Host: Hello everybody. Welcome to Health Chatter on this bright sunny day in Minneapolis, Minnesota. Thanks for being with us. We've got a great show today on quality improvement and quality assurance with a dear colleague that I go back quite a ways with. So stay tuned. I'll introduce her in just a second. We have a great background research team that does wonderful that provides us, Clarence and I and Barry with wonderful information that guides us in our discussions. Maddie Levine Wolf, Aaron Collins, Deandra Howard, Matthew Campbell, Sheridan Nigard are second to none. Sheridan also does our our marketing. And and Matthew does our um our production to get the shows out to all of you in good, good form. Uh, Clarence Jones is my partner in this since day one. Thank you Clarence for being with us. Barry Banes is our medical advisor and provides some medical insights into this show as well. Thank you to everybody. You're all special people. Human Partnership is our sponsor for these wonderful podcasts. You can check them out at Human Partnership.org. Great Community Health Organization. I recommend that you check them out. Also you can check us out. Health Chatter podcast.com where all the research is on there and there's also you can obviously listen to the podcast, but also, if you'd like to, you can also read the transcript of it as well. So thank you to everybody. And let's get the show going. Today we have a wonderful guest with us. I I don't know how how long I've known you Jennifer, but it's been a while and it's uh it's been very, very special and we know how to connect with one another for sure. But then when we decided to do a show on this, you were the natural person to connect with. So thanks for being with us. Uh, Dr. Ludblad leads Stratis Health, an independent non-profit quality improvement organization based in Bloomington, Minnesota that leads collaboration and innovation in healthcare quality and patient safety. She has extensive background in leadership, organizational development, program management in both the non-profit and education settings. Um, you've been at Stratis Health for how long now, Jennifer? It's been a while.
Jennifer: More than 25 years. I found my professional home and I love it.
Host: Wow, wow, wow. Wow. Well, there's a long history of of Stratis Health that really started out as what was once called the uh peer review organizations around the country. We were the one in the state of Minnesota back then it was called the Foundation for Healthcare Evaluation and then it it morphed into Stratis Health and a variety of different things that you're involved with today. So thank you. Thank you so much for being with us today. You're a special guest for sure. So let me start this out and then you guys can you know, chime in on this. It's like for those of us who have been involved in, um, in health, there's always this, um, umbrella, I guess you might might want to say that's over our heads that we're always looking at quality improvement and quality assurance. And it's almost whether it be at a community level, whether it be internally within hospitals and hospital systems, um, delivery of care, etc. So there's always that um, how is it that we we improve and how is it that we assure that we're we're going in um in the right direction. So, let's start out with that first of all, what comment on that a little bit, Jennifer from your from your experience.
Jennifer: Yeah, the headline when you think about quality is that quality assurance is getting it right and quality improvement is doing it better. They are two sides of a really important coin and whenever you have a recurring process, a recurring activity, you need both of those, right? You want to be sure that whatever standard that you've set, whatever way you've determined that things want to go, whatever your goals are, you want to be sure you can do that each and every time, quality assurance. And we're all in the business of improving, making things better. In health care, that's essential to what we do, right? New research comes out, new evidence, new studies, new approaches, we want to continue to improve so that we're delivering and getting the best possible care for the patients that we are supporting and serving. So, again, I I think this is a great way to start a conversation about quality is quality assurance and quality improvement. They are they are different, distinct, related and one is about getting it right and one is about doing it better.
Host: Yeah, you know, um, for all the years that I've been involved in in in health, it always seemed to me that, um, and correct me if I'm wrong, that, um, it seems to me that one of them quality improvement, um, really is a um, a measurement or an assessment of some of some type based on something that you're seeing or or dealing with and then assurance is and again, correct me if I'm wrong is is going forward. How is it that okay, now that we know, how do we assure that these types of quality aspects are maintained. Does that seem reasonable yet today with all the things that we're dealing with?
Jennifer: Yes, yes and it's more than that. I'll give you a couple of examples. So, um, one is a non-clinical or non- health care example. So, our health board meets four times a year. So that's a recurring activity. There are a whole bunch of things we need to do behind the scenes in order to make sure that that meeting goes smoothly, that we're able to get that full engagement, that everything lines up for all the details and logistics that needs to happen. So, we've created a checklist. It details who's responsible for what and at what time and how much in advance of or in follow up to the meeting and that checklist is quality assurance for us. That's helping us get it right so that we can take best advantage of the wonderful people who are the contributors on our board. So that that's a simple example of quality assurance. Anytime we have something recurring, we have tools that we can use to help us get it right. And and we measure that. So there's measurement that's part of both. Um, and and I'll give you a clinical example or or kind of health care example. We know that there are certain things that when someone is having a heart attack or a stroke that are time sensitive when they reach the emergency department. So we need to get those right because those are actually life and death situations that timing of certain things in an emergency room is something we want to have protocols, we want to train people and we want to get it right every single time. We want to assure that we are meeting those time sensitive medical care needs. That's quality assurance. We measure that, we track that, we assure that we are doing that for the patients in the emergency department. In the emergency department, maybe we've noted that um, it's tough times in emergency departments right now. There's a lot of boarding, there's a lot of people that stay in emergency departments too long. So maybe as a hospital we're committed to saying, we want to improve, we want to move people through the emergency department better. So we look at our data and we see that the average time that someone spends from the moment they walk in the door till either they're discharged or admitted is four hours or 10 hours or whatever it might be. We set some goals, we measure, we do some small tests of change, we try to understand what are the barriers to doing better and we look at that emergency department throughput and that's maybe an improvement project that we have. So, again, we use data in a lot of ways in all parts of quality and that can inform and guide our work and help in our decision making.
Host: So you know, I've been really interested in is, you know, certainly when I was involved with um, the Foundation for healthcare evaluation years and years ago, um, we were really in the healthcare delivery arena, all right? But now with with the great work that you guys are are doing and embracing that, it embraces the, it embraces a major component of public health, it embraces a major component of community. And this is certainly where, you know, Clarence and in in the work that he does. So, how is it that you deal with that trifecta and balance between those those three?
Jennifer: That's where the action is. Yeah, so absolutely Stratis Health and when it was the Foundation for healthcare evaluation, has its origins in focusing on quality, what was originally quality assurance and then evolved to quality improvement and patient safety, working with and through healthcare organizations. But now so much of our work is focused on building bridges between healthcare and community. And right alongside that comes with the, I would say overdue recognition that most clinical outcomes, most health outcomes for a person are far less related to the care, clinical care they receive, the medical care they receive, then a whole bunch of other social and environmental factors affecting their health. So, again, health care has come to this realization a bit slow from our perspective, but we're now there and we're now understanding that health- related social needs are such important drivers of a person's overall health. And if we're not doing our work and focusing on the quality of health and care in ways that include what happens outside of the walls of health care, then we're not really thinking about whole person care. So that has completely changed our orientation. That's completely changed how we engage and the kinds of cross sector facilitation and convening and planning and action that we're helping to have happen in our communities.
Clarence: And that's great. And and you know, I I you know, for those of us who have been in the field a long time, I mean, you know, 25, 30 years ago I I I never would have guessed that we would have had community health workers for instance. Okay.
Host: Go ahead, Clarence.
Clarence: You know, I think, you know, one of the things when it when it comes to this kind of thing about, you know, we talk about different groups and talk about different uh strategies that we have to use. This is a this is a very, very impactful issue that's going to affect us one way or another, economically. Right. Right. You know what I mean? And that's that's the one thing that sometimes we don't we don't talk about, but it's true. I mean, in families where you have these issues, I mean, it could hinder families from working, you know, or it could it hinder families who don't have insurance, you know, I mean, and if you let it go long enough, then all of a sudden it still becomes an economic issue because somebody's going to have to take care of it. You know what I mean? So I think that part of, I mean, part of what we never lose the humanity and talking about this topic, but you also I think we also have to be honest that this is a this is a very, very important issue for us uh individually as well as as uh as as group.
Host: You know, I what I've been really interested in is, you know, certainly when I was involved with um, the Foundation for Healthcare Evaluation years and years ago, um, we were really in the healthcare delivery arena, all right? But now with with the great work that you guys are are doing and embracing that, it embraces that, it embraces a major component of public health, it embraces a major component of community. And this is certainly where, you know, Clarence and in in the work that he does. So, how is it that you deal with that trifecta and balance between those those three?
Jennifer: That's where the action is. Yeah, so absolutely Stratis Health and when it was the Foundation for healthcare evaluation, has its origins in focusing on quality, what was originally quality assurance and then evolved to quality improvement and patient safety, working with and through healthcare organizations. But now so much of our work is focused on building bridges between healthcare and community. And right alongside that comes with the, I would say overdue recognition that most clinical outcomes, most health outcomes for a person are far less related to the care, clinical care they receive, the medical care they receive, then a whole bunch of other social and environmental factors affecting their health. So, again, health care has come to this realization a bit slow from our perspective, but we're now there and we're now understanding that health- related social needs are such important drivers of a person's overall health. And if we're not doing our work and focusing on the quality of health and care in ways that include what happens outside of the walls of health care, then we're not really thinking about whole person care. So that has completely changed our orientation. That's completely changed how we engage and the kinds of cross sector facilitation and convening and planning and action that we're helping to have happen in our communities.
Clarence: And that's great. And and you know, I I you know, for those of us who have been in the field a long time, I mean, you know, 25, 30 years ago I I I never would have guessed that we would have had community health workers for instance. Okay.
Host: Go ahead, Clarence.
Clarence: You know, I as as as you're talking Jennifer, it just it it it's like I I have this question because I'm I you know, I'm on another organization that does a lot of the data. Uh, and then I I'm just learning more about you and and the work that you're doing. What's the role of community in acquainting people with the work of health? And the reason why I asked that particular question is because you're asking for community input, I mean you're you're you're evaluating community input, those kinds of things, but I'm not sure that people understand the importance and and when I say and again I'm talking about community, I'm you know, I'm just saying in general, the importance of being engaged in working with you. You know what I'm saying? Because you you know, I I don't I don't I I I'm just I mean it's like a revelation for me right now to hear what you do, what you're asking for, you know, other places you get the data, you see the gaps between the systems and those kinds of things and you say, well, who's in there now that you got this huge gap between community and you got between systems, who is in there taking a look at that information and how is that information being processed so that the community can make an informed decision about its health. And I don't I don't think that that that message I think the message is very important and and it's good to know that that that it's there. I just don't think that people know about it. So, that's my comment.
Jennifer: Well, we look to you and organizations like yours to help us with that. You know, change happens at the speed of trust. And so we we want to build those trusted partnerships. Sometimes we're behind the scenes facilitator and change agent, right? So we're we're not the one out in front, but we're kind of helping bridge and make those connections. In other ways we're reaching out and bringing community organizations together so that they have um strength in numbers and voice because it often feels like an uneven playing field. I'm going to give you an example of an initiative we've been leading for the past few years in Minnesota that's about co-creating a shared approach to social needs resource referrals in the state, right? So as I as I mentioned, there's this increasing understanding of the importance of health-related social needs. And now health systems are interested in that and how they make referrals and health plans and payers are interested. But a system that addresses health related social needs is only as good as the community- based organizations are in terms of their sustainability, their infrastructure, their ability to move those data through and respond to and meet those needs. So we, you know, we eventually want to get to a system where we have closed loop referrals, like everybody has party to the same information. But often times it feels like the health systems and the health plans, the payers wield more power because they tend to have more resources. So we've created this um process by which we have a guiding council and we have intentionally had members on the guiding council that are disproportionately larger numbers of the community organizations, smaller numbers of health care and smaller numbers of health plans and payers because if it doesn't work for the community organizations, it's not going to work for anyone else. So let's elevate and empower the voices of community and how they co-design this work so that in the end we can have a system that works universally for all parties in this multi- sector approach. So that's an example of bringing together community organizations and that community voice in the co-design process in ways that aren't just token representation, but they're actually the majority of who's in this group and so they're driving the discussion, they're driving the direction of the work. But we we welcome those partnerships. We know we need trusted partners that are on the ground and in the field in communities like yours Clarence in order to do our work. So we're constantly seeking and engaging those sorts of relationships and partnerships. So let's let's figure out how we can work together.
Host: Barry, go ahead.
Barry: Okay. So I I want to uh do a simplification for myself, but then um, I want to uh do a a deeper dive into the quality improvement aspect. So, there's like two parts of my brain, you know, or left and a right and right, still working pretty well. Um, but I I I'm sort of like a data geek and when all the data started to to be uh more easily available, more easily collectible and more easily analyzable, um, you know, for me, the quality assurance side of the equation or the that side of the coin, um, is that we've identified what is the best practice, what is the best clinical evidence support, and then you know, you talked about checklists which you know, that's uh actually there's a great book uh written by a To Gonde called the checklist Manifesto, uh, which is uh really a a good a good read as well. Um, and and so I always looked at quality assurance as sort of checking that what we know is the best thing are we doing that. So it's more I don't want to say backward looking but it's you know, it's more reactive. It's let's see what we've done, okay? And then the other side is and for quality improvement is, well, what are the things that we could make better? And data has in my thinking really expanded the ability for us to do quality improvement because of access to that data or getting data in a uh very short term to sort of examine things. So my, okay, with all that as the preamble here, the question is, there are so many things, and this is the creative part of my my brain, there are so many things that we can improve. And so from a a Stratus health, you know, perspective and where, you know, you you know, your perch on the balcony as it were, um, what processes do you see uh the most effective for identifying which areas we should be looking at quality improvement on. I know it's not there's not a secret sauce for this, but you know, there's so many things that we could go after. How how do you go about uh, you know, sort of narrowing the field for what to focus on?
Jennifer: Wow, I I'm going to give two answers to that Barry because I feel like it's so important to offer a little bit of historical context on that availability of data and then I want to describe what what we're doing today to help make those decisions. And there is a little bit of a secret sauce. So I'll I'll leave that there just as a little teaser for you. But first, I want to go back to um, two seminal reports that were issued in 1999 and 2001 by what was at the time called the Institute of Medicine. Um, to human and crossing the quality chasm. Now those are 25 and plus years old and so it might seem like they're not relevant today, but they so dramatically changed the public's understanding of healthcare quality and medical error and drew attention in ways that prompted significant change in what is still with us today in particular around what you're asking about related to quality measurement. So, prior to those reports, hospitals or clinics or nursing homes did a fair amount of measurement and it was very much done within their own vacuum, within their own organization. What those two reports caused to happen is the transparency around quality measurement and reporting that we have today. It was a long and sometimes painful journey and we're still on it in many ways. But in the early and mid 2000s, we for the first time had hospitals reporting publicly a set of quality measures, common measures across all hospitals, similarly for nursing homes, similarly for home care agencies and that was really breakthrough at the time. So, the important part of that is instead of just looking inward and having data about what your own healthcare facility is doing, for the first time we have the ability to benchmark and compare. And boy, if there's something that motivates healthcare organizations and clinicians and healthcare leaders to do better is when they see how they compare to their neighbors or competitors or someone else down the street. So, I think there are the jury is still out about whether those data are useful for consumers, which was the hope and still is the hope, but it absolutely has um, caused, you know, healthcare leaders and and clinicians to say, oh, we're we're doing better here, let's let's share that broadly with our community and with our patients or we're not doing as well. We need to do better in these areas. So, that ability to benchmark and compare has has really significantly changed how quality measurement, quality reporting, the whole milieu of who does that at a federal level, at a state level, at a regional level. So, it's super helpful for us in context setting, prioritization and filtering and determining what are the important things to be focusing on so that our work, which is sometimes at a very hyper local level or at a regional or state level is also feeding up to what we are saying are important nationally in terms of our health related goals.
Clarence: Well, I want to I just want to be a do a disclaimer here right now is that you've also uh provided uh resources for us. We did a whole person assessment for the Hispanic Latino community. So I know uh I know about your work. I know the the the support that you're doing. So thank you very much for that.
Jennifer: We're proud to support the work of human partnership. It's an an excellent organization doing excellent work. You also asked about assessing progress. Again, data is a really important part of quality, whether it's quality assurance or quality improvement. And we assess that progress in multiple ways. Sometimes it's very formal in terms of data collection methodologies where we might be looking at um claims data from the healthcare records. We might be looking at clinical data in an electronic health record. We might be looking at population data, that's surveillance data coming out of public health. And just as importantly, we might look at self- reported data. We often develop tools that are readiness assessments or maturity matrices where we're working with organizations and communities to help them understand their strength and assets and gaps and then working with them to make change and then reassessing where they are. So, it is both a quantitative data analysis and a sense of progress and qualitative because that's often just as important. Data as I said is so key to quality, but we know that what helps people feel compelled and motivated is the stories that accompany those data. And so we're often packaging and thinking about those together. What are the data and stories that are compelling to drive and support and motivate change.
Host: Barry, go ahead.
Barry: Yeah, I want to uh build on on that uh piece as well. And one wondering if there are some natural pathways that Stratus is able to uh wander down uh to get uh um involvement and recruitment of different communities and uh I know that this that I'm I'm thinking of this mostly at a micro level, meaning you know, local, um and at the same time I know that Stratus has also been involved with multi- state collaborations with like organizations as well. But I'd like to I guess for this, you know, what what are the natural pathways like to get uh, you know, either to or through Clarence uh you know, Clarence just to pick on you a little bit, um, you know, but to get down at at a community level, are there are there common pathways that um that we can all learn from and be thinking about.
Jennifer: Well, you you just used a word that's what we kind of sit on when we do this work, which is we listen and learn. We we ask who who where are the influencers in this community? Who are they? Sometimes they're in formal leadership roles, sometimes they're in informal leadership roles. Where are networks already existing? Who's already working together? Because we want to leverage and build on what's already in place in a local community. And recognize the importance of that context given the nature of our work and business model, we we'll get funding that helps us support something for a few years, but our funding always ends. That's the nature of getting a grant or contract. And our goal is to leave that community in a better position with better capacity to do what they're doing and doing well after our engagement. And so we're not trying typically to create new infrastructures, new systems, new approaches. We're trying to build capacity in what's already there. So we listen and learn whatever that unit is. If it's a if it's a single community or a region or a state, who are the associations? Who are the networks? Who are the trusted partners that are there and how can we work with and through them to carry out whatever work we're doing? And again, this notion of co-design has become so important in our work so that they're co-designing in ways that are meaningful and actionable and sustainable in however they're defining community.
Host: You know, I it's it's tough. You know, you brought up also Patty and and I and I and I want to touch on this a little bit too. Caregivers. It's like, oh my gosh, you know, I you know, I had a very, very dear colleague, he was actually my doctoral advisor who came down with with with Alzheimer's and to be honest with you, that was the first um, the first time I actually saw somebody going through it over a um, a period of time. And, um, I remember distinctly being in their home and, um, noticing that there there were like posted notes just about everywhere, you know, to remind, you know, where to go to get a cup or where to go to get your medicine. So, let's touch on this a little bit. The I'll I'll be bold by saying the stress and strain that it puts on caregivers or your your loved ones. So how does how from a public health standpoint do we deal with that? Are we addressing that? Or are we just making it known that there is?
Patty: Yes. Well, um, in Minnesota the the University of Minnesota uh actually um supports. So so our work on dementia at MDH is is partially funded through the the bold Act, building our largest dementia infrastructure. and through that um funding, there's also three centers of excellence to support state grantees. The University of Minnesota um operates as the bold center of excellence on dementia caregivers and they're building out a ton of resources. Um, and I think a while back there was this campaign that Wilder led about, um, kind of like helping people identify as a caregiver because that's not necessarily how people identify, but that's sort of how the resources are communicated. So, if you are just kind of finding yourself in this role and it just feels like your familial duty and and it's not all negative, right? It's not like, oh the burden, the Like it's hard and it feels hard, but you might not identify with it being a burden just like culturally that might not make any sense. Um, so I think the way just like just like how we're talking about risk factors or earlier detection and diagnosis, it needs to be kind of a culturally community specific approach to connecting caregivers to resources. Um, and they really need resources. Like they're they're and the other thing is that there are a lot of resources. So this is where kind of our public health role in, um, building clinical community linkages comes in because if you know, the the provider, the care team really needs to know what the resources are locally, culturally, and have a way to to identify that people are a caregiver for one. So that could be, you know, making sure that that caregiver is um because sometimes they're not really asked any questions in the visit. And you know, even if you're like that sandwich generation caregiver and you're in your own primary care visit, wouldn't it be good to know someone's dealing with that and that it is a social determinant of health for chronic disease and that making sure that they're getting resources that they need. Um, so to me that's like we we have the connections and the collaboration, um, but we need I think that just more support, you know, is needed to address this topic.
Host: Clearance, last words here.
Clarence: I am so excited and happy that we had this conversation. I I think that uh for me, uh Dean Finnegan, you said some things that I like, yeah. It it it it's what I've been thinking, it's what I've been feeling, it's what I've been experiencing. I mean, I think the whole idea about we have to work together even in this time of transition and and and and and turmoil, you know what I mean? And uh we have to figure out what our role is and what role do we want to play. That's why I always like to use the term self- identified, you know, you know, I always say when I go out to a a a uh a organization, I said, what can you do? They said, oh, we can do everything. No, you can't. You know what I mean like, you know, and it's really it's really unfortunate you got to talk to people like that, but no, you can't do everything. What are you what are you self- identify as important so that I know that I can depend on you and trust on you in order to be able to to to handle that which we're asking you to do. And I think we're at that place right now where we can do that, we can forget that Kumbaya kind of stuff. We got to get we got to get down to brass tech, we got to get down to the rubber hit the road. I mean, it's like this is this is not a joke. And I think that if we try to continue to do the things in the same way that we've done them, we're not going to be successful and those those those illnesses and diseases that you talked about, they're going to continue to laugh at us and and grow even stronger. So I love what what what this conversation what you've said. I appreciate it and I'm glad somebody at your level has said this. I'm gonna I'm gonna use your your words for a lot of folks. So anyway, that that's my thoughts.
Host: Glad to be helpful. You know, I think, you know, a thought that I hope that we can leave the show with is, um, forging ahead with what's reasonable and what's doable. If we carry those two torches, I think that we'll we'll come up with some fairly quick creative solutions that'll make uh people feel comfortable that yes, we aren't compromising our our public health and and medical care going forward. And I'm I'm hoping that will be To continue this conversation, we're our next show, uh, we're going to be doing addressing health in anxious times and it's just going to be the health chatter gang. Um, and you know, it it's going to be some interesting perspectives because, you know, there's the the the elder statesman here and then on the other hand, we've got some really good young talent in the public health field that can give perspectives as well. So I think that that will be a a useful balance of ideas going going forward. And then down the road for all the listening audience, we're going to have a a live show. We'll keep you posted on that as well. John, I want to thank you for being on our show yet again and, um, I we we reserve the right to bring it back because you you you definitely bring in words of wisdom to the uh, to the whole enterprise here. So thanks again for for being on health chatter.
John Finnegan: Oh, my pleasure.
Host: So everybody out there, keep health chatting away.
