Outcomes managers take lead in quality initiatives

Projects aimed at improving patient care and safety

Just six months after North Mississippi Medical Center began a project to ensure that patients received the recommended medications after a heart attack, the hospital’s mortality rate for heart attacks had dropped dramatically, from 15.3% to 8.2%.

The project and its success is just one example of how the hospital’s outcomes managers, experienced RNs who take the lead in quality initiatives and developing order sets and protocols, have helped the rural health center in Tupelo, MS, focus on quality improvement.

The hospital received a site visit last year from the Baldrige National Quality Program and recently received the American Hospital Association McKesson Quest for Quality Prize in recognition of its leadership and innovation in quality, safety, and commitment to patient care.

Outcomes managers are assigned by service line and act as a liaison between the physician group and other clinicians. They research the medical literature, looking for new guidelines and new standards of care, then collect and run data to see how the hospital is doing.

"We look for opportunities for improvement in processes. These are things that the physicians and nurses recognize but don’t have time to deal with. We make a comparison between how we do something and the standard of care, and that is where we go to work," says Jan Englert, RN, leader of outcomes management.

Projects have included everything from eliminating hematomas after a heart catheterization to documentation and coding initiatives to working with physicians on specific mechanisms to help them remember to prescribe beta-blockers for heart attack patients.

"It runs the gamut. The outcomes managers do many different things during a given day within the context of their job description," Englert says.

The hospital looked at administration of aspirin, beta-blockers, and ACE inhibitors after a heart attack before those recommended treatments became part of the Centers for Medicare & Medicaid Services (CMS) core measures.

"One set of core measures is based on American Heart Association evidence-based medicine. When they were announced, we were already looking at these indicators. We don’t think we should wait around for somebody to mandate that we follow the best practices," Englert explains.

Kim Jones, RN, BSN, cardiology outcomes manager, spearheaded the heart attack medication project. She started by examining patient data to find out just how often the aspirin, beta-blockers, and ACE inhibitors were administered.

"At first, some physicians didn’t believe our data was accurate. We had other physicians examine the charts and affirm what our research had shown," Jones says.

Jones and her team created a "red-ticket" project, creating a tool that indicates which physicians either fail to prescribe the recommended medications after a heart attack or fail to document in the chart why they were contraindicated.

The tool is a red sheet of paper that asks, "Did we define a heart attack in this patient?"

If the answer is "yes," the tool lists the recommended practices in the core measures with a place to check each if it wasn’t administered.

If they didn’t have a beta-blocker, the outcomes manager checks the box that says there is no contraindication in the medical record. If physicians get a red ticket, it’s documented in their outcomes information and may affect their re-credentialing.

The project had an unexpected benefit — ensuring that all heart attacks were coded correctly and increasing reimbursement.

When she examined the data, Jones determined that physicians were not always defining a myocardial infarction (MI) on the chart.

"If the patient had a huge MI, the physicians would document it, but with smaller heart attacks, they were writing down acute coronary syndrome. There wasn’t a code for acute coronary syndrome, so those heart attacks were not included in our statistics. The tool helped identify things that it was never intended for," she says.

After determining that some heart attacks were being documented as acute coronary syndrome, Jones arranged for the laboratory to send her a list of all patients whose cardiac enzymes were elevated. "I started looking at the charts and determining when the patient had all indications of a heart attack, but the physician didn’t list a diagnosis of heart attack on the chart," Jones says.

Instead of around 500 heart attacks a year, Jones determined that about 900 patients were admitted with heart attacks each year. Adding the correctly documented additional patients lowered the hospital’s MI mortality rate.

The initiative increased reimbursement as well as improving patient care, Jones points out.

"Coders can’t code acute coronary syndrome, so we weren’t getting paid for those patients," she says.

Jones attributes the dramatic drop in the mortality rate to more physicians prescribing the recommended medications and more accurately charting smaller heart attacks.

When she began the project, only about 50% of heart attack patients were getting beta-blockers. After the project was implemented, the figure increased to 95%.

Now the hospital consistently is in the 99th percentile on the core measures for heart attack.

At North Mississippi Medical Center, no one department is responsible for quality. The hospital has decentralized quality improvement and taken it to the bedside, Englert reports.

"The outcomes nurses make sure that quality of care occurs from the time the patient comes in until the patient leaves. Traditionally, people tend to wait for a quality person to come around with a check list. But for a patient to receive quality of care all the time, every member of the staff needs to understand and work on quality," Englert says.

The outcomes managers get a project started and work with the pharmacists and other appropriate disciplines to get it implemented. Later, the outcomes managers check back to see how things are going and which physicians have adopted the recommended actions.

At one point, Englert and another nurse were the only outcomes managers. After several successful initiatives, the organization assigned seven nurse case managers into outcomes manager positions. "Now instead of a centralized quality process, the outcomes case managers are dedicated to each service line," Englert says.

A recent project ensures that every patient who is admitted to the hospital is screened for deep vein thrombosis (DVT) and pulmonary embolism (PE) risk factors through an automated nursing admission assessment record.

"We had quite a few instances where patients had complications and prolonged hospital stays due to DVT/PE, and we felt like we could improve our outcomes. When we looked at how many patients received appropriate prophylaxis, we found that the numbers were low," says Karen George, RN, BSN, clinical outcomes manager for the medical service line.

George worked with Dereck Young, clinical pharmacy specialist, to research the medical literature on DVT prophylaxis and compile the hospital’s data, comparing them to benchmarks.

In many cases, patients were receiving either inadequate prophylaxis for DVT or none at all, Englert says. "We had patients who needed to be receiving pharmacological prophylaxis who didn’t even have anti-embolism stockings. The literature on DVT clearly indicated that just being in the hospital places these patients at risk," she explains.

George and Young worked with physicians, nurses, and other disciplines to develop the protocol. They met with physician groups and nursing units throughout the hospital system to educate them on the reason for the DVT protocol, what it does for patients, and to share outcomes data from the pilot project.

"They attended at least 50 different meetings and spent a lot of time gathering data and creating the presentation. The whole project took about a year from inception to the time it was rolled out across the system," Englert says.

The DVT protocol was piloted on two units before it was rolled out in the entire hospital. The protocol was so successful that it has been integrated systemwide.

Every patient admitted to the hospital is screened for DVT/PE risk factors and receives a score based on their identified level of risk. Depending on the score, a physician order set prints and is placed on the medical record. The record includes the patient’s total score, identified risk factors, and recommendations for appropriate DVT/PE prophylaxis.

"The information is available to the physician who looks at the risk factors and determines what is appropriate for the patient. It’s driven by physician, but we give them the reminder to encourage them to order," George says.

The outcomes managers read current medical journals and guidelines to make sure their units are following the best practices.

"We look at benchmarks to see where we can make improvements. We are at the national average on many indicators, but we want to see if there are things we can do that will make us better. Our medical director says that if the hospital is losing money on a procedure, there must be inefficiencies or variation in practices. This shows us areas to look into," Jones says.

Sometimes a nurse or physician brings up an issue that spurs a project. For instance, the nurses on the cardiac unit reported that some patients were coming back from cardiac catheterization procedures with hematomas.

Jones and her team investigated the hematoma problem. "It was challenging to find articles and evidence-based practices on hematomas after a cardiac catheterization," she says.

The team looked at the amount of medication, the size of the patient, and other postoperative factors that could indicate a trend. They looked at physician practices and the closure devices used to see if one had a higher rate of complications than another.

The team found out that there was a difference in the types of closure device used in the cardiac catheterization lab and suggested that physicians consider changing.

Physicians have responded favorably to the outcomes managers and their projects, partly because the outcomes managers work with them to change processes in ways to make their lives easier, Jones says.

"Physicians respond to good data, and they respond to somebody who will help them change the processes that make their job more difficult. The outcomes managers have developed a close and trusting relationship with the physicians because they’ve worked with them on changing processes," Englert says.

(Editor’s note: For more information, contact Jan Englert, RN, at e-mail: jenglert@nmhs.net.)