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HLQAT Hospital Leadership and Quality Assessment Tool. Reed Fraley, Senior VP Ohio Hospital Association April 28, 2011. Today’s Objectives. Review and understand the intended outcomes of the OHA project Describe the process used by the OHA project team

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Hlqat hospital leadership and quality assessment tool

HLQATHospital Leadership and Quality Assessment Tool

Reed Fraley, Senior VP

Ohio Hospital Association

April 28, 2011

Today s objectives
Today’s Objectives

  • Review and understand the intended outcomes of the OHA project

  • Describe the process used by the OHA project team

  • Examine ways to analyze the HLQAT survey data

  • Discuss interventions being developed as a result of the HLQAT survey

  • Discuss strategies for engaging board members in actions related to the survey results


  • Hospital Leadership and Quality Assessment Tool

  • HLQAT is a self-assessment tool to help hospitals identify and improve leadership structures and processes associated with high performance in clinical quality measures


  • What does HLQAT do?

    • Gauges the effectiveness of your hospital's roadmap for quality

  • Who created HLQAT?

    • Study from University of Iowa in 2006 Journal of Patient Safety lined HLQAT to Mortality, Morbidity and Complication rates

    • Commonwealth Fund & CMS introduced the “tool” and expanded the research

    • IFMC, ActiveStrategy, DotComments working on “post-Commonwealth” research


  • Serious gaps in perceptions of quality between

    • Board C Suite  Clinical Managers/Staff

  • Goal: reconcile perceptions to allow people to address FACTS

Role of the ohio governance institute
Role of the Ohio Governance Institute

  • OHA Governance Institute

  • How HLQAT fits with the Institute's goals

  • Why the pilot

  • What the Governance Institute plans to do with the results

Oha project
OHA Project

  • Pilot hospitals receive a snapshot of their facility benchmarked against other hospitals locally and nationally on a continuum of leadership attributes correlated with high performance on clinical quality measures

  • Pilot hospitals receive resources for survey interpretation and action planning

  • OHA targeted a gap analysis to focus on difference in perceptions between Board, C Suite and Clinical Managers

Process used by the oha project team
Process used by the OHA project team

  • Seven pilot hospitals participated in administering the survey to staff:

    • Board Members

    • Administration

    • Clinical Managers

Survey process
Survey process

  • Taking the survey

Survey process1
Survey process

  • Viewing Results

Survey process2
Survey process

  • Knowledge seeking

  • Established goals and priorities

  • Effective communication

  • Collaboration

  • Clear roles

  • Non-punitive culture

  • Public reporting

  • Process improvement tools

  • Adequate resource allocation

  • QI education

  • Monitoring and evaluation

  • Rewards/recognition

  • 100 questions

  • 30 minutes

  • 12 domains

Analysis of hlqat results
Analysis of HLQAT Results

  • Normalized against the Board perceptions

  • Used Board perceptions to understand the gaps between the Board and other groups


  • OHA Pilot Removed 3 Domains from results:

    • Monitoring and evaluation of QI progress

    • QI for all staff

    • Collaboration across functions and levels

What we did next
What we did next

  • Collaborative discussion face to face

    • Graphed data

    • Compared results between hospitals

    • Shared individual hospital committee and reporting structures

    • Shared data reported to committees

    • Shared frequency of data collection and data distribution

Committees and frequency of reporting
Committees and Frequency of Reporting

  • Committees

    • Quality Committee

    • Safety Committee

    • Medical Executive Committee

    • Board Level

  • Frequency of Reporting

    • Ranged from monthly to quarterly

Data shared
Data Shared

  • All Pilot Hospitals reported at least:

    • Core measures

    • Medication Errors

    • Hospital Acquired Infections

    • Patient Satisfaction

    • Sentinel Events

  • Score Cards

Teased it apart
Teased it apart

  • Take away points:

    • Face to Face meeting as a group was critical

    • Discussion on what was a priority and why

    • Discussion on what could be excluded and why

    • General consensus that every hospital had serious gaps in perception of quality between groups: Board, C Suite, Clinical Managers

What we excluded
What we excluded

  • Removed 3 domains for reporting purposes

  • Color coded dashboards; prefer control charts

Agreed upon strategies
Agreed Upon Strategies

  • Patient Stories

  • Frequency of Reporting to Board

  • Communicate same measures to Board and Bedside

  • Resolution and Feedback Loop

  • Importance of Patient and Staff Safety Reporting

Board communication
Board Communication

  • Score Card Big Dots

  • Measures Commonly Reported

  • Additional Items Reported

  • Frequency of Reporting

  • Patient Stories

  • Measures Communicated to Board and Bedside?

  • Resolution Feedback Loop?

Suggested interventions
Suggested Interventions











Strategies for engaging board members
Strategies for engaging board members

  • Institute of Healthcare Improvement

    • Boards on Board, etc.

  • Quality should be high on Board agenda

  • Safety & Quality needs to be a priority

    • Staff safety

    • Patient safety

  • Control charts not dashboards

  • Patient stories: include good as well as bad stories

Next steps
Next Steps

  • Pilot Boards acceptance

  • Compare Pilot & HLQAT results

  • Take second survey

  • Modify approach

  • Longitudinal study - correlate required Ohio quality reports with HLQAT surveys

  • Keep improving !


  • Perception variance great

  • No uniformity in perception variance among hospitals

  • Minimal feedback

    • to staff

    • on problem resolution efforts

  • Quality leaders seeking help

  • Boards & management perceptions vary