From good to great: Cofer brings quality initiative to Erlanger

Growing up in Beckley, West Virginia, Joe Cofer wanted to be an engineer like his father and went to Georgia Tech to pursue his dream of learning to design airplanes. He quickly learned his engineering interests were more in industrial engineering than fluid dynamics, physics and other aerospace-related disciplines.

Cofer graduated with a degree in industrial engineering and was on his way to work at Texas Instruments in Dallas when he said he realized he really wanted to practice medicine like his grandfather. His grades weren't good enough to get into med school right away so he enrolled in the University of Tennessee at Chattanooga as a post baccalaureate special student and found a passion he is still pursuing four decades later.

After earning his medical degree in Memphis, Dr. Cofer got a surgery clerkship at Erlanger Medical Center and has never left the hospital. At Erlanger, he met his mentor, Dr. Phillip Burns, who later called Cofer, by then a gifted surgeon, to become program director for Erlanger's surgery residence program.

Cofer worked for two decades at Erlanger to ensure that resident surgeons were adequately trained in all areas and able to sit for their boards to become effective licensed surgeons. While performing surgeries himself and helping train future surgeons, Cofer helped lead the effort to establish the award-winning Project Access in Chattanooga for physicians to donate their time to give medical care for thousands of low-income persons each year. In 2013, Cofer was elected chairman of the American Board of Surgery, the national certifying board for surgeons.

But while he has practiced medicine as a surgeon, educator and industry leader, Cofer has maintained his industrial engineering mindset and his desire to find ways to improve quality, efficiency and outcomes.

In 2004, Cofer was at a Boston convention listening to Darrell A. "Skip" Campbell Jr., a top surgeon at the University of Michigan who leads the Michigan Surgical Quality Collaborative, talk about ways to improve surgical outcomes and hospital quality.

"I became enamored with quality and worked to make sure that Erlanger was the first Tennessee hospital to join the American College of Surgeons National Surgical Quality Improvement Program in 2005," Cofer recalls.

With 21 hospitals now a part of the Tennessee Surgical Quality Collaborative, Cofer said participating hospitals are able to measure and see best practices and learn from one another about ways to improve quality. As a result, from 2009 to 2012, those hospitals in the quality collaborative reported 19 percent fewer post-operation problems, 3.75 fewer deaths per 1,000 cases and better outcomes for 142,258 persons worth an estimated $75.2 million.

That success led Erlanger CEO Kevin Spiegel to ask Cofer this summer to lead an expanded quality initiative at Chattanooga's biggest hospital.

"We develop the metrics, monitor the results and report the data back to nurses, doctors and others," Cofer says. "These are all becoming far more important now to grade a hospital's performance. We're OK at Erlanger, but we need to do better."

Cofer is studying hospitals across the country as he builds the new quality program and staff. He has consulted with another former surgeon, Dr. Henry Pitt, who is the chief quality officer for Temple University Health System in Philadelphia and previously served in a similar role at Indiana University Hospital in Indianapolis.

"Hospitals have had quality programs for decades, but the focus on quality has become much more intense over the past five years," Pitt says, noting that more data on quality is now measurable and payments by Medicare and other insurers is becoming more dependent upon the quality of care provided by hospitals.

In the past, if a patient checked back into a hospital after surgery then the hospital was paid for even more treatments. But new Medicare rules are limiting what is paid for each procedure and readmissions after surgeries degrade hospital quality ratings and can prove costly for a hospital's bottom line.

Pitt said hospitals and payers are refining definitions and measurements for quality, which now number 2,422.

"We really need to focus on the key measures of quality, which in the long run will result in both better health care outcomes and lower costs," Pitt says. "We're switching from volume to value. Because it was the right thing to do in the past, people worked on quality. But now that the money paid to providers is really related to it, people are paying much more attention now."

Cofer has focused his early quality initiatives where he long trained resident surgeons - north wing 8 at the hospital's main campus in downtown Chattanooga. The new Erlanger quality director has met with nurses and other staff members to develop ways to improve the patients experience and limit chances of errors or oversights in care.

"That has been shown to really improve patient satisfaction," Cofer says. "Patients feel like, "hey, these patients care about me."

The new initiative has pushed hourly rounds to ensure nurses get into patient rooms on a regular basis and made sure all change in nursing shifts is talked about in the patient's room without the interference of new admissions or other distractions during shift turnover. When the nurses finish talking about the shift change, they can ask the patient if they left anything out or if there is some unmet need.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey also provides a portrait of patients' experiences in U.S. hospitals.

"Surgeons, for many years, really never had an objective way to determine whether we were doing good or bad," Cofer said. "All you had was insurance claims data and nobody believes that."

The NSQIP is an accepted prospective data base that collects surgical information tied to 30-day outcomes. "That's something we've never had before," Cofer said.

Patient satisfaction is measured through Hospital Consumer Assessment of Health Care Providers and Systems (HICAHPS) surveys, which was developed by the Centers for Medicare and Medicaid Services to ask questions of Medicare patients about how they evaluate their care. Erlanger also is sharing more information about outcomes with its surgeons and other doctors.

"As physicians, we love to get a report card, and doctors tend to be highly competitive and 98 percent of physicians come to work every day wanting to do the best job they can," he said. "If there are metrics that fairly judge how you are doing, people will adjust their behavior and how they do their jobs to get better. Physicians are hungry to get data they can believe in."

Data is collected for up to 50 data points, including age, BMIs, smoking, diabetes, blood pressure and about 20 different complications, wounds and blood clots. The data from local surgery outcomes is compared with national and state data.

"I always believe we are not where we want to be because I'm convinced there is no aspect of what we do that we can't do better," Cofer says. "Our goal is to get us to a point where we are acknowledged as the best. It's still a work in progress."