Evo Terra (Host): Welcome to Health Talk with the Valley Health System presented by the Valley Health System. I'm Evo Terra. And with me is Dr. Krystal Coffman, Director of Quality at Henderson Hospital. Today, we discuss why hospital quality matters and what every patient should know. Thanks for joining me, Dr. Coffman.

Krystal Coffman: Thanks for having me. I'm excited to be here.

Host: So, quality, what is the main function of a quality department in a hospital?

Krystal Coffman: Oh, that is such a difficult question to answer, but I'm going to give it a try. So, the quality department, at least at my hospital, Henderson Hospital, is responsible for making sure that our patients are safe and well cared for while in the hospital. But we do not do this alone. And we work with many other departments in roles like risk management, infection prevention, nursing, environmental services, and many, many others.

A hospital in the United States is regulated by a lot of different agencies. Things like CMS, which is the Center for Medicare and Medicaid, the state, OSHA, fire Marshals. The list goes on and on. Each of these agencies has regulations or rules that we have to follow with the goal being safety. Safety for patients, their families, visitors, our staff providers, and anyone else that comes into the building.

In order to do this, we have rules or policies that our staff must follow. A lot of what I and those who work in my department do is make sure that we're following those rules to keep our patients and the staff safe. We also review and analyze data, looking for things we can do better. We report that data to our hospital leaders and some of it goes to those regulatory agencies and other things like insurance companies, for instance. And this is to prove that we are doing things the right way and keeping people safe.

Host: So, tell me about the various quality designations are in hospitals, and what do they mean.

Krystal Coffman: So, there's a lot of different kinds of quality designations. So, there's one that some people may have heard of. It's called a Leapfrog Score. So, the Leapfrog is a national nonprofit organization whose focus is quality and safety. And we participate in this, everyone in our hospital, our hospital system, and our corporation twice a year in the spring and the fall, and they grade us based on quality and safety and patient experience. Just like in school, A to an F, right? So, same thing. We also get scored By CMS Center for Medicaid and Medicare Services. Every year, they publish a star rating that you can go and look at and that's one to four stars and measures things that are similar to Leapfrog.

But then, we also have insurance companies that will have their own quality indicators. A good example of that is Blue Cross Blue Shield. They have a program called Blue Distinction and facilities who excel in certain things like joint replacement or spine or other programs might carry a Blue Distinction from that insurance company. There's the American Heart Association. They have a program called Get With the Guidelines. With them, data about programs like stroke. Heart attacks, heart failure and so forth are put into their systems. And every year, if your program meets certain benchmarks or criteria, you win or you earn a quality achievement award.

But probably, in my opinion anyway, the most important designation is the accreditation standard. So, CMS grants a couple of organizations the power to survey our hospitals and determine if they're safe quality facilities. One of the most common in our country is called the Joint Commission, or TJC. This is the accreditation body for Henderson Hospital and the Valley Health System. While being accredited is considered voluntary, you cannot receive reimbursement from CMS for Medicare and Medicaid patients if you are not accredited. This survey takes place about every three years and takes three to four days depending on how big your facility is. They look over the facility, they review charts, they talk to staff, talk to patients. This is all an attempt to verify that we're doing the right things for our patients, which takes us back to trust but verify.

Host: So that's a lot. So, my question is, gosh, with so many different metrics out there and ways to measure and reporting that you have to do, what are the key metrics that you track most closely?

Krystal Coffman: Oh, that's a great question. So, we have metrics that we follow, looking at data to make sure we're hitting the marks. And there are things that we look at internally for ourselves and then things that we look at externally because they're reported to other people. So as I mentioned earlier with Leapfrog for instance, that program looks at things like readmissions. It looks at hospital-acquired infections. If we're using barcode scanning when we give medications, if our providers are doing computer order entry, what the nurse to patient ratio is, and a whole host of other things. So, these metrics are things that we obviously would follow very closely in order to meet those standards and achieve the good scores for Leapfrog. Right now, in our hospital at Henderson, we are primarily focused on three things: patient falls, patient experience, and readmissions. So, that's where a lot of our effort goes.

Host: Okay. Let's talk about the people at the hospital who are not in the quality department. How does the staff of a hospital, what role do they play in addressing quality issues or identifying quality issues?

Krystal Coffman: That is an excellent question. So, our frontline staff are absolutely crucial to quality and safety for our patients. If they don't follow the rules, do things the right way, or stop and ask for help when something is not right, then bad things can happen.

To give you an example, we have an initiative in our hospital called Stop the Line. It sounds simple, but something that is essential to assuring safe care. Basically, we teach our staff that if something doesn't seem right or is not being done according to policy, we empower them to speak up and stop whatever is happening until the concern can be addressed. To give you an example of this, let's say someone comes to the hospital to have something done to their right knee, there are a lot of safety checks that happen to make sure the procedure is done on the correct knee and not the left one. If in this scenario one of those checks, maybe the surgeon didn't initial the correct knee for the operation, which would be the right one in this case, and if it's not done, I would expect my staff to stop the line and refuse to move on and proceed with the surgery until that step was done. The surgeon initialed the correct knee, the right one, and it was validated that that was in fact the correct one to operate on. It sounds redundant and it is. We do that on purpose to make sure that there are backups to the backups so that we don't make mistakes and errors, and our frontline staff are the ones that have to follow those rules and make sure those things happen.

Host: Yeah. Very good to have everybody involved with this process. So, let's think about the patients, and that's kind of why hospitals exist, right? I'm assuming patients have some input when it comes to driving quality improvement, yes?

Krystal Coffman: Absolutely. So, we actually have several things that we do to seek out patient and family feedback to help us improve our care. So, most people don't realize that what is called patient experience is a large factor in quality scores for hospitals. Many of our regulatory agencies consider patient experience or their perception of their care to be an important quality indicator. So just in of that, it's a huge factor.

At Henderson Hospital, we conduct leader rounds. So, this is where someone from the leadership team from charge nurses up to and including our CEO actually visit with our patients while they're in the hospital. We go see patients every day. We ask how their care is. If our team is communicating their plan to them, if they're doing things to keep them, the patient safe, like washing their hands, checking their ID band when giving them medicine, things such as that, protecting them from falling. We also participate in the patient experience surveys. Patients or other families, family members receive surveys that ask about the care they receive, if they were treated with respect, if they were listened to, and about 30 other things. Those return surveys or discussed daily in our safety meetings and the data's compiled. And we also read the comments to look for things we can do better in the future. So, it all feeds together.

Host: Well, it definitetly sounds like, there in Henderson, you are taking care of business and making sure that quality is key all the way through. Krystal, thank you very much for all the information today.

Krystal Coffman: Well, thank you for having me. I enjoyed it.

Host: And that was Dr. Krystal Coffman. For more information, visit valleyhealthsystemlv.com. If you enjoyed this podcast, please share it on your social channels and explore our entire podcast library for topics of interest to you. I'm Evo Terra, and this has been Health Talk with the Valley Health System presented by the Valley Health System. Thanks for listening.

Disclaimer: Physicians are independent practitioners who are not employees or agents of the Valley Health System. The system shall not be liable for actions or treatments provided by physicians.