Critical Path Network

Case managers take the lead on quality initiatives

Collaborative efforts improve patient care

At El Camino Hospital in Mountain View, CA, nurse case managers, called care coordinators, often take the lead in quality improvement initiatives, working with the multidisciplinary team on the unit to come up with ways to improve patient care.

"We have a very strong care coordination department here. The care coordinators work collaboratively with the nursing and medical staffs on the hospital’s throughput process and quality improvement initiatives," says Susan Bukunt, RN, MPA, CPHQ, director of clinical effectiveness and care coordination.

The care coordinators are part of the multidisciplinary team on their units, attend rounds, and participate in department meetings and executive meetings with the physicians.

"Our strength is that we have a good relationship with the physicians. They appreciate the assistance the care coordinators provide them," Bukunt says.

The care coordinators compile data on the hospital’s compliance with clinical paths. If the data show that that the hospital isn’t meeting the targets for compliance or that length of stay is increasing, they examine the medical records to determine the cause and develop quality improvement initiatives.

For instance, the care coordinator in the department of orthopedics worked with the rest of the team to determine why the cost of joint replacement hardware was increasing.

The team looked at costs by physician and determined that the cost of certain types of prostheses was driving some of the cost increases. The hospital was able to negotiate with the vendors on a lower price.

When the data showed that the hospital didn’t always meet the four-hour window for starting antibiotics in pneumonia patients, the medical unit’s care coordinator, physicians, and nurses formed a performance improvement team that worked together to improve compliance.

"They looked at the data and drilled down to find the obstacles, then looked at ways to overcome them," Bukunt reports.

The team determined that the patients were leaving the emergency department prior to the first dose of antibiotics. A simple recommendation of not letting the patient with a diagnosis of pneumonia leave the department until the first dose was started resulted in a major decrease in time.

When she examined the data, Bukunt determined that a pulse oximetry test for pneumonia patients was not being documented 100% of the time.

She reported it to the care coordinators, who started looking for pulse oximetry documentation when they were screening the charts. The care coordinators worked with the nurses, and the hospital is now at 100%.

"They’re in the charts all the time, reviewing all the notes and consultations and taking a look at the big picture for the patient," she says.

Process improvement team

The care coordinator on the critical care unit has been working with a process improvement team on an initiative to decrease the incidences of ventilator-acquired pneumonia.

"The care coordinator became very involved on that team. We’ve gotten the ventilator-acquired pneumonia rate down to zero," she says.

The care coordinator worked with the critical care team to make sure the beds of patients on ventilators are elevated, that patients have a sedation vacation every day, and that they are weaned from the ventilator in a timely manner.

"She works closely with the clinical manager and is involved on rounds in that department," Bukunt says.

Reports on use of pathways

The care coordinators are responsible for reviewing the clinical pathways regularly and updating them. The care coordinators are assigned to specific clinical pathways and work with the physicians and nurse managers to make sure that they are current with national best practices and evidence-based medicine.

For instance, on the surgery unit, one care coordinator is in charge of general and gastrointestinal surgery, and one is responsible for the neurological and gynecological clinical pathways.

They do literature searches to determine if other hospitals are doing things differently and bring the recommended updates to the physicians. No changes are made in the clinical pathways without physician concurrence.

The department compiles reports on the use of all clinical pathways, including length of stay and cost outliers by unit and by individual physician. The care coordinators take the reports to the chief physician in each department and work with them to present data to the attending physicians

The clinical pathways for surgery and obstetrics are the most highly used, with between 90% and 98% of the cases in compliance.

"In those areas, it’s easier to standardize the practices," she says.

Computerized data entry

The medical clinical pathways, such as congestive heart failure, have a lower utilization, partly because there is a much larger group of physicians who admit patients with those diagnoses, Bukunt says.

"With some medical diagnoses, we go with evidence-based practice guidelines, such as the core measures, rather than push the clinical pathway. Clinical pathways tend to tell you to do this on Day 1 and this on Day 2. We are moving more toward standard order sets. We want to make sure the recommended care is started early versus dictating day-by-day care," she adds.

The hospital has computerized order entry, making it easy for the physician to click on standing orders.

"It discourages handwritten orders and that in itself encourages the use of the pathways," she says.

At El Camino Hospital, care coordinators are assigned to specific units and share responsibility for the patients on that unit with the quality resource nurse and a social worker.

The unit staff work together as a team, collaborating on discharge planning. The nurse handles the utilization review and quality review. The case managers make referrals to social work.

For instance, a 54-bed medical unit has two care coordinators, a quality resource nurse who is an RN, and a social worker. The critical care unit, surgical unit, and maternal and child health unit have a similar structure.

The care coordinators follow the patients only when they are in their units and transition their care to care coordinators in other units.

For instance the critical care care coordinator would follow a patient until he or she is transferred to the surgical unit where the surgical care coordinator picks up the case and follows the patient until discharge.

"We tried other models, such as assigning a care coordinator to follow the patient from door to door. This made it difficult for the care coordinator to be where he or she was needed most. This way, they are always on the unit and available to whoever needs to see them," Bukunt says.

Care coordination

The care coordinators have offices in the areas to which they are assigned, in close proximity to the nursing stations so they can see when the physicians come onto the unit.

"They work very closely with the treatment team to coordinate care and make sure the referrals are handled in a timely manner. They make sure that there are not discharge delays. For instance, if a patient is scheduled for discharge over the weekend, the care coordinators make sure everything is in place," she says.

The care coordinators conduct a paper review on all patients on their unit and use the information to prioritize which patients the multidisciplinary team will evaluate on their weekly or biweekly rounds.

El Camino Hospital is one of about 3,000 nationwide involved in the 100,000 Lives Campaign to improve patient care and prevent avoidable deaths.

Initiatives include sending in rapid response teams at the first sign of patient decline; delivering evidence-based care for heart attack patients; preventing adverse drug events by medication reconciliation; preventing surgical site infections; preventing central line infections; and preventing ventilator-associated pneumonia.

The hospital was singled out by for a case study on hospital quality initiatives by the Commonwealth Fund in 2004. The report cited the hospital’s comprehensive quality improvement initiations, information systems, clinical pathways and protocols, and case managers/care coordinators as factors that contributed to the hospital’s culture of safety and quality.