The patient is the winner in the pursuit of perfection

Grants used to improve health care quality

Given $2 million to improve health care quality, what could a hospital do with the money? That question is being answered now as the second stage of the Pursuing Perfection program of the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Quality (IQI) gets under way.

Seven facilities were selected in April to receive grants of $1.9 million. They are: Cambridge Health Alliance of Cambridge, MA; Cincinnati Children’s Hospital Medical Center; Hackensack (NJ) University Medical Center; HealthPartners Medical Group and Clinics of Minneapolis; McLeod Regional Medical Center in Florence, SC; St. Joseph Hospital in Bellingham, WA; and Tallahassee (FL) Memorial Healthcare.

James M. Anderson, Cincinnati Children’s Hospital Medical Center president and chief executive of the only children’s hospital in the group, calls the Pursuing Perfection project "the engine that drives the transformational change that is necessary for us to become the leader in improving child health."

Their hospital had two pilot projects that were reviewed as part of the grant process. One focused on bronchiolitis and the other on cystic fibrosis.

The bronchiolitis project included providing better access for parents to their children’s charts, better managing patients so that they can be discharged faster, and better use of evidence-based approaches in determining which children needed to be hospitalized for the condition. For the latter two initiatives, there has been significant improvement. There has been a 71% decrease in discharge times, and Cincinnati Children’s now is below the national average in admissions for bronchiolitis.

Cystic fibrosis (CF) patients benefited by having more say in their daily schedule. Outpatients and their parents now are part of a goal setting process that has improved satisfaction, and the program achieved a staggering 50% increase in the number of CF patients getting flu shots, up from 36% last year to 86% this year.

For the next two years, the grant will fund several additional goals:

— to extend the comprehensive redesign of inpatient and outpatient care delivery for chronic care to diabetes and juvenile rheumatoid arthritis;

— to give patients and parents more input into when they have outpatient clinic;

— to minimize pain for newborns and children with cancer, fractures and lacerations, as well as postoperative pain;

— to dramatically improve efficiency and safety for patients preparing to undergo surgery; and

— to extend to acute conditions beyond bronchiolitis the extent to which care is family- centered and based on the best medical science.

At St. Joseph Hospital in Bellingham, WA, a team involved in the first phase of the grant concentrated on improving care for diabetic and congestive heart failure patients and their families through the development of a shared care plan, creation of care teams, and the redesign of services in the hospital, clinics, and community. Further work on these two areas will continue in phase two, in part because the conditions are so prevalent in Whatcom County. In 2000, St. Joseph Hospital had almost 700 admissions related to diabetes and almost 900 admissions related to congestive heart failure. The Pursuing Perfection project goals are to reduce both admissions and readmissions by creating chronic-care services programs that help patients learn to manage their own care.

Among the key items to achieve success will be changing the way care is delivered. According to project executive Marc Pierson, MD, delivery changes will focus on evidence-based protocols to support continuum-based care; disease registry functionality for providers and patients; using leading-edge technology to improve the flow of information between patients and providers; and patients self-managing their care in collaboration with virtual care teams that are based throughout the care continuum.

The project team also will target improving the safety of the medication-management process between providers and patients.

Overall improvement

Pierson and his team hope to demonstrate improved access to care, increased patient self-management and satisfaction, and a decrease in medication errors associated with care at different points in the health care system. Areas for improvement include increased monitoring of critical factors such as glucose levels for patients with diabetes and weight fluctuations for patients with congestive heart failure. One of the specific goals is that every single diabetes patient will meet his or her personal goal for glycohemoglobin levels. Overall, it is expected that hospitalization, re-hospitalization, and inpatient mortality rates significantly will decrease.

Hackensack (NJ) University Medical Center in used its grant money to work on community-acquired pneumonia, heart attacks, and stroke. A team of physicians, advanced practice nurses, and pharmacists worked to streamline the care while achieving near 100% compliance with the performance measures from the Centers for Medicare and Medicaid Services Quality Improvement Project.

"This team approach is integral to the success of these projects," said Peter A. Gross, MD, chairman of the department of internal medicine and project leader for the grant. "The seven areas the medical center has chosen to tackle involve some of the most pressing health care issues in our society."

The pilot programs include: improving function in patients with heart failure, reducing complications of atrial fibrillation by improving anticoagulation safety, providing better access to appropriate care models for geriatric patients, reducing medication errors and improving safety, reducing stroke complications and speeding up stroke patients’ rehabilitations, saving heart muscle in heart attack patients, and implementing methods to prevent diseases by early diagnosis.

Cambridge (MA) Health Alliance spent the first-phase grant on projects for local residents with asthma and diabetes. During the next phase, the system will add more clinical and administrative projects, including depression, children’s oral health, patient flow, and open access for specialty and ancillary services.

Diabetes care also was a grant target for HealthPartners in Minneapolis. Its second pilot was to create "the perfect doctor/patient encounter." For the latter project, HealthPartners wanted to improve appointment and information access for patients requiring primary care and specialty care. Five additional pilot projects in phase two will focus on depression, emergency room care, breast cancer, pediatric diabetes, and the management of pain and suffering at the end of life.

Targets for the grant at McLeod Regional Medical Center will focus on beating national best-practice rates for treatment of heart disease and eliminating adverse drug events. For the latter, McLeod will capitalize on enhancements in computer technology and provide extensive training to medical and hospital staff.

At Tallahassee (FL) Memorial HealthCare, first-phase projects were to redesign medication systems and address patients with acute coronary syndrome. Six additional projects for phase two of the program include cardiovascular, diabetes, end-of-life care, patient flow, customer service, and quality of work life.

"All 12 organizations have demonstrated a deep commitment and the will to contribute to the never-ending pursuit of perfection," says Donald M. Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement. "We are confident that all of these outstanding organizations will continue their efforts to pursue perfect care and will become models of care that the world can emulate."

[For more information, contact:

  • James M. Anderson, President and Chief Executive Officer, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229-3039. Telephone: (513) 636-4200.
  • Peter A. Gross, MD, Chairman, Department of Internal Medicine, Hackensack University Medical Center, 20 Prospect Ave., Hackensack, NJ 07601. Telephone: (201) 996-2000.
  • Donald Berwick, MD, MPP, President and Chief Executive Officer, Institute for Healthcare Improvement, 375 Longwood Ave., 4th Floor, Boston, MA 02215. Telephone: (617) 754-4800.]