Teamwork key part of heart failure initiative

Organizations receives GWTG award

The Center for Heart & Vascular Health of Christiana Care Health System, a large healthcare organization based in Wilmington, DE, has received a Get With The Guidelines–Heart Failure Gold Quality Achievement Award from The American Heart Association, signifying that it has reached the goal of treating heart failure patients with 85% compliance for at least 24 months to core standard levels of care. (Those levels of care are enumerated in the American Heart Association/American College of Cardiology secondary prevention guidelines for heart failure patients.)

"This means that overall 85% of our patients met every single performance measure," explains Timothy J. Gardner, MD, medical director of the Center for Heart & Vascular Health and past president of the American Heart Association.

Gardner goes on to explain that in specific areas, compliance was much higher than 85%. "So, for example, smoking cessation was 97%, beta-blockers 93%, and so on," he notes. "That [overall] number is a tricky thing; it asks, how many patients had every single compliance benchmark met? You may have had 97% in smoking cessation, but in getting all patients to meet every single measure, we were at 85%."

Gardner says that the center saw significant improvement as a result of the program. "We went from compliance before the program started of about 60% where patients met every single performance measure," he says. "Even in areas where we were doing pretty well, there was improvement. For example, we were at 87% for patients receiving beta-blockers at discharge, but we moved up to 93%."

Team organization critical

"Prior to initiating the program in 2007, we were very aware of the compliance targets and we were working hard to achieve good quality performance for our patients," notes Gardner. "However, we were not nearly as well organized in team functioning as we became when we joined the program."

Gardner asserts that success was achieved by having all the key members of the team participate. In addition to physicians and nurses, that included social workers, discharge planners, pharmacists, and so on, "working together to identify goals and helping all our patients meet those goals." The overall goal, he says, was to get to 90% or better in all measures.

"Teamwork is recommended as part of the program," Gardner continues, noting that the program contains a wealth of information to help set up your facility's initiative. For example, there is a slide set that reviews the history and rationale for the program. "They have a series of slides that talk about elements for success, which include an initial education workshop on the elements of management of heart failure patients," he says. "Then they talk about having a champion — it's usually a doctor, but it could be a senior nurse or a P.I. individual."

Creating care teams

Next, he says, you put your team together. "The next key element," says Gardner, "was to make everyone aware of the benchmark data — where are we beginning, and what are our goals."

"For us, creating the care teams they recommended really brought together doctors and nurses in caring for the patients," Gardner continues. That involved identifying the key personnel.

"We have over 60 cardiologists, but we knew we needed support from the medical director for the program, so the system took on the responsibility of hiring someone to do that," says Gardner. "We contracted with a heart failure specialist to be our medical director, and also provided him with an NP to allow them to essentially oversee the in-hospital care — and in some instances follow-up care — of many patients."

The nature of medical care for patients with complex conditions is what makes the team structure essential, Gardner notes. "You need physician leadership, dedicated hands-on and well-informed nursing care, and you need to provide education and support for things like nutrition and compliance with medication — you need a village," he explains. "People with different competencies are required to deal with such a complex, challenging situation like a chronic illness."

Next, the team "cohorted" the heart failure patients at the two Christiana hospitals to two particular nursing units, "and spent a lot of time and effort educating nurses on the unit on the patho-physiology and pharmacology and clinical scenarios for heart failure patients," says Gardner. "This included our pharmacy, nutrition people, our social workers and discharge planners, who were not only part of this team but participated in regular rounds with this group — and also interacted with patients and their families."

It's also essential, he says, for those interactions to include both the patient and their family members. "Many patients at home get hands-on care, and if the family is not equally well educated about disease processes and things that either help the patient or make the condition worse, that patient will be back days after discharge," Gardner says.

In order to be sure to accomplish this critical goal, Christiana hired additional nursing personnel and social workers, "to help with the complex transition care of these patients," says Gardner. "Primarily, that means to help them and their families know what they need to do in terms of medications, exercise, return appointments, and so on, when they leave the hospital."

Measuring results

How does Christiana monitor compliance? "We have a P.I. team, and they use the measurement tools that are part of the program," Gardner explains. "We obviously have to measure a lot of things these days with reports to groups like CMS, and 'Get With The Guidelines' focuses on those we need to document for heart failure management."

Gardner says the team tracks both collective and individual performance and, when required, leadership will consult with physicians. "We would start perhaps with a letter from the PI team that might go something like this: 'Dear Dr. ----, we noted in review of this case that you did not order an ACE inhibitor for this patient despite the fact the guidelines indicate this was the right treatment. Perhaps there was a contraindication, but if so, it was not documented. Could you indicate what it was?'"

If a doctor fails to comply two or three times he or she would get a call from the medical director, Gardner says. "They would have a polite discussion about why the doctor may not have chosen a specific action, and there will be an opportunity for some education," he notes. "Part of our improved compliance has been our ongoing educational effort." The same process, he adds, takes place with nurses, who are "also counseled by their own peers," says Gardner.

User-friendly program

Another key to the success of the "Get With The Guidelines" program, says Gardner, is that it's very user-friendly. "It's sort of set up to help care groups like ours initiate a focus on heart failure patient management," he says. "There was a lot of educational material and structured methodology for our PI team to assess where we were in terms of meeting national benchmarks or best practices for the management of heart failure."

The program includes a number of tools to help the providers get started and work through their performance improvement processes, including:

  • Team meeting tools: A guide to help leaders organize and motivate their team and get things going.
  • Success stories: Details about how other hospitals have used the program effectively.
  • Smoking cessation resources: Numerous tools and tips.
  • Clinical tools: They include heart failure-specific order sets, discharge instructions, and patient education materials.

The tools, says Gardner, "Forced everyone to look at the data, work together, get motivated, and make things happen."

While Christiana has not formally tracked mortality outcomes, "We have tracked readmissions, and we have reduced them somewhat; we feel we're doing much better with transitions of care," Gardner reports. In addition, he says, "We realized that some of these patients were not able to get back to see their own cardiologists within one or two weeks to make adjustments on their medications, so we started a 'discharge clinic' where we offer to see them within four to seven days of discharge, so we can do medication adjustments and make sure the patient is on the right path."

[For additional information contact Gardner at (302) 733-1241.]