Lara Goitein

Lara Goitein

It’s a no-brainer: Doctors, nurses and other front-line staff probably know best how to make hospitals work better.

The U.S. strategy to improve health care aims to hold providers accountable for results, which often leads to more focus on what’s being measured rather than overall quality.

While Christus St. Vincent Regional Medical Center toes the line for national metrics — recently earning a five-star rating from the U.S. Centers for Medicare & Medicaid Services — the Santa Fe hospital has rebelled against the system for the past seven years with its Clinician Directed Performance Improvement program (CDPI).

Teams of doctors and nurses since 2013 completed 44 projects that have, for example, drastically reduced hospital infection rates and reduced patient readmission rates.

The hospital has paid about $1.3 million a year to fund the program, the essence of which is to allow to doctors and nurses to set aside work hours to carry out improvements. Christus St. Vincent has 10 doctor/nurse-led service teams with up to 80 other front-line staff assembled to work on these projects.

Doctors are paid to work on performance improvement about one day a week and nurses approximately half that time. This sort of commitment does not occur elsewhere, said Dr. Lara Goitein, founding medical director of the Clinician Directed Performance Improvement program.

“People are giving a lot of lip service to ‘we have to engage doctors and nurses in quality improvement’ but they don’t want to pay for it,” said Goitein, currently on sabbatical while Dr. Theresa Ronan serves as CDPI’s medical director. “Nobody’s doing it.”

Goitein authored an article in the February issue of the peer-reviewed Health Affairs journal, described by the Washington Post as “the bible of health policy,” detailing Christus St. Vincent’s journey of giving doctors and nurses the freedom to find solutions to common hospital problems.

“This is the first national recognition of CDPI,” said Goitein, who in 2018 also presented the hospital’s accomplishments in Boston at the Institute for Healthcare Improvement/National Patient Safety Foundation conference.

Goitein was surprised that Health Affairs, which she describes as “the leading health policy journal in the world,” chose to publish her report focusing on a single hospital.

Health Affairs has published many articles on quality improvement that detail how the indicators used to measure quality do not resonate with clinical staff, Health Affairs Editor-in-Chief Alan Weil said.

“Goitein’s article describes a circumstance where clinicians were involved from the outset in defining and creating the quality improvement enterprise,” Weil said in an email. “In addition to the positive results for patients, the paper describes a unique approach to implementing quality improvement in a hospital setting and we thought others could learn from this example.”

Christus St. Vincent CEO Lillian Montoya recalls the one-star rating the hospital had at the time CDPI was launched. The hospital was willing to jump at an opportunity to invest in substantial improvement and building trust by engaging medical staff and other hospitals in the process, she said.

“There is an incredible sense of pride for what we have transformed into,” Montoya said. “Nobody wants to break that chain. … We have personalized health care and exceptional medicine that resulted in a five-star rating and having a collaboration with the Mayo Clinic.”

Among the profound outcomes of the program, Goitein said, has been a much lower rate of hospital-acquired infections and the dramatic improvement in the culture and morale of hospital employees in recent years.

Goitein said any hospital could carry out a similar in-house, doctor-led improvement program. She noted that Christus St. Vincent actually records up to $2 million additional revenue attributable to the $1.3 million annual expense.

“You can do this without being a large, academic medical center,” she said.

Goitein said recently retired Dr. John Beeson embraced the initial CDPI concept as he became the hospital’s chief medical officer in 2014.

“The doctors asked for a physician-led quality program that gives them time and support,” she said.

A pilot effort was first carried out in the hospital intensive care unit and quickly expanded to the entire hospital.

The program has 13 current projects, from which Goitein chose to single out three: hospital-initiated treatment of opioid use, early mobilization of intensive care unit patients and antibiotic stewardship reducing overuse of antibiotics.

“They are projects that might not be on the hospital’s radar screen if doctors had not made them front-and-center on the hospital’s quality agenda,” Goitein said.

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