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 Safety

At 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-19

Foundational 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. 7

Priority 3: Modify Quality Reporting and Management Activities

In 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 Building

Quality 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 programs.

QI leaders and medical trainees are no strangers to virtual learning. Studies have shown that web-based QI curricula are effective in disseminating QI principles to geographically distant learners.10 As we consider the implications of COVID-19 on QI capacity building, more of our programs have begun to use secure online conferencing platforms. For example, some facilities paused all in-person sessions for a voluntary resident quality and healthcare leadership training program in mid-March due to intense clinical care priorities resulting from the COVID-19 surge. After the surge, a combination of in-person and webinar didactic sessions were offered, depending on the type of activity planned.

For Quality Academy, a program within Tier 2 initiated in October 2019 with chief quality officers from across the system, virtual learning will become a critical component during its relaunch. Quality Academy is a voluntary training program that provides staff the skills and tools needed to lead QI at the frontlines of care, ultimately building local capacity within facilities and sites to mentor others in quality. The program includes a combination of didactics, interactive exercises, and discussions, which will teach participants to lead a QI project at their facilities. While portions of Quality Academy cannot be conducted online, we will build virtual elements into the curriculum, including presenting topics through webinars, using polls to ask questions and gather feedback, and engaging in small groups within online sessions. During QI project development, participants will be asked to think through COVID-19 response efforts that focus on equitable access to healthcare services.

We also must consider education for medical students and residents. Because of the immediate response to COVID-19, medical education was shortened, and hospitals were forced to cancel residents' educational conferences, electives, and off-service rotations so they could solely focus on the crisis. For medical students, all lecture-based learnings were moved to online platforms, a method not uncommon to students, especially those at schools where attendance is not mandatory.11 The crux of any medical education is apprenticeship training, with students in clinical settings obtaining hands-on training from experienced physicians; interruptions in clinical rotations may have a dramatic effect on a medical student's career trajectory. This raises a potential issue: What impact, if any, will such an interruption of clinical training have on the future for healthcare and the medical profession?

Conclusion and Implications for the Future

The pandemic has forced us to reassess and think creatively about quality in the post-COVID-19 world. We all yearn to get back to normalcy, but we are cautious of the potential harm “normal” quality and safety activities could cause healthcare workers who are still reeling from their experiences through the COVID-19 surge. Workforce emotional support and wellbeing has been and continues to be at the center of all quality activities as we balance system learning and improvement in preparation for the next wave and continue to build a culture of trust and transparency. Another key priority is to sustain beneficial new processes operationalized during the surge, which may contribute to future resiliency.

Quality management and reporting remain crucial to driving change that improves care, even during a pandemic. Identifying specific COVID-19-related quality measures and developing process improvements are important to enhance our response to a possible future surge. Continuing education through our QI capacity building structure, with COVID-19 considerations in mind, will also build staff resiliency. We, like everyone else, are grappling with the question, “What is quality in the post-COVID-19 world?” Learning as we go and sharing lessons broadly across the organization and beyond within each of the 4 priorities articulated will help foster a culture of continuous improvement in the post-COVID-19 world.

source: https://www.liebertpub.com/doi/10.1089/HS.2020.0120