality competency standards and a workforce assessment tool to help CHRISTUS better understand the level and type of work their staff were performing. "With NAHQ's Workforce Accelerator, I was able to defi ne the roles better for quality management professionals, standardize these roles and educate senior leaders on the eight competency domains that drive a strong quality management department," Ms. Lauzon-Vallone said. "They liked the fact that I was using a nationally recognized organization in quality management with validated tools." Using the standards established within NAHQ's Workforce Accelerator , CHRISTUS Health standardized all quality professional job descriptions throughout the organization, using the industry- standard, twice-validated NAHQ Healthcare Competency Framework ™ . In addition, the framework was woven into each job description and all job-specifi c competency forms. The new competency forms supported onboarding and continual educational growth of each quality professional to maximize their skillset over time. The road to improvement: How CHRISTUS Health upskilled quality teams + boosted patient outcomes This Executive Brief was produced and brought to you by

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