The executive leadership at Covenant Health traces its commitment to quality improvement to a 2004 board retreat, when a visiting physician from the Institute for Healthcare Improvement presented information about the 100,000 Lives campaign. The speaker drove home the importance of reducing mortality rates in hospitals, striking a nerve with the leaders and board members of the Knoxville, Tenn., five-hospital system.
Following the retreat, every member of the board signed a quality pledge, and the hospital’s executive leadership made a similar commitment, aiming to consistently reduce the organization’s adjusted mortality rates over the next few years.
Once mortality rates and other key quality indicators became top priorities, Covenant’s leaders realized that improving clinical decision support, documentation and transparency would be the best way to achieve their goals. To get there, CFO John Geppi says, Covenant made major, across-the-board investments in information technology infrastructure and training to create the systems that would ultimately translate into patient safety and transparency.
“We made a conscious decision that every hospital has access to the same technologies,” Geppi says. “We focused on things as a system, so that everybody gets the same level of information by which to make good quality decisions.”
Early Access for Consumers
From the outset, Geppi says, Covenant knew that improving quality would demand relentless measurement and reporting. Otherwise, it would be difficult to convince the board that the hospital’s efforts were paying off.
“Every member of our board signed the quality pledge,” Geppi recalls of the 2004 retreat. “We felt like we had to start reporting, so we launched a quality Web site.”
Covenant had been publishing some quality data on its Web site since 2001, long before other hospitals were doing so. But the executive retreat inspired further transparency. Today, the system has a separate site for quality data, www.covenantquality.com, where consumers can access quarterly reports on each hospital as soon as the reports are delivered to Covenant’s board, months before the data is released by the Centers for Medicare & Medicaid Services and the Joint Commission. The site also provides updates on Covenant’s quality initiatives, information on topical issues like MRSA and the hospital’s infection control policy, and details about its latest technological innovations.
CEO Anthony Spezia says getting ahead of the curve on transparency back in 2001 was a deliberate decision because the hospital recognized that consumers would eventually demand quality reporting from their providers. “The time will come when people are in charge of their health care dollar whether they want to be or not, and they will make decisions about price, quality and service,” he says.
Along those lines, CIO Mike Ward says the hospital is now considering adding personal health records to its Web site, as patients become increasingly sophisticated and demand more access to information.
“The needs of the organization and the consumers have changed,” Ward says.
Door-to-door documentation
When new patients arrive at Covenant, clinicians immediately begin gathering data to determine whether they fit into any at-risk, core measure populations. Those patients are then tracked using situation-background-assessment-recommendation (SBAR) reports that are sent to portable devices worn by clinicians on call. By tracking patients with congestive heart failure and pneumonia early on, physicians and nurses are able to access all of the patients’ clinical data as it is recorded. “That shows the collaboration between IT and quality leaders,” says Sandra Marshall, Covenant’s senior vice president for organizational effectiveness. “We have an IT person on the quality council that meets with them monthly. For ideas or thoughts, that’s where their expertise is wonderful.”
Covenant’s IT department also works closely with the system’s five chief nursing officers to develop technology priorities that closely support quality projects. For example, the system’s sophisticated electronic medical record constantly generates updates on each patient, much of which translates into “noise,” Ward says. So the IT department meets regularly with nursing staff to determine which data should be saved in the clinical record and which is redundant or inessential. Those conversations are especially important as the health care system increases its capacity to record clinical data, Ward points out.
“You may capture 10 measurements,” Ward says. “Will we put all 10 in the EMR? Do you capture and put each into the clinical record, or only what’s appropriate? Nurses have all different data elements, and they’re looking at increased volume.”
To strengthen the relationship between nurses and IT, Covenant selects nurses who are early adopters of new technology to serve as training liaisons, bring other clinical staff up to speed on the latest improvements and make decisions about how systems should operate.
“Part of the process for nurses is that they have to determine things like how frequently is the blood pressure going to be taken,” Ward says. “It may have a technology focus, but it’s also about process improvement and training.”
The next big challenge, Marshall says, will be rolling out bar-code-assisted medication administration, which will begin later this year. Covenant is also in the early stages of redesigning its emergency department EMR to capture and save as much clinical data as possible. The long-term goal is to redesign the entire documentation process of a patient’s ED visit, avoiding redundant steps and instantly repopulating the data if he or she is admitted.
“We’re asking what medications the patient is on at home [while they’re] in the ED,” Marshall points out. “We shouldn’t have to ask the same thing on the floor. That’s happening today.”
One Size Doesn’t Fit All
Not every IT project at Covenant has run smoothly. In 2005, the system unveiled an ambitious new wireless project that allowed nurses at a pilot rural facility to document medication administration in the hall or the nurses’ station. But when Covenant began implementing the same wireless infrastructure at its main facility in Knoxville, problems ranging from signal interference from a nearby airport to University of Tennessee students attempting to use the hospital’s wireless signal convinced Covenant’s leadership to temporarily scrap the project and seek a new solution.
“What may work in one facility” may not be a success elsewhere, says Ward, who adds that Covenant works hard to evenly distribute its IT resources throughout its facilities. “The technology worked in a single-level facility. When we went to the rural facility, there was no wireless bleed-over. We thought it was going to be working great.”
Undaunted, Ward regrouped, and in 2007, Covenant began working with a new wireless vendor. Earlier this year, the organization reintroduced wireless technology at its larger facilities. The experience taught Ward that the IT department had to be flexible to meet clinicians’ needs.
“That’s an ongoing challenge,” Ward says. “With the clinical documentation put in place, you have to get the technology there. A team of programmers has to be working constantly with the quality side of the house.”
Cautious on CPOE
While Covenant has aggressively pushed its transparency and clinical documentation agendas for the last several years, the system’s leadership made a deliberate decision to hold off on rolling out computerized provider order entry until it had strong support from staff. Spezia, citing the hasty, unsuccessful CPOE rollouts that have plagued some hospitals, said he wanted to wait until all doctors were on board before going forward.
“We didn’t want to go down the road of beginning a CPOE installation to [then] have it come to a grinding halt,” Spezia says. “If it doesn’t have physician support, it’s not going to work.”
To avoid a failed implementation, Covenant has been carefully working with its physician advisory council to prepare for next year’s installation, Ward says. The process mirrors the way Covenant works with its nurse early adopters. “You really have to have physician champions in place,” he says. “They have to be advocates for change.”
Ward also wants to be sure that Covenant has the IT tools on hand to support the upcoming rollout. For years, Covenant has been one of 12 McKesson customers to participate in its clinical leadership program. Within the program, Ward says, Covenant has focused on adopting new clinical documentation tools, while other participating systems have been more involved in CPOE. Another challenge, he adds, will be managing CPOE adoption so it can be implemented consistently across Covenant’s facilities.
“We have to get the tools where they not only work in a single facility, but in multiple facilities,” Ward notes.
‘Insatiable Appetite’ for Data
Since the 2004 retreat, Covenant’s quality team has reported its mortality index to the board each quarter. According to Marshall, the most recent data placed the mortality index at 0.77. The average mortality index score for hospitals is 1, and Covenant hopes to eventually bring the score down to 0.6. So far this year, the hospital estimates that the lowered mortality numbers translate to 211 lives saved based on the expected number of admitted patients at risk for dying.
But Covenant’s quality department doesn’t simply focus on mortality. The hospital’s EMR records 80 percent of CMS core measures, putting it in good shape as CMS and other insurers increasingly focus on performance as a driver for payment.
“We felt early on that we needed to get our arms around core measures before it affected reimbursement,” Geppi says. “We made the effort to begin that several years ago. It’s paid dividends.”
Indeed, that focus on transparency translates to the IT department, which has developed roughly 80 metrics to track how its projects impact the hospital globally, down to how much money is saved by its e-mail system’s ability to block spam. Those metrics are then reported back to the board to demonstrate the importance of IT investments. For Ward, the process of constantly developing and supporting new metrics is central to the hospital’s efforts to improve patient safety and support transparency.
“On the network side, we wanted to invest in more tools and capability to get to a finer level of analysis,” Ward says. “We have regulatory agencies out there continually changing the game, all under the principle of improving health care. They’re leaving it to the IT department. They’re asking for more and more clinical data, and there’s an insatiable appetite. For the poor folks trying to enable it, we’re trying to keep up and capture data.”
Vital Statistics
Covenant Health, Knoxville, Tenn.
President and CEO: Anthony Spezia
CIO: Mike Ward
Number of Beds: 1,556
Number of Employees: 9,000
Number of IT Employees: 213
IT Operating Budget as a Percentage of Total Operating Budget: 2.4%
IT Capital Budget as a Percentage of Total Capital Budget: 15.1%
Key It Projects for Covenant Health
| Project | Description | Vendor | Target Date |
| Medication Order transmission system | Install system to reduce medication order time and transcription errors | Developed internally | Completed |
| Surgery Information System | Connect OR to scheduling, supply chain and performance management systems |
McKesson | Completed |
| Bar-Code Medication Administration | Implement bedside bar-code scanning for medication delivery | McKesson | 2007-2009 |
| Wireless Infrastructure | Introduce wireless technology throughout health care system | Meru Networks | 2008-2009 |
| Surgery and Supply Chain Analytics | Standardize practices and optimize inventory management | McKesson | 2008-2009 |
| Lab Information System | Facilitate electronic ordering, results reporting, medical necessity checks and link to physician practices | McKesson | 2009 |
| Computerized Provider Order Entry | Switch from written physician orders to electronic system | McKesson | 2009-2010 |
