Critical Path Network

Project participants reaping the benefits

Improvements seen in CHF, AMI measures

Facilities that are participating in the Premier/ CMS demonstration project already are seeing the benefits in improved quality — not to mention the attendant incentives. For example, Cleveland Regional Medical Center in Shelby, NC, has seen dramatic improvement in congestive heart failure (CHF), acute myocardial infarction (AMI), and hip and knee core measures.

"We started with CHF, because it had the biggest opportunity for improvement," recalls Elizabeth Popwell, CHE, vice president of systems management, who says the facility's baseline year was 2003.

"Our readmission rates were much higher than benchmark — 12.09%," she says. "We were really concerned, what with the advent of pay for performance."

One of the things that appealed to her about the demonstration project was its weekly monitoring tools. "We felt that would help us in our journey to improve," she says. "What we had done historically for QI initiatives was retroactive chart reviews. In CHF, for instance, that would probably mean looking back on a given quarter four to six months later. I knew of no way to meet our vision if things continued that way."

With the demonstration project, she says, "We'd be able to collect data concurrently, monitor results in real time, and make the necessary adjustments." Thus, her hospital's entire PI model was changed. "Formerly, PI teams would languish on for 18 months, which is very ineffective," says Popwell. "We already know the evidence and what best practices are."

So, as participation in the project began, Cleveland Regional decided to employ rapid cycle changes. "Then, we hired a staff person to do nothing but round on patients — review charts and see if they were getting what they needed," Popwell explains.

When the individual, who is an RN, started, she looked at issues such as whether a patient got his or her LVS (left ventricular systolic) function tests, or if his or her ejection fraction was on the charts. "If it was not, she would talk to the physician or nurse and ask why," says Popwell. "We call it an 'expediter' role; she made sure nothing slipped through the cracks."

Popwell admits that initially, some doctors would have given her a different, less flattering name, but that was before they saw the results. "We not only met the benchmarks, but we improved outcomes," she says. "In 2005, our readmission rate was down to 7.6%."

As for discharge instructions, in the baseline year 12% of patients went home with appropriate instructions. "After our first year, 96% were going home with them," notes Popwell.

The return on investment for the new position is "phenomenal," says Popwell, who is getting ready to hire a new "expediter."

Once she saw those results, Popwell and her team moved straight onto AMI. "We had gained so much buy-in from the docs, once we showed that our 'aggravating' led to significant improvements," she shares.

PI approaches

The same held true for AMI. Mortality in the baseline year was 8.57%; in one year it was reduced to 6.47%. "We've had similar results for hip and knee," says Popwell. "Our 2003 baseline for knee surgery infection rates was 2.6% — the worst decile. In one year, we went to 0.9% — the best decile. Hip surgery infection rates were also reduced — from 2.8% in 2003 to 1.81% in 2004.

"We've maintained the improvements, too," says Popwell. "A lot of our core measures are in the top 10%; in fact, if we drop below 95%, I get nervous."

At Aurora Sinai Medical Center in Milwaukee, the quality improvement team has seen improvements in community-acquired pneumonia through its participation in the program. (Editor's note: As we went to press, data still were being finalized.)

"As we received the data from Premier and CMS, we used it to look at what processes we could improve on," recalls Ann Staroszczyk, RN, MS, director of quality. "We started with CAP."

"Some of the processes we focused on were obtaining blood culture prior to antibiotics, antibiotic selection for ICU patients, and timing to first antibiotics and influenza pneumococcal vaccines," adds Michelle Sarnoski, quality coordinator for the pneumonia initiative.

One of the major activities embarked on was a monthly meeting with the ED, she says. "We'd review the pneumonia charts from the previous month and look at processes and how we could improve," Sarnoski relates.

One of the PI approaches selected was to have the ED director give positive feedback to the staff who performed well on the pneumonia initiative. "He also pointed out to them when they were not meeting the standards, but he gave them a lot of positive reinforcement when they met them," says Sarnoski. This reinforcement was given in writing, and the department created a "Wall of Fame" where their names were posted.

If patients come in with signs and symptoms of pneumonia and are treated within the appropriate time period (i.e., blood cultures, pulse oximetry) there are forms that can be filled out that in essence say to the staff member, "Great job; we're proud of you," says Sarnoski. "When somebody sees someone else on the 'Wall of Fame,' it becomes and incentive for them to get up there as well."

The bottom line, she says, is that "It's the daily attention to detail that makes the program a success."