Strategies for Achieving an A-Hospital Safety Grade

For more than 20 years, The Leapfrog Group has collected, analyzed, and published hospital data on safety and quality to bring transparency to the public and emphasize the importance of safety in our nation’s hospitals. Each year, Leapfrog publishes their Hospital Safety Grade and ranks all short-term acute care hospitals with a letter grade ranging from A to F.

Recently, Leapfrog convened a panel consisting of three healthcare CEOs, all running A-rated hospitals, to discuss how they made patient safety a top priority in their hospitals.

Meet the Three Healthcare Organizations

St. Bernard Hospital, Chicago, IL

Charles “Chuck” Holland is the president and CEO of St. Bernard Hospital in south Chicago, Illinois. St. Bernard has been on a journey to improve patient safety through the lens of health equity. They were given an “F” rating by Leapfrog just a few short years ago but were able to turn their safety and culture around, earning an “A” rating two years later.

Located on the south side of Chicago, St. Bernard’s patients have a serious gap in life expectancy compared to those who live in more well-resourced communities nearby. Patients in those communities live, on average, 30 years longer than those who live near St. Bernard. Learning about this statistic was eye-opening for Holland.

“Health equity is a huge issue for me and I’m on a journey to understand the intersection between patient safety and health,” said Holland. He shared that 80% of their patients use Medicaid as their source of payment for hospital services, which does not cover cost of care. As a result, they are constantly trying to advocate for more resources.

“There is no quality or safety without equity,” said Holland. After receiving the “F” rating, he discovered that there was no point person assigned to patient safety. Holland rectified that by hiring a patient safety officer and identifying improvements for teams, clinical leaders, physicians, and staff to make on a daily basis.

Advent Health, locations in CO, FL, GA, IL, KS, KY, NC, TX, WI

Terry Shah is the president and CEO of Advent Health, a health system with facilities across the United States. It can be difficult to have cohesive change and culture across such a wide geographic region, but annual leadership meetings and a commitment to transparency have led to Advent’s success.

Shah emphasized getting his 450-member leadership team together every fall as one strategy that helped the widespread organization feel more cohesive. “inculcating something across all organizations and 95,000 people takes an army,” said Shah. He said adopting Leapfrog standards, improving CMS Hospital Star Ratings, and observed versus expected mortality rates are the quality measures that everyone in the organization focuses on.

Advent Health has also embraced aligning goals and performance with patient safety. This gives everyone specific accountability to increase outcomes positively. Shah said he put about 35% of everyone’s short-term improvement accountabilities on outcomes associated with patient safety. Additionally, they invested in clinical infrastructure to make sure that they had company resources to do what needed to occur clinically as well as to educate, train, and teach as necessary.

Hartford Healthcare System, Connecticut

Finally, Jeffrey Flaks is the president and CEO of Hartford Health System, with facilities across the state of Connecticut. Hartford has consistently scored highly in patient care measures and has had “A” ratings from Leapfrog across the whole health system, which includes a thousand-bed academic medical center, a 500-bed teaching hospital in the inner city, rural, suburban, and coastal hospitals, ambulatory surgery centers, and more.

Maintaining one standard of care across so many facilities means a wide spectrum of patients who fall into many categories. “Leadership matters, the team matters tremendously, and most importantly, the culture matters,” said Flaks.

Part of the culture at Hartford Healthcare System, like Advent, is tying patient safety to individual goals and therefore compensation. Flaks also emphasizes working transparently, meaning identifying mistakes, taking accountability for them, and then learning from them so they do not occur again. This level of transparency is something that new employees tend to be surprised by, but quickly get on board with.

The Major Strategies that Drive Improvement to their Leapfrog Score

During the panel, five major themes were discussed: addressing health equity and nurse shortages, achieving diagnostic excellence, and enforcing unparalleled transparency. Oh, and of course they shared a few words about AI, because that’s hot on the industry’s mind. Each CEO believes these themes to be key strategies if your goal is to become an A-rated hospital in the Leapfrog program.

Addressing Health Equity

When looking to improve patient safety, health equity cannot be taken out of the equation. Each facility represented on the panel confirmed the disparities they uncovered between the care of Black and White patients. 

One way to make strides in this gap is to identify community-based organizations (CBOs) with whom to partner. Finding people who live and work in the community around your health facility cannot be emphasized enough as an effective strategy to gain the trust of the actual community members.

Additionally, adding a commitment to health equity very specifically in the organization can also be key. Hartford created a Center for Equity in order to face their challenges head-on. Advent has a Chief Health Equity Officer, and an individual health equity plan lives at each of their facilities. Advent also processes data tied to diagnosis outcomes in order to view them through a lens of race, gender, socioeconomic class, etc. And St. Bernard has statements about equity and racism directly on their website rather than shying away from or denying that equity can be challenging.

Addressing Nursing Shortages

Another ongoing issue in healthcare that these organizations have been facing is the nursing shortage. Staffing in general plays a large part in the quality of care that patients receive, and registered nurses (RNs) play arguably the biggest role.

Nurses were already in short supply when the COVID-19 pandemic hit in 2020. As a result of the pandemic, more than 100,000 nurses left the workforce – and many of them were under the age of 35 and worked in hospitals, according to the American Association of Colleges of Nursing website.

So how can healthcare systems meet this challenge head-on? At Advent Health, they create standards and teams that include RNs and Nursing Assistants. They have also invested in education, visiting high schools, and offering nurse’s aide jobs with the promise of further education. They will pay for nursing school and beyond – helping their staff earn BSNs and master’s degrees to become nurse practitioners as well.

These measures have helped Advent’s turnover rate go from a high of 29% during the pandemic down to 16%, with a goal of lowering it even further, down to 12%.

St. Bernard had to examine the amount of money they were spending on agency and traveling nurses and had to right-size their organization. They also studied the role of nurses and the role of physicians and determined the best fit for both jobs in order to keep patients safe at all costs.

Hartford Healthcare System has invested in nursing leadership as well as education, having a Chief Nursing Executive and creating a central nursing leadership team so that they are part of the decision-making process across all levels of the system.

Hartford was also having issues finding nurses in more rural areas who were willing to stay in those areas. To address this, they invested in establishing nursing schools in these hard-to-staff regions, with the aim of cultivating local talent who would be more likely to remain and serve their communities.

Achieving Diagnostic Excellence

Diagnostics are another area closely tied to patient safety and positive patient outcomes. How do we prevent diagnostic errors from harming patients or from even occurring at all? Is that something that is achievable?

According to Advent, this ties into transparency and accountability. Identifying problems, acknowledging them, and doing your best to fix them when possible. And if that’s not possible, then learning from them so they do not occur again. Part of that is including physicians in work teams rather than permitting them to behave or feel above the rest of the work group. “The units that have the highest engagement scores across the team, physicians, nurses, techs, everybody, are the places where people are the most comfortable speaking up in the chain and questioning something that may cause harm to a patient,” said Shah.

A Short Word on AI

Artificial Intelligence (AI) may also be a consideration here. Although there remains a lot of skepticism around AI and how effectively it can aid, Hartford is already invested in creating systems and seeing them through.

Hartford collaborated with MIT's Professor Dmitri Bertsimas to establish H2O, the Holistic Health Organization, and together they developed an innovative solution for Intensive Care Units (ICUs). This product is designed to minimize the length of patient stays and optimize care transitions within the ICU. Although it hasn't been implemented across all institutions yet, it has been in use for over a year and has successfully reduced the average length of stay.

Flaks shares that he is “a tremendous believer in both AI and machine-based learning.” The H2O AI effectively tells the physician during rounds exactly what experience is anticipated for that patient, using a tremendous amount of data points that would be far more difficult for a human to summarize.

Shaw agrees that AI could be used to make patient experience and various health care practices more efficient. “It will be best for the patient and it’s going to be better for the system in the long run,” he said, though he admits that upfront costs could be high.

Transparency is Key

Throughout the panel discussion, transparency as a concept within an organization and within a culture appeared again and again. While everyone has specific standards to maintain and achieve, the most important aspect to remember is having a goal of continuous improvement.

“What matters is as stewards of the organization, are we getting better? Are we learning and are we better tomorrow than we were today?” said Flaks.

Transparency lends itself to honesty and to giving room for people to admit their mistakes and learn from them, rather than punishing them for getting something incorrect. “Drilling down on these measures and being more transparent really helps…patient safety guidelines,” said Shah.

Holland agreed and also stressed the importance of getting patient feedback on safety measures and what it means for them and how it relates to the community so that all stakeholders are involved.