Taking Quality from the ‘Back of the House’ to Front of Mind: Stephanie Mercado, CEO of the National Association for Healthcare Quality

Michael Carrese: Hi, everybody, I'm Michael Carrese. You might think improving healthcare quality is largely in the hands of the clinicians providing the care, but much of this difficult work is actually done by healthcare quality professionals who lead quality reviews, institute new protocols for safer care and focus on performance improvement, among many other efforts. To understand more about the world of healthcare quality improvement, we're joined today by Stephanie Mercado, the CEO and Executive Director of the National Association for Healthcare Quality. Since assuming the role nine years ago, she's focused on standardizing competencies for the healthcare quality profession and increasing awareness of its value within the healthcare industry. We'll also be learning about the healthcare quality workforce report that NAHQ recently released. Thanks so much for joining us today.

Stephanie Mercado: Great, thank you so much. I'm delighted to join you.

Michael Carrese: So, we like to start with learning more about our guests and their career path and in your case, you actually have spent quite a bit of time in the healthcare association world. Tell us about that experience and what eventually led you to your current role at NAHQ.

Stephanie Mercado: Sure. So, I actually began my association work about twenty years ago in supporting the American Orthopedic Association and the American Academy of Physical Medicine and Rehabilitation. Both of those organizations were focused on supporting physicians and so for about the first ten or eleven years of my career, I really got to understand a lot of the issues in the “front of the house” of healthcare where healthcare is delivered. As I was invited to interview for the position at NAHQ, what I realized is that it would be a wonderful opportunity to learn more about the work in the “back of the house” of healthcare, and increasingly, quality and safety are being driven by the back of the house of healthcare. Most certainly, we see all sorts of clinical providers who are having their clinical quality competencies play out on the frontlines, but that's really leveraged by a lot of the work that's being done behind the scenes for people working in healthcare quality.

Michael Carrese: I rattled off in the introduction some of the things that quality professionals focus on: quality reviews, new protocols, performance improvement...but if you were in a hospital setting, for example, how would you recognize those people? Like, what departments do they belong to and how are those functions distributed in a healthcare system typically?

Stephanie Mercado: Well, that's an interesting question because most organizations' quality departments were developed on the fly at a local level without the benefit of a standard, so they're all set up just a little bit differently. But some examples of where you would see quality showing up is most certainly in the quality department. There are also areas that focus on safety, risk management, infection prevention, project management and other areas like that which sort of have an interface or connection to quality, but the way that they show up at organizations is a little bit different.

Michael Carrese: Thinking about this, in practical terms, say you had a hospital that was not happy with its infection rates. I take it the quality folks are the ones who would analyze what was going wrong and come up with a plan to improve it and train everybody. Is that the sort of function that we should keep in mind as people in our audience are thinking about what it is that the quality professionals do that NAHQ represents?

Stephanie Mercado: I think in part, the answer to that is yes, we definitely focus on supporting healthcare teams to improve things including infection rates, for example. But part of that improvement also involves utilization of skills around health data analytics. So, before you can figure out exactly what you want to improve, you need to know what areas are the ripest for improvement and that includes really understanding the data. Not only that, but then using that data to create information that you can share with the team so it will really help them all understand not only what changes need to be made, but why they need to be made and then really being able to synthesize that to get executive engagement and buy-in. Health improvement is a big topic and health data analytics is a big area for us, as are others that play into that as well. Certainly, population health and other considerations would come into the mix and population health is one of the domains of quality as defined by our healthcare quality competency framework.

Michael Carrese: Yes, we're gonna get into that. But first, I want to back up and have you talked about NAHQ itself...your size, your scope, what you do for your members, and what your key priorities are?

Stephanie Mercado: Sure, of course. NAHQ was actually founded in 1976 and its roots had been in quality assurance. The organization was founded by a group of individuals who found themselves in retrospective chart reviews, trying to understand -- about ten years after Medicare came into law -- what the government was spending so much money on. Over the years, the profession had evolved, and really began to focus on things not just looking backward, but trying to improve things prospectively and then really getting into some of the more current topics, as I mentioned, around health data analytics, population health, care transitions, quality leadership integration and more. So, as the organization has evolved over the years, I think it has really stood the test of time and really advanced a great mission. We began as an individual membership organization and certification organization. NAHQ offers the only accredited certification in healthcare quality, the CPHQ. About fifteen thousand individuals hold that certification today and we have about ten thousand members of the organization as well. 

Furthermore, we are expanding the work that we do to support healthcare organizations because we really believe that if we're going to advance our mission to improve healthcare quality and make healthcare better that we need to work on a larger scale. So, working with healthcare organizations, going into their organizations to help them assess their quality workforce, and planning to organize them differently, more effectively, and how to really train and upskill those individuals so that we can see that they have the potential to have their potential unleashed by their employer. So, individual certification and membership, healthcare organization support, and then because of all that, we actually also have launched a new division around intelligence, because we are getting so much data into our organization about what the workforce is doing. We have found ourselves with the first and only database in the world that understands who is doing what work in healthcare quality, at what level, in reference to the healthcare quality competency framework that we created. We have a lot of intelligence and knowledge about what work is going on and we have ambitions then to not only understand that in today's environment, but to prospectively make recommendations about how we should set things up to be even better in the future.

Michael Carrese: We've mentioned the competency framework a couple of times, let's get into that now and have you tell us what the need was to develop it in the first place, and how it's been developed and played out over the years?

Stephanie Mercado: So, as healthcare has evolved over the last six or more decades, quality has kind of been a moving target. As I mentioned, as healthcare leaders have tried to put their staff structures and teams together, they've really built that on the fly at a local level without the benefit of a standard. If you take that one step further, you understand that most people in healthcare quality came into the profession because they were really good at something else. So, there are not a lot of academic pathways and training for people who want to pursue healthcare quality as a career, as a profession, and so what the need for us was in creating that framework was to really define the career path options for people working in healthcare quality or interested in working in healthcare quality. It's such a vast framework with eight domains, twenty-nine competency statements and then -- for the purposes of the career pathing -- 486 skills at the foundational, proficient and advanced levels. It's really a robust framework that gives people an idea of where they can go as individuals, and if you look at it from the broadest context, it helps organizations understand the full gestalt of quality. So, if you're a high-functioning quality organization, your team does all the things that are listed in the framework, and that's how you know you're doing quality well and correctly.

Michael Carrese: It sounds like a big training challenge for the employers...or to what extent does NAHQ get involved in providing that?

Stephanie Mercado: It is a big training challenge, and we do support training as well. We have a lot of content that we have created for individuals who are pursuing their own career paths. People can count on us as a provider of foundational, proficient, and increasingly advanced content across all of our competency domains and of course, the certification is really important as well. We are supporting healthcare organizations with that at scale, and trying to help them really train their teams as well. The challenge with that is, it's not just about training. It's really also about making sure that your team is put together in the best way to activate their knowledge and their skills to do their best work. 

I spoke with a healthcare leader the other day that said, over many years, their organization sent 30,000 people to LEAN training, and that they had never taught any of them how to work together to LEAN their system. So, huge investments were made in training of individuals, and next to no investment was made in putting all of those pieces of that really important puzzle together and activating improvement in those areas. So for us, it's about training, but it's also about the structure and process and roles and responsibilities that are needed to help teams do their best work and really support patient outcomes in all the best ways.

Michael Carrese: I'm wondering how this work has been received, generally speaking. Do you think quality is perceived differently within healthcare systems as a result of this? Do you think it's a better understood and appreciated function?

Stephanie Mercado: I think that there are a lot of different views of what quality is, and even what safety is, and so we are on a journey to really change the perception of what it is. Historically, quality has been viewed as more passive, more retrospective, more focused on regulatory and compliance -- check the box, jump through the hoop, pass the test -- all the things that everybody hates about quality, frankly. Our view is to make it more prospective and actually solve problems for patients and even the workforce who is delivering care to patients. 

So, from a leadership perspective, are people viewing quality differently? I would say they are starting to, and we really need to let them know as well that if they're not sure that quality has worked then they did not do it right. I sometimes hear that from healthcare executives, "Oh, yes, Stephanie, we tried that quality thing for a long time, it didn't work. We're moving on to something like transformation.” Transformation is a word. It's not a plan, right? So start with that. And then secondly, they really need to re-evaluate their perspective on all the things that are included in quality, and really make sure their team is prepared and skilled to do the work because there are not career pathways that are well advanced in this profession. The responsibility for educating and training and preparing the workforce is with the employers and so they really need to get engaged and own this issue. Because from NAHQ's perspective, we see quality and safety as both the process and the product of all of our work in healthcare and so we've really got to focus on that and invest in the workforce that's really advancing these very important ambitions.

Michael Carrese: You recently released a report that took a fresh look at the quality workforce and whether it's actually advancing the priorities that you all have on quality, safety and equity, among other things. As I understand it, you found that the focus of the quality workforce is narrower than you would wish it to be.

Stephanie Mercado: Right. So, what our report finds is that we are further along in our journey with regards to the regulatory and accreditation space, the patient safety space, and the quality leadership and integration...which is the kind of putting it together part of making sure that stakeholders are working together to pursue quality. Those findings make sense to us, because of all of the work that's been done, like I said, over six or more decades to really regulate quality and to regulate, to certain extent, safety. Of course, the report To Err is Human was instrumental in really getting people to understand that safety needed to be a priority. So, when we looked at the data, we said, "Yeah, that makes sense that we would be further along in those areas.” Of course, there’s still a long runway for improvement in those as well. 

But what we found was that the areas that we think are most important for the future of healthcare are the things where the workforce is performing at lower ends of the competency spectrum. Those include health data analytics, areas of performance and process improvement that are about change management, that are about project management and areas like population health, care transitions, and quality review and accountability. That last piece is huge because what that really involves is measurement and providing feedback loops to all of the different providers of healthcare and then the payment models are associated with that. So, measurement, feedback loops and payment models...that's a huge part of the future of healthcare. These are the areas that the workforce is not very far along on, and in which we have a lot of work to do. So, when people say quality maybe didn't work for my organization, we say it's probably because the emphasis of your organization -- like many others across the country that we work with -- is always those three areas, so if you're not covering all of your bases, you won’t achieve all of your goals.

Michael Carrese: What's the reaction, the reception been to this, and what are you telling the health systems they need to do to turn this around?

Stephanie Mercado: The response has been amazing and we got a big “thank you, NAHQ for helping us understand this issue” which is really rewarding and fun for our organization to get to explore new territory and create new solutions to solve a lot of the old problems in healthcare. When we think about what people are doing with this and how it's being activated, we've had something like four thousand unique downloads of that report in less than a month. So, a huge amount of engagement and traction. We've had a lot of our stakeholders go to our website and download a toolkit we made that has presentations with talking points so that they can communicate this message in their local environments. We are really mobilizing a lot of people to understand these issues and to narrate them with us. So, very positive. 

The next steps and kind of action items in the report were across three categories. First was with the employers. What we're recommending to employers is that they take a broader and deeper view of what quality is, and that they commit to covering the bases that are outlined in the full healthcare quality competency framework. We also recommend to them that they really take ownership of training, education and skilling for their quality workforce, and that they pay for it. Our data tells us that about 50% of the people who are getting educated in quality and safety are paying for it out of their own pocket. We see employers supporting all sorts of education and training and we think it is critically important that they support that in quality and safety, which like I said, is the process and the product of our work. 

Additionally, we called on the regulatory and rating organizations that are out there to really understand that there has been a lot of focus on what needs to change in healthcare for a very long time -- layers and layers of rules and requirements and things that must be accomplished -- but there has been too little focus on how to change it. Today, we're saying this is the how, and we think the organizations that are making the rules should also create some structural standards that tell healthcare organizations they should actually support their workforce to do that work well. We want them to start making sure that the employers are training their teams and certifying their teams and preparing them to do their best work. 

Then finally, the third stakeholder group that we spoke to in that report was individuals. What we want them to understand is, you gotta be responsible for your own self, too, right? We really want individuals engaging in their own professional development and lifelong learning and really taking ownership at the same time as the employers are taking ownership so that both stakeholder groups are stepping up together to make sure that they're advancing quality and safety.

Michael Carrese: You have your hands full. I actually spent about ten years at an academic medical center, so when you were talking about all of the requirements and everybody saying what has to be done, it really rang true. I know how incredibly complicated this is, but also how incredibly important. I mean, it goes well beyond patient care and affects the system's legal situation, financial situation...everything.

Stephanie Mercado: Yeah. I think healthcare has gotten really good at making easy things hard. So, what we like to do at NAHQ -- and what we think the competency framework really offers -- is an opportunity to make hard things easy, or at least easier. We can focus people on the right work so that we're not sort of bogged down and just wiped out with all of the reporting requirements, but we can really shift the focus to the things that matter most to people working in healthcare, which is making healthcare better and helping people not just watch the same mistakes happen all the time. So, we have solutions for that, that we're really excited about.

Michael Carrese: That's great. So, one of our favorite questions for guests is to give us some direction. We're a teaching company and we love to fill knowledge gaps. Is there a topic -- and it could be related to this, it could be something else -- that you really care about that you think people just don't understand and you would say Osmosis, “Make a video about that.” What would that be?

Stephanie Mercado: Yeah, there is. I just actually got back from the Jefferson School of Population Health's annual colloquium. David Nash founded that program and has done a beautiful job of putting it together. He is now followed by Billy Oglesby, who is the new dean there. One of the things that I think that people just in general don't understand is the complexity of healthcare with regards to all the personal nuances that patients really bring into the mix and the effect that patients and community have on healthcare. There are a lot of important papers and research and thought leadership done about what really affects healthcare. We know that zip code affects healthcare. We know that education is a huge, huge driver of healthcare and health. And so I think that people think that if a patient goes to a doctor, they're going to get fixed, whatever their ailment was. But the challenge is, they go home to where they live and their home, or their community or their family or their care situation may not be conducive for them to get better from whatever their situation is.  That really is not good for the patients and it also is a real reason why we are seeing costs just spiral out of control in healthcare. 

We're treating things in a very specific and acute way and not understanding the full environment that the individual is a part of and the kind of barriers to them getting better. So, they keep coming back to healthcare and we keep having them go through that and keep paying for all those expenses too. So, I think some knowledge for your group about the social determinants of health, what population health is, and also the healthcare and cost components of those topics will be really important.

Michael Carrese: Super important. You know, the classic example is a physician who will tell somebody who needs to lose weight to get more exercise and leave it at that without understanding that the person may live in a bad neighborhood where there's no park nearby so they don't have any way to exercise safely. So, taking that whole patient's life into account and identifying all the obstacles that there might be to them complying with the treatment plan and the recommendations...that's where the game is.

Stephanie Mercado: Yeah. Another similar example would be a patient who has uncontrolled asthma who continues to go back to the emergency department. No sooner do they get stabilized and sent home, then they're back at the emergency department again. And why? It's because of poor living conditions, poor environmental factors. So we have seen healthcare organizations, in addition to prescribing medication and things like that, prescribe a window air conditioning unit for the patient who will literally waddle out with it from the emergency department so that their living conditions can be better so that their health can be better. It's just amazing to see those types of things. Same with diabetic patients. Uncontrolled diabetic patients often are not in that situation because they're out of medicine. They're in this situation because they're out of food, and so sometimes just feeding people makes them well. So, those would be some of the topics that would definitely surface if you cover a subject like that.

Michael Carrese: That's a great, great suggestion. Appreciate that. I'm afraid to say we're gonna have to wrap it up there. We're out of time. But I want to thank you very much, Stephanie Mercado, for being with us today and wish you all the best in your, as I mentioned, incredibly complicated, but incredibly important work that you're doing there at NAHQ.

Stephanie Mercado: Thank you so much. It's been a pleasure and I hope we talk again soon.

Michael Carrese: I'm Michael Carrese. Thanks for checking out today's show and remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.