Critical Path Network: Case managers take the lead in clinical quality indicators
Critical Path Network
Case managers take the lead in clinical quality indicators
Hospital meets CHF, AMI, pneumonia indicators 96% of the time
When NorthEast Medical Center in Concord, NC, began an initiative to improve compliance with clinical quality indicators in 2003, compliance for the congestive heart failure and pneumonia clinical indicators was at 84%. In the most recent quarter, the hospital met those indicators 96% of the time.
When the Centers for Medicare & Medicaid Services (CMS) introduced its quality indicators, Leesa Bain, the hospital's vice president for clinical effectiveness, looked for the most effective way to meet the requirements while remaining cost-neutral. She chose the case management department as the most qualified and logical staff to monitor and affect compliance and collect the data without duplicating job functions, says Deb McGowan, RN, director of case management.
"The case managers open every chart, collect all the clinical information, and see every patient. They have a good relationship with the physicians and bedside nurses, which is critical to changing physician and nurse behaviors and processes. It made sense that this was the right group of people to be in charge of the CMS quality indicators," she adds.
In addition to collecting data for the CMS core measures, the hospital participates in the Institute for Healthcare Improvement's 100,000 Lives Campaign.
At NorthEast Medical Center, case managers are responsible for coordination of care and discharge planning, as well as making sure that all protocols and guidelines are being used appropriately. The hospital has a separate utilization review staff who also assist in data collecting retrospectively, utilizing the hospital's case management software.
The case managers also collect information concurrently and can identify when the clinical quality indicators are not being met.
A key component of the initiative is a quality improvement tool, developed by the case management department, which is used weekly to identify the bedside or emergency department nurse and the physician who are responsible for an indicator not being met. The tool, referred to as the Weekly QI Tool, is a spreadsheet with all the clinical quality indicators on it. The tool highlights, in real time, areas for process improvement and identifies the responsible staff.
The case managers make a note of the staff who were responsible for the patient every time a quality indicator isn't met.
At the end of every week, the case managers generate a report that goes to every nurse manager, the chief executive officer, and the vice president of quality. The report contains data on the cases that did not meet the clinical indicators, along with the clinicians who were responsible.
For instance, if a patient did not get an antibiotic within four hours because the physician didn't order it, the report includes that information along with the name of the physician. If the physician ordered the antibiotic but the nurse didn't give it within the four-hour window, the report identifies the nurse involved.
"No one wants their name on the list that goes to the CEO," McGowan says.
The information goes back to the manager's level, where it is used to make quality improvements. If a physician is the person who failed to follow the recommended quality indicator, the medical director talks to the physician and makes sure the oversight doesn't become chronic. Incidents of missed quality indicators also are addressed at department meetings.
"This tool has been very helpful in identifying where gaps occur and has helped the clinical staff understand how the clinical indicators affect patient care," McGowan says.
The report is particularly useful because staff get reports on the clinical indicators every week, when the lapses are fresh in their minds, rather than at the end of the quarter, when they may have forgotten the particular incidents when they failed to meet the indicators, she points out.
The hospital has staff who assign patients to case managers upon admission. Case managers receive their daily census when they come in.
"Each case manager has a set of priorities. The clinical indicator patients are the No. 1 priority. They are seen early in the day so the case manager can make sure that they are receiving the recommended care," McGowan says.
For instance, case managers on the cardiac units see all heart attack and congestive heart failure patients to make sure that the clinical indicators are considered, every single day.
Affecting outcomes
If there is a missing indicator that can be taken care of concurrently, the case manager goes in person to the nurse and reminds him or her that the indicator needs to be followed.
"Their review is done in real-time, which means that can actually impact the outcomes," McGowan says.
For instance, if a patient is being discharged at 2 p.m. and the case manager observes that smoking cessation education has not taken place, she can alert the bedside nurse to make sure it occurs.
In addition, the hospital's discharge system is coded to prompt the nurse to make sure the indicators are being met.
For instance, if the patient was hospitalized with an AMI, the discharge system prompts the nurse to make sure the ACE inhibitors and beta-blockers have been prescribed.
If there is something that can't be impacted, such as an incidence in which a pneumonia patient did not get an antibiotic in a timely manner, the case managers collect the information and enter it into the quality improvement tool.
"If we can't impact it, we don't do any education concurrently, but by entering it into the tool and tracking it on a weekly basis, we can quickly identify the people who are not meeting the indicators," McGowan reports.
The case managers who are responsible for the emergency department work with the staff educators to make sure that the pneumonia indicators are being met.
If a patient is admitted overnight and the case manager finds that the recommended indicators were not followed, she does a root-cause analysis of what might have happened to cause the oversight.
"We still have an issue with the antibiotic being administered to pneumonia patients within four hours. We meet with the emergency room physicians almost every month to share the information with them. In addition, we go over the records, case by case, to determine if it is a nursing process issue or an ordering issue," McGowan says.
When the quality indicator initiative began, the case management staff worked closely with the hospital's surgeons to make sure the appropriate antibiotics were being administered for infection prevention in a timely manner following surgery.
"The surgery service line coordinator met with the physicians and pointed out the times when the physician didn't give the antibiotic in a timely manner and when the right antibiotic was not prescribed. The surgeons changed their practice patterns and began using the correct antibiotics," McGowan says.
In some cases, they modified their standing orders to ensure compliance.
"At a recent surgery meeting, one of the early noncompliant physicians was actually lecturing new physicians on the importance of these indicators in affecting patient outcomes. What a great moment," McGowan adds.
In one case, the team called in a pharmaceutical representative to explain to a physician why the antibiotic he was prescribing was not the best one for patients who had had bowel surgery.
In 2005, the hospital was meeting the surgical infection prevention indicators 85% of the time. By July 2006, the figure had risen to 99%.
McGowan attributes the success of the program to the high esteem in which case managers are held by the rest of the staff.
"At this hospital, case managers are seen as people who coordinate the care. The clinical indicators just become part of what they coordinate. One role is to ensure that the patients get the best evidence-based clinical care. For instance, if a patient needs to have certain medications prescribed when they leave the hospital, ensuring that happens is just part of coordinating the care," she says.
The physicians and service line nurses already had a good relationship with the case managers and welcomed their help in meeting the indicators, McGowan adds.
"It wasn't like someone from the outside, in a newly created position, coming to interfere with patient care. The case managers are respected clinicians, and the rest of the treatment team knows they can depend on them for help," she says.
For more information, contact Deb McGowan, RN, director of case management, NorthEast Medical Center, Concord, NC. E-mail: [email protected].
When NorthEast Medical Center in Concord, NC, began an initiative to improve compliance with clinical quality indicators in 2003, compliance for the congestive heart failure and pneumonia clinical indicators was at 84%. In the most recent quarter, the hospital met those indicators 96% of the time.Subscribe Now for Access
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