Stephanie Mercado, CEO of the National Association for Healthcare Quality: Meet the Hidden Teams Driving Quality of Care

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health. You might think improving healthcare quality is largely in the hands of clinicians providing the care, but much difficult work is actually done behind the scenes by professionals who lead quality reviews, institute new protocols for safer care and focus on risk management among many other efforts.

To understand more about the world of healthcare quality improvement and the workforce involved in it, we’re joined today by Stephanie Mercado, CEO and Executive Director of the National Association for Healthcare Quality, nicknamed NAHQ. Since, assuming the role eight years ago, she’s focused on standardizing competencies for the healthcare quality profession and increasing awareness of its value within the healthcare industry. Thanks so much for joining us today, Stephanie.

Stephanie Mercado: It’s my pleasure. Thank you so much for having me.

Van: Let’s start, Stephanie, by having you tell us a little bit about your path into this role and NAHQ’s mission within the landscape of healthcare and healthcare quality.

Stephanie: Absolutely. I came to NAHQ as the CEO and Executive Director having had previous experiences working with medical professional societies. So, my background has been pretty exclusively working in healthcare for the past twenty-plus years and really working in mission-driven organizations that represented professions. Professions always need to be advanced and developed, so that’s really the background that I bring to the table.

I was very interested in working with NAHQ because it represented an opportunity for me to explore, as you said, the other half of the equation in healthcare. I had come from, like I mentioned, the medical professional society perspective which is really what I would describe as the “front of the house” of healthcare where the action is on the ground with the patients. It was becoming increasingly clear to me ten years ago and prior that there was a lot of important momentum and work being done at the “back of the house” of healthcare. That’s where the policy decisions were getting made, the improvement agendas were being put together, and there was conversation about patient safety, improving outcomes and lowering costs. I was really interested in having the opportunity to explore that side of healthcare.

So, that is how I arrived at NAHQ. Where we fit in the healthcare landscape at this point is really to advance healthcare quality competencies across the entire continuum of care, for everyone involved in delivering healthcare and focusing on quality. Most certainly at the very center of our bullseye, our target is going to be people who work full-time in roles in healthcare quality. But we also know that healthcare quality is really a team sport, and so it’s really, really important that anyone working in healthcare have a minimum skill set, knowledge, and vocabulary in healthcare quality so that they can contribute on a holistic level to advancing safety and quality goals in the organization. So, we help people understand what the requisite competencies are, gain the skills, gain the knowledge, and really help them move their own careers forward and at the same time, really advance healthcare goals and objectives.

Van: I’m so glad you’re introducing us to this world of back-of-the-house healthcare professions. I can imagine around the dinner table as families are talking about the world of careers and the world of occupations to their nieces and nephews, that these quality jobs are probably not rolling off the tongue and not in the not in the conversation. So, you are at the forefront of developing a healthcare quality competency framework. Tell us more about what those competencies are about and why you launched it a few years ago?

Stephanie: So if I may, I’m going to start with the “why” before I talk about the “what.” For the past couple of decades, healthcare has been very squarely focused on quality and safety and we see that through well-known reports: The Institute of Medicine’s To Err is Human report and its Six Aims of Healthcare, and many more great work products. One of the things that I’ve been exploring with the board is to say, “If everybody is on board in advancing quality and safety, and we’ve removed so many barriers to that over two decades, then why have we not gone further and why are we not doing better than we are today with quality outcomes and lowering the cost?”

We believe one of the key reasons we have not gone far enough and fast enough in advancing our healthcare quality objectives is because, as much as it’s important to know what we want to do to improve it, we actually have to know how. So, that “how” question became very, very important to us to answer and to say, “What would it take to activate the workforce who is bought-in and who is engaged in driving quality and safety? They agree on what. Now, let’s tell them how.”

I will also say, to your point about the conversation at the dinner table, if you think about any clinical discipline in healthcare — medicine, nursing, physical therapy, and others — it is known and understood and expected that there is a well-worn academic pathway to achieving those careers. The same is not true for people in a lot of roles — not all of them — but in a lot of roles working in the back of the house of health care, including healthcare quality. Even those people who come from clinical disciplines, who may be really, really good at their medical profession or nursing career, are not well-equipped to be working in healthcare quality without the healthcare quality competencies.

So we said, “Okay, let’s take the opportunity to document what is expected from a competency perspective.” We created a competency framework that has eight dimensions, twenty-nine competencies, and 486 skills that are stratified against foundational, proficient and advanced levels. Now, when people hear the eight dimensions, they are on board. When they hear there are more 29 competencies, they usually say, okay. Four hundred eighty-six skills…I usually have people looking for the nearest exit. Like, “Absolutely not! I am not going to be able to master 486 skills!” And what I would share with you and those individuals is you don’t have to. The workspace and the competencies in healthcare quality are incredibly vast.

What NAHQ has been able to do through the eight dimensions, twenty-nine competencies and 486 skills is be able to, one, start to identify career pathways for individuals who can sort of pick and choose what they want to skill in. It also represents a whole framework for what a high-functioning quality organization looks like. We know what a good quality shop is because we defined it. It is the eight dimensions, twenty-nine competencies and 486 skills. If organizations are doing all of those things, then we believe strongly they will be succeeding.

We are moving towards proving that with data as well, to say that this is the path forward. We developed it because there was no educational pathway, and who could accept that, right? You wouldn’t accept a surgeon operating on you if they had learned their job on the fly at a local level without the benefit of a standard, right? We have an expectation that they have learned the right way to do it, and we wanted to offer the same for healthcare quality competencies.

Van: I really appreciate your leadership in this area. You talked about the fact that for many of these jobs, there’s no clear academic path to break in. Let’s dive a little bit deeper into that. What kind of person would be good at entry-level jobs in this area of quality and safety?

Stephanie: So that’s interesting. As we have developed the competency framework, we have also amassed the first and only database in the world that helps us understand who is doing what out there. We are starting to understand…let’s call it the “DNA” of a high performing individual or a high-performing organization. What I can tell you is that the people who are successful in healthcare quality roles are more like-minded than they are like-type.

I would say that they really are very invested in improvement as a way of life. They believe wholeheartedly that things could be better and that they could be part of the solution. Those people are people who see the proverbial burning building and run into it and say, “I can help. I can fix that.” People with those kinds of attitudes are very good in healthcare quality.

I would say that in terms of clinical and non-clinical backgrounds, our research shows that there’s not a material difference, so any background is okay so long as you are really committed to investing in competency development and getting those skills. So, it’s a very diverse group of individuals and they can be trained on this. That’s what NAHQ does. From NAHQ’s perspective, we not only have defined the standard but are teaching to that standard and certifying to that standard. I’d be happy to talk to you more about that as well.

Van: I love that you have already developed the curriculum and the certification and the standards which would help employers more easily recognize these competencies. Let me ask you a very practical question because our audience will be a lot of workforce development practitioners. If I’m trying to break into the healthcare industry — or helping a client or a participant break into the healthcare industry — via this quality control backdoor, will employers recognize these competencies somehow as a way to identify that I’m, you know, one step above the next competitor?

Stephanie: Yes, and increasingly so. The number one way that the competencies are recognized today is through the CPHQ. It’s a certification which stands for Certified Professional in Healthcare Quality. We have about 14,000 CPHQs active today and CPHQs are increasingly required or preferred for more and more roles in healthcare.

The market has recognized this. Jeff DiLisi, who’s the CEO at Roper St. Francis, has told me that if he had two candidates in front of him and one had a CPHQ and the other didn’t — and all other things were reasonably equal — he would pick the CPHQ. He knows that because he’s hired CPHQs and they do a good job for him.

Not only that, but NAHQ actually just published research in our journal — JHQ, the Journal for Healthcare Quality — where we were able to confirm that individuals holding the CPHQs are performing at higher ends of the competency spectrum than their non-CHPQ peers. People sort of believed in the past that CPHQs were in a better position to perform, but we actually have proved it at this point. That’s important, and I think will be increasingly important as we move the conversation forward and really start to understand that the back of the house needs validated skills in quality and safety as much as those in the front of the house of healthcare.

I would also say one more thing if I could related to the CPHQ and also related to who is a good fit for it. It is a good fit for clinical and nonclinical roles if you’re working in health care quality. We see more and more that a lot of organizations — training organizations, nursing organizations — are actually hardwiring the CPHQ credential into their masters’ training program.

So for example, we’re working with Western Governors University, which has put this into the Master in Nursing curriculum, and some of our other content as well. We’re doing the same with George Washington University, and continue to do that with others, and have actually been working with some Health Business Administration programs as well. We’re earlier on in that journey, working with those academic organizations, but that’s us moving upstream so we can help not only in healthcare delivery where it’s at and skilling the current workforce, but also in preparing the next generation as well.

Van: Stephanie, would you be recommending to others that if they wanted to come into this field, let’s say with a sub-baccalaureate certification — like a certificate of completion — could they actually earn some type of NAHQ credential that just allows them to break in or should they go get, for example, a clinical credential and then add this as an upskilling competency?

Stephanie: Either way. NAHQ has other competency development programs in addition to the CPHQ. There are things that come before the CPHQ because the CPHQ is, as a matter of fact, the only accredited certification in healthcare quality. It’s pretty robust, very attainable, but takes a fair amount of commitment and effort to be able to achieve the certification.

If someone wanted to start at a level that was a little more entry-level — and had four to five hours to dedicate towards training instead of forty or fifty hours or more — then I would start with our HQ Principles certificate program, because that’s going to help people know if quality is right for them. That’s a wonderful offering that we have and as a matter of fact, we are updating it and we’ll be publishing a brand new version at the beginning of 2022 that covers principles across the continuum of care.

So it kind of becomes like a choose your own adventure of learning activity, where we offer the base information that we think people should know around health care quality competencies, and then we apply it to hospital health system settings, to long term care settings, to behavioral health settings, to managed care settings. So, we’re able to really make it relevant so that people can get the most out of the learning activity. Those would be a couple of paths.

I would say one more even before that would be Healthcare Quality Concepts, which is something that we offer to healthcare organizations. This is a one-hour training and is actually designed for the frontlines. So often the back of the house, the quality people, are leading the priorities in health care improvement but the front of the house, in all the clinical disciplines, are the ones who see the patients and touch the patients and have the best opportunity to interface with quality.

Lifespan in Rhode Island, for example, was an early adopter of the Concepts course, and they’re training 10,000 individuals on their front lines to understand the concepts of quality and safety because people think it’s something that they have to go looking for, but it’s always just in front of them at work. It teaches them to identify it. They’re actually seeing that event reporting — which is a way to capture safety issues and quality issues — is increasing, which is a good thing because after having gone through the training, people are able to identify potential or actualized risks and safety events. This is really working for them.

There’s a big spectrum there. Concepts, then principles, then CPHQ. We are also in the early phases of building out micro-credentials, which would be sort of the CPHQ plus, and that’s where we get into depth on things like population health, health data analytics, performance and process improvement, quality management, quality leadership…those are some of the topics that we’re exploring but you’ll get a bit of all of those things throughout all of our programming. It just graduates into a sort of a crescendo as people become more and more invested in the discipline.

Van: Oh, I am so glad you are here on this podcast, because you’re sharing what could be a great differentiator for students as they come out and consider how to stand out in their career. Our conversation brings up a question that people would think about, which is artificial intelligence. I’m sure you’ve been asked, what is the role of AI in this world with quality of care?

Stephanie: I actually did a talk on this in September at our annual conference, NAHQ Next. I think AI is going to be increasingly important in healthcare and increasingly utilized, but I don’t believe that it is going to take the jobs of a lot of the people coming up looking for careers because I think that there’ll be other jobs for them to do. We know that, not only in the United States but around the world, we are not seeing babies being born at the replacement rate for the current workforce needs. So, there isn’t going to be, in my opinion, a shortage of opportunity or a shortage of jobs, it’s just going to be that people are going to have to skill in different areas so that their work can complement what AI and other technologies are bringing to the table. I think a lot of it’s going to be in the sense-making of what AI is presenting. I think it’s also going to be in acting on what AI is telling us about our patients and what their needs are. I see a big role for the healthcare workforce in the future, regardless of what technology is present.

Van: Did you see a shift in skillsets of the healthcare quality workforce that came about from the pandemic?

Stephanie: I would not say that we saw a shift. What we saw was a higher sense of urgency placed on these skills. Historically, the roots of the quality profession really are in the regulatory and compliance areas. Over the past several decades, that has really grown to expand into topics I’ve discussed: health data analytics; population health; care transition across the continuum; quality leadership; system integration…all sorts of things.

What happened when the pandemic hit, you think about that proverbial burning building. When there are challenges in health care, what do you need? Number one, you need people with the spirit to run into that building and people in quality who want to improve, did that. They stepped up, and said, “If you have a problem, I am willing to help figure out how to solve it.” So when they did that, they brought skills to the table around systems and process and structure. They brought the ability to stand up things like crisis command centers and telehealth programs launched not in seven months or in two years, but in seven days because they could use a quality tool called rapid cycle improvement and say, “We’re going to stand it up. We’re going to do the best job we can today, but we have a method to evaluate what’s working and not working about this and we will continue to improve it.

Healthcare leaders really relied on people working in quality to come forward with their toolkit and with that spirit to solve for these challenges. As a matter of fact, we actually did some pulse check research with our constituents. We saw at various touch points during the pandemic, they felt more valuable in their organizations. By the summer of 2021, close to 60% were feeling more valued at work because they had the skills, and when they were called on, they knew what to do to help solve problems. It was great. So, no, the skills have not changed, but the opportunity to express them is more and I believe strongly that will continue to be the case in the weeks, months and years ahead because we’re going to have more challenges in healthcare, not less, and we need more problem solvers, not less.

Van: Stephanie, could you decipher for me within an organization, is there usually a group that is the quality control or quality indicator group, or how is it structured within an employer organization? And maybe this ties into how your members and their organizations are feeling about workforce development in this space at this time?

Stephanie: Right. I would say there is not one model for quality in an organization. That goes back to the same concept of the competencies being built on the fly at a local level without the benefit of the standard until NAHQ developed that standard. Think of the same in terms of how the structures evolved. Healthcare leaders increasingly learned over the past decades that they needed more people to do this type of work, but they were each kind of left on their own in terms of figuring out what the structure should look like.

Generally speaking, there will be a quality department in an organization. That quality department will usually, but not always, be the organization that focuses on regulatory and accreditation, reimbursement, and health data analytics. They will focus on giving physicians, nurses and other providers feedback on their performance, talking with them about how their patients are doing from a health outcomes perspective, and talking to them about improvements. The people in the quality departments will lead things around cost reductions in the organization, efficiencies, how to improve safety, reduce falls, reduce catheter-associated urinary tract infections — all sorts of things. So, there’s almost always a quality department but the work that it does is a little different.

Sometimes we see improvement in a different department than quality. Sometimes we see population health in a different department than quality. But we believe that it all needs to be under one umbrella, very well-coordinated and to have this “capital Q” quality space. We also want less emphasis on quality control, which we believe is a retrospective view, and more prospective work, like actually shaping health outcomes and financial performance of an organization by aligning all of that work.

Van: Stephanie, I’m curious, if you were the head of the quality department doing prospective work, let’s talk a little bit about the future of care and this scenario where more care moves to the home and hospitals only take the most serious cases. What would be the role of the quality department? What are prospective things, proactive things that you could do?

Stephanie: Thank you for asking. We could have a whole other interview on this and, if that were an opportunity, I would love to bring in Patty Resnik from Christiana Care who is also on our board of directors. She has a long background in quality and was actually called on to launch Christiana Care’s Hospital at Home Initiative with other healthcare executives.

What I would share with you is that it doesn’t matter where healthcare is delivered, it still needs to be delivered in a way that is highly focused on quality and outcomes. I think that the role of the healthcare quality professional becomes more important when you’re coordinating a more complex system and needing to work with a more diverse set of stakeholders. It will include things like better medical records and making sure that medical records are focused across the continuum of care. It will include things like making sure that there’s a way for the stakeholders to communicate. It will include more things like remote monitoring, and setting up standards.

For example, in the health at home model all of a patient’s data will be constantly sent towards a hub where the information is read and understood and prioritized on a minute by minute, hour by hour basis. Then, healthcare gets deployed into the home when the patient needs it. So, if that is true, there’s a lot of logistics that need to be coordinated as well. I think with where healthcare is going quality will be more important than ever, because it doesn’t matter where it’s delivered, or who’s delivering it. It matters how it’s coordinated, and viewed over the long term.

Van: How does data privacy play into your world?

Stephanie: One of our competencies is health data analytics and also the regulatory and compliance space. So, data privacy is one of the topics that is covered by that. We all want to make sure that people are very familiar with concepts around HIPAA and other requirements for data security and privacy security. I do think that this is something that we need to continue to watch and monitor because we’re taking in a lot more data every single day and connecting a lot more data dots, and we’re also using data and AI to help inform our behaviors on the future. So, we need to make sure we have really good information so that we can treat the patients well. It’s a pretty big topic, but it is within the wheelhouse of those working in quality.

Van: Well, it sounds like this space and these occupations will only grow in importance and in value in the delivery of care in the future.

Stephanie: Absolutely. I believe that strongly. Like I said, healthcare needs more problem solvers and that’s what people who work in quality do. They understand systems, they understand process, they understand structure, they have a vocabulary for quality, they have the toolkit for quality, and they have that energy and enthusiasm and that spirit of improvement, which right now is really important. The healthcare environment is fatigued and kind of beat down based on two years, and more to come, with a pandemic.

Also, knowing that we are going to continue to see an aging population, knowing that there’s a lot of delayed health care maintenance for people who did not get some screenings and proper primary and preventative care during the pandemic. So, as I’m looking at this, I’m seeing that things are going to get more challenging even when we can get COVID a little more under control. The challenges that we had in health care before the pandemic didn’t go away and as a matter of fact things have probably gotten tougher, so we’re going to need more people who have that energy, enthusiasm, optimism, and the skills to really improve healthcare.

Van: As I listen to you explain what is going on, it’s clear to me that this whole space of quality and patient safety plays a very important role in the strategic priorities of the provider organization, and I was wondering if you wanted to elaborate any more on that?

Stephanie: Absolutely. I’m going to point to Dr. Jeff DiLisi at Roper St. Francis in South Carolina again. He is the CEO there and has put three main priorities for his organization moving forward. Certainly, quality and safety are at the top of the list, as is workforce development and engagement. I love that about him and the way that he’s thinking about where we go from here because I agree with it. I think that the only path forward is a focus on quality and safety.

We are going to be experiencing a lot of challenges financially with health care. We already were, and they’re going to get worse, and we’re not going to save our way to prosperity. We’ve got to solve these challenges. Not only that, but we need to do a better job taking care of patients. The patient safety data is not where it needs to be and as a matter of fact, we have seen serious setbacks with the pandemic.

Hospital-associated infections, for example, are in a worse place than they were five years ago. We’ve stepped five years back in time, and that’s a real challenge that we need to overcome. I also think that looking forward in terms of a quality agenda and where to focus…as much as it’s upsetting that those data points are where they are, what it tells me from an optimist’s point of view is that when we were focused on quality and safety before the pandemic kind of sidelined a lot of our “run the business” quality activities, things were improving. We’ve got to get back to that. We need to get back there, and we need to do more of it so that we can continue to improve.

So, yes, I think healthcare executives are facing the cost pressures, they’re facing the patient safety pressures, and they know they need to do better. Some people would say, “I can’t ask my workforce to do one more thing. They don’t need one more training. They’re burnt out. They’re maxed out.” But I think inspired leaders like Jeff DiLisi really understand that the path forward is quality and safety, and it is advancing and engaging your workforce. That’s how you’re going to build culture, too. The time to support workforce is right now because they need it very badly.

Van: It sounds like in the perfect world, every single occupation within the healthcare provider would have acquired some or more of the competencies that you’ve laid out today with us.

Stephanie: Absolutely. Healthcare is a team sport, as they say, and it’s really important that the whole team has some level of knowledge and skills and shared vocabulary on quality because it’s going to reduce friction. If we have only part of the team understanding what we’re trying to do and why we’re trying to do it, we’re going to go slower. They don’t all need the highest order of training and skills but at some level, absolutely, yes. And I would take it one step further and say, if you think about what the patients are expecting when they go into healthcare organizations, I think it is assumed that the workforce is trained on quality and safety, and that is not always true.

Van: Ooh, you make me think. And you’re absolutely right. If this is a team sport, a common vocabulary will certainly bring confidence to the patient. So, let us begin wrapping up. I would like to ask you what makes you optimistic about the future of care?

Stephanie: Great question. What makes me optimistic about healthcare moving forward is that it is a problem that has to be solved. Walking away from it at this point is not an option. Our patients and the citizens of the United States of America and around the world are absolutely counting on us to get this right and failure has too many negative implications — not only for patients and patient safety but financially, bankrupting our governments and a lot of our systems because we have to get this right. We are starting from a place that is positive, but could be a lot better.

So, I like that we’re standing on a solid foundation in healthcare and I believe that we can make it better if we’re working on the same priorities, advancing the same objectives, and leveraging the single biggest resource that we have in healthcare, which is our workforce. I believe in the people doing this work and I believe that if our healthcare leaders can prioritize them and their development efforts, that we can, should, and will do better.

Van: Thank you, Stephanie, for the call to action and for your leadership of NAHQ in this whole area. Are there any closing comments that you’d like to leave us with?

Stephanie: I would just like to say thank you. It has been my pleasure to spend time with you. I think the work that you’re doing is incredibly important. Whenever I can speak with people who care as much about workforce development as I do, it’s a good day. Soo, thank you so much, Van, for your time and all the work you’re doing with your organization.

Van: Likewise, Stephanie. I learned so much and I’m sure our audience will share my sentiments as well. I’m Van Ton-Quinlivan with Futuro Health. Thank you again, Stephanie, for joining us, and thank you to all of our listeners who are checking out this episode of WorkforceRx. I hope you will all join us again as we continue to explore how to create a future-focused workforce in America.