Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World

Health SecurityVol. 18, No. 5 CommentaryFree AccessPicking Up the Pieces: Healthcare Quality in a Post-COVID-19 WorldCjloe R. Vinoya-Chung, Hillary S. Jalon, Hyung J. Cho, Komal Bajaj, Jean Fleischman, Marlee Ickowicz, Electra Nassis, Lili S. Wei, Daran Kaufman, Geralda Xavier, Khoi Luong, Marilen DeOcampo, Georgia Conley, Darwin Edwards III, and Eric K. WeiCjloe R. Vinoya-ChungCjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Search for more papers by this author, Hillary S. JalonCjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Search for more papers by this author, Hyung J. ChoCjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Hyung J. Cho is also a Clinical Associate Professor, Department of Medicine, NYU Grossman School of Medicine, New York, NY. Komal Bajaj, MD, MS-HPEd, is Chief Quality Officer, NYC H + H/Jacobi; and Daran Kaufman, MD, MBA, is Chief Quality Officer, NYC H + H/North Central Bronx; both in Bronx, NY.Search for more papers by this author, Komal BajajHyung J. Cho is also a Clinical Associate Professor, Department of Medicine, NYU Grossman School of Medicine, New York, NY. Komal Bajaj, MD, MS-HPEd, is Chief Quality Officer, NYC H + H/Jacobi; and Daran Kaufman, MD, MBA, is Chief Quality Officer, NYC H + H/North Central Bronx; both in Bronx, NY.Search for more papers by this author, Jean FleischmanJean Fleischman, MD, FCCP, is Chief Quality Officer, NYC H + H/Queens, Queens, NY, and an Associate Professor, Department of Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY.Search for more papers by this author, Marlee IckowiczCjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Search for more papers by this author, Electra NassisElectra Nassis is a Second-Year Medical Student, SUNY Downstate College of Medicine; Lili S. Wei, MD, is an Assistant Clinical Professor of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, NYU Langone Hospital; and Geralda Xavier, MD, MBA, FACEP, is Chief Quality Officer, NYC H + H/Kings County; all in Brooklyn, NY.Search for more papers by this author, Lili S. WeiElectra Nassis is a Second-Year Medical Student, SUNY Downstate College of Medicine; Lili S. Wei, MD, is an Assistant Clinical Professor of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, NYU Langone Hospital; and Geralda Xavier, MD, MBA, FACEP, is Chief Quality Officer, NYC H + H/Kings County; all in Brooklyn, NY.Search for more papers by this author, Daran KaufmanHyung J. Cho is also a Clinical Associate Professor, Department of Medicine, NYU Grossman School of Medicine, New York, NY. Komal Bajaj, MD, MS-HPEd, is Chief Quality Officer, NYC H + H/Jacobi; and Daran Kaufman, MD, MBA, is Chief Quality Officer, NYC H + H/North Central Bronx; both in Bronx, NY.Komal Bajaj is also an Associate Professor, Department of Obstetrics & Gynecology and Women's Health; and Daran Kaufmann is also an Associate Professor, Department of Pediatrics; both at Albert Einstein College of Medicine, Bronx, NY.Search for more papers by this author, Geralda XavierElectra Nassis is a Second-Year Medical Student, SUNY Downstate College of Medicine; Lili S. Wei, MD, is an Assistant Clinical Professor of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, NYU Langone Hospital; and Geralda Xavier, MD, MBA, FACEP, is Chief Quality Officer, NYC H + H/Kings County; all in Brooklyn, NY.Search for more papers by this author, Khoi LuongKhoi Luong, DO, is Chief Medical Officer, Office of Post-Acute Care, NYC H + H, New York, NY.Search for more papers by this author, Marilen DeOcampoCjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Search for more papers by this author, Georgia ConleyCjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Search for more papers by this author, Darwin Edwards IIICjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Search for more papers by this author, and Eric K. WeiAddress correspondence to: Eric K. Wei, MD, MBA, Senior Vice President, Office of Quality and Safety, NYC Health + Hospitals, 125 Worth Street, Suite 507, New York, NY 10013 E-mail Address: [email protected]Cjloe R. Vinoya-Chung, MPH, is an Assistant Director; Hillary S. Jalon, MS, is a Senior Assistant Vice President; Hyung J. Cho, MD, is a Senior Assistant Vice President and Chief Value Officer; Marlee Ickowicz, MPH, is Senior Director; Marilen DeOcampo is an Associate Director; Georgia Conley, RN, BSN, MPA, is an Associate Director; Darwin Edwards III is an Assistant Health Care Planner and Policy Analyst; and Eric K. Wei, MD, MBA, is a Senior Vice President and Chief Quality Officer; all in the Office of Quality and Safety, New York City Health + Hospitals (NYC H + H), New York, NY.Search for more papers by this authorPublished Online:12 Oct 2020https://doi.org/10.1089/hs.2020.0120AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail ON MARCH 1, 2020, New York State Governor Andrew Cuomo confirmed the first case of the novel coronavirus 2019 (COVID-19) in New York City.1 Unfortunately, by April 30, 2020, over 22,000 New Yorkers had contracted COVID-19.2 New York City Health + Hospitals (NYC H+H), the nation's largest municipal health system, overwhelmingly experienced the pandemic's disproportionate impact on immigrant and lower-income communities firsthand. With a mission to deliver high-quality health services with compassion, dignity, and respect to all New Yorkers, regardless of income, gender identity, or immigration status, quality of care has always been of paramount importance to NYC H+H. The quality of care has even greater relevance, given the severity and complexity of the COVID-19 pandemic in New York City.NYC H + H is tasked with improving the quality of care at its 11 acute care hospitals, 5 post-acute care facilities, a large federation of ambulatory care centers (named Gotham Health), community and home care services, and correctional health services. This effort is spearheaded by the NYC H + H Office of Quality and Safety, which supports each facility and service. In 2018, the Office of Quality and Safety formulated a transformation plan with 4 main tenets: (1) create and foster a culture that allows quality improvement (QI) to thrive, prioritizing psychological safety and wellbeing of frontline staff; (2) build QI capacity across the system's over 40,000 employees; (3) align improvement activities so all staff are working toward the NYC H + H mission and vision; and (4) develop data governance and analytics to guide improvement activities. When the COVID-19 surge hit NYC H+H's communities, much of the Office of Quality and Safety efforts to align quality activities within these 4 tenets had to shift immediately. Using an "all hands on deck" approach, NYC H + H refocused quality priorities to address the COVID-19 surge in ways that best supported the challenges of our most essential resource, the frontline workforce.As the number of COVID-19 cases decline across the city, it is important to reflect on how the pandemic has informed and will continue to evolve healthcare quality efforts. We must pause and think methodically about the path forward for quality, including how and what to prioritize in our "new normal." Through a series of conversations with various quality leaders throughout NYC H+H, we developed a framework around 4 key priorities, outlined below, as "Quality Guiding Principles" in the post-COVID-19 world.Priority 1: Focus on Psychological SafetyAt the core of all NYC H + H quality work is the psychological safety and wellbeing of our workforce. The original first tenet of our quality transformation plan centered on building a culture of safety to encourage transparency, trust, and wellness in frontline staff. As COVID-19 plundered our communities, addressing emotional distress and psychological safety remained at the forefront of our efforts.Like many healthcare workers across the globe caring for COVID-19 patients, our staff members experienced insurmountable grief, anxiety, and stress from the burden and uncertainty brought on by the pandemic. Consequently, we are aware of a "parallel pandemic" caused by the emotional toll and second victimization of staff.3 In recognition of the heroic and tireless efforts of frontline workers, a focus on quality will amplify efforts on promoting empathy and further encouraging safe spaces for employees to actively address how they feel while delivering care.4 The emotional and psychological support provided during the surge included integrating respite areas for staff to take breaks and debrief in 1-on-1 or group settings through NYC H+H's Helping Healers Heal program, providing peer-to-peer support and expedited access to mental health expertise. Growing and sustaining these empathy-building and psychological safety efforts will be critical in the future of quality at our health system.To best support our workforce, we are committed to truly understanding and responding to their needs.4 While we must resume the essential activities of quality and patient safety, including huddles, adverse event investigations, and root cause analyses, we will be balancing these requirements with the realities of an emergency response to a pandemic that put tremendous stress on staff and facilities. Our staff cared for patients under extreme circumstances while fearing for themselves and their families. We must acknowledge their lived experiences and base new priorities in QI on candid feedback from frontline workers, obtained through surveys and focused conversations, about what went well and how the quality of our COVID-19 response could be improved in the future without placing undo pressure or blame. Feedback from these assessments will then be reviewed with all staff. Directing attention to the future, we can use forward-looking tools—such as tabletop exercises, drills, and simulations—to hardwire processes that worked during the pandemic as a way of promoting quality and safety while improving staff readiness.We are compelled to address a critical question as we consider ways to provide staff emotional support and psychological safety across the system: To what extent did burnout and second victimization during the COVID-19 surge affect our workforce,3 and will this impact healthcare quality in the future? Therefore, prioritizing psychological safety will be a key aspect integrated into QI projects. To underscore this, a system chief wellness officer position has been created, which integrates psychological safety, care experience, and QI roles. As we further assess the emotional toll of COVID-19 on the NYC H + H community, it is crucial for us to place psychological safety at the core of the quality framework.Priority 2: Reprioritize QI Activities for COVID-19Foundational to all QI activities across NYC H + H are the system's 5 strategic pillars: quality and outcomes, care experience, financial sustainability, access to care, and culture of safety. Specifically, improvement projects conducted throughout facilities and services within the system align with at least 1 of these pillars. While the strategic pillars continue to be essential in prioritizing quality activities post-COVID-19, we must also consider the effects of the pandemic on the workforce.It is important to also note that many changes were rapidly implemented during the COVID-19 surge. We must review these changes and formalize ways to sustain and reimplement useful processes in consideration of another surge, especially those that expanded access to care. For example, we quickly implemented a centralized telehealth palliative care program with 5 hospitals during the surge, as critically ill COVID-19 patients and their families faced challenging end-of-life decisions.5 Disaster credentialing and onboarding of 64 palliative care physician volunteers from less-affected areas across the country supported local palliative care telehealth efforts in the system, and over a 2-week period, volunteers completed 109 palliative care video or phone consults with patients and families needing to discuss end-of-life care. Despite not having a strong telehealth infrastructure within the system prior to the pandemic, volunteers and hospital site leads noted substantial benefits of the program. Resilience of the system in consideration of COVID-19 depends on learning from rapidly tested programs like this, and the ability to quickly develop similar efforts will allow us to be more flexible and expand healthcare services remotely.In conjunction to expanding access to telehealth services, our experience during the pandemic reinforced the importance of our preexisting, robust language access services, as the patient population we serve speaks more than 200 languages and dialects. With ever-changing clinical and public health guidance around COVID-19, we must ensure that our diverse communities continue to have equitable access to reliable information about their health.Lastly, protecting our staff from unnecessary exposure to COVID-19 is a priority. An early report from the Centers for Disease Control and Prevention reported that between February 12 and April 9, 2020, approximately 10% of US healthcare staff who acquired COVID-19 during the pandemic required hospitalization.6 International efforts, such as Choosing Wisely, have now expanded focus in consideration of COVID-19, and our clinical workflows and QI must be streamlined to reduce overuse, now more than ever, to protect patients and frontline staff. 7Priority 3: Modify Quality Reporting and Management ActivitiesIn response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) announced relief in March 2020 in the form of postponements and exceptions to quality reporting. This offered reprieve to 1.2 million clinicians participating in the Quality Payment Program, to hospitals involved in the Hospital-Acquired Condition Reduction and Value-Based Purchasing Programs and to more than 15 additional national quality reporting efforts in which hospitals, home health, rehabilitation, and long-term care facilities participate.8 The New York State Department of Health (NYSDOH) also exercised its enforcement discretion by lifting reporting obligations to hospitals for the NYSDOH Hospital-Acquired Infection Program and suspending sepsis data reporting requirements, due to New York hospitals' COVID-19 execution and response. For most of these programs, data from January 1 through June 30, 2020, will not need to be submitted to comply with quality reporting requirements. This unprecedented action granted flexibilities for healthcare communities, including NYC H+H, to eliminate reporting burdens, allowing healthcare providers to focus on patient care at the height of the COVID-19 pandemic.Preceding the pandemic, CMS began alleviating the burden of quality reporting by developing a measures framework, which organized the most meaningful metrics for healthcare facilities to report within 19 "meaningful measures areas." These areas promoted alignment across quality initiatives and encouraged healthcare organizations to focus on meaningful outcomes for patients and providers.9 Additionally, NYC H + H conducted an exercise at the end of 2018 with stakeholders across its 11 acute care facilities to reduce the number of metrics, from more than 150 to 46 "meaningful measures" (ie, 24 quality and 22 care experience measures) that are now reported to the Quality Assurance Performance Improvement (QAPI) Committee to the Board of Directors (the Board). The metrics were grouped into 6 meaningful measures areas, including healthcare-associated infections; preventable harm; admissions and readmissions; preventive care; prevention, treatment, and management of mental health; and care experience. The system's post-acute care, Gotham Health, community care, and correctional health services went through a similar process focusing on the most meaningful quality measures for their services. At the time, this was an extraordinary, collaborative effort across multiple stakeholders. However, in our post-COVID-19 "new normal," we must rethink these prioritized measures and include a subset of COVID-19 measures to consistently and meaningfully report for quality purposes. Examples include a longitudinal review of the number of patients tested for COVID-19, patients with positive COVID-19 tests, and COVID-19 inpatient days. One challenge in identifying and reporting COVID-19 quality measures consistently is that evidence and best practices related to caring for patients with the virus are frequently changing. As we identify potential COVID-19 measures to report for quality purposes, it is important to carefully consider the impact of doing so, since practice guidelines are still evolving and stresses on the system will vary as case load changes. Therefore, our quality measures must be flexible and adaptive.The Board has consistently prioritized quality and engaged with facility leadership to understand goals for improvement. Through quarterly, facility-based QAPI committees reporting to the Board, we incorporated discussions about COVID-19 execution and response at each facility's meetings. This not only gives QAPI board members an opportunity to inquire about the response, but it also affords facility leadership, clinicians, and staff a chance to share their successes and challenges as they continue to treat and learn about COVID-19 in the communities they serve. This transparent dialogue with QAPI committees reporting to the Board about the monumental efforts combatting COVID-19 will evolve as we continue to understand the ways in which we can improve quality as it relates to COVID-19 response.Priority 4: Resume QI Capacity BuildingQuality cannot advance without building internal QI capacity across all staff and without the involvement of frontline workers. Outlined in our transformation plan is a focus on developing skills, understanding, and expertise at all levels of the workforce so we can effectively drive change and make sustainable improvements. To optimize staff roles in QI, we constructed a 4-tiered approach: Tier 1 – develop a shared, baseline understanding of quality in all NYC H + H employees; Tier 2 – develop the next generation of QI leaders, targeted to both clinical and nonclinical staff; Tier 3 – build managers and supervisors' ability to empower those leading QI efforts in Tier 2; and Tier 4 – build executives' capacities to sponsor QI efforts and align with the NYC H + H mission and vision. Over the past year, most activities and trainings to support this transformation had been in-person meetings until the pause due to the COVID-19 response. However, the post-COVID-19 world in lieu of new social distancing guidelines and restrictions on in-person meetings will necessitate innovation to continue QI capacity building leaders and are to have that QI are in QI to As we consider the of COVID-19 on QI capacity more of our programs have to use For example, facilities all in-person for a quality and healthcare leadership program in due to clinical care priorities from the COVID-19 surge. the surge, a of in-person and were on the of Quality a program within Tier 2 in 2019 with chief quality from across the system, learning will a critical during its Quality is a program that staff the and to QI at the of care, building local capacity within facilities and to in The program a of exercises, and which will to a QI at their facilities. While of Quality cannot be conducted we will build into the including through to and and in within QI will be to think through COVID-19 response efforts that focus on equitable access to healthcare also must consider for and of the response to COVID-19, was and hospitals were to and so they could focus on the For all were to a not to especially those at is not The of is with in clinical settings from experienced in clinical have a on a This a potential will such an of clinical have on the future for healthcare and the and for the pandemic has us to and think about quality in the post-COVID-19 We all to to but we are of the potential quality and safety activities could cause healthcare workers who are still from their experiences through the COVID-19 surge. emotional support and wellbeing has been and to be at the of all quality activities as we system learning and improvement in for the next and continue to build a culture of and key is to sustain new processes during the surge, which to future Quality management and reporting crucial to change that care, even during a pandemic. quality measures and developing process are important to our response to a future surge. through our QI capacity building with COVID-19 in will also build staff like are with the is quality in the post-COVID-19 as we and across the and within each of the 4 priorities will foster a culture of improvement in the post-COVID-19 New York State Governor Cuomo novel coronavirus in New New York State March 1, New York State Department of Health NYSDOH COVID-19 a pandemic – a national to protect Bajaj to psychological safety during and for Healthcare Improvement June of volunteers for a New York City safety system COVID-19 pandemic response. COVID-19 of health care with COVID-19 – February 12 – April 9, Cho Choosing in the COVID-19 to healthcare workers. Centers for Medicare & Medicaid Services CMS relief for clinicians, hospitals and facilities participating in quality reporting programs in response to March Centers for Medicare & Medicaid Services – of a learning for quality improvement The of in Quality Improvement of Care of Care No. healthcare staff to understand the of quality improvement in practices during Health Services No. and to Quality of Care in 1, No. 1 2020 To this R. Vinoya-Chung, Hillary S. Jalon, Hyung J. Cho, Komal Bajaj, Jean Fleischman, Marlee Ickowicz, Electra Nassis, Lili S. Wei, Daran Kaufman, Geralda Xavier, Khoi Luong, Marilen DeOcampo, Georgia Conley, Darwin Edwards III, and Eric K.