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MUMC recognized for using evidence-based care
Hospital reduces cost, improves efficiency
In 2007, Premier Inc. began its Quest program, enlisting hospitals to collaborate and evaluate quality, efficiency, safety, and transparency with oversight from the Institute for Healthcare Improvement. One of those charter members, Memorial University Medical Center (MUMC) in Savannah, GA, was recognized as a top performer.
MUMC was noted for its success in:
Marty Scott, MD, MBA, vice president of quality and patient at MUMC, says the hospital's baseline mortality index in 2007 was 0.76. That rate decreased to 0.61 in 2008. As he explains, that means initially about one of four patients who came in "so severely ill or injured that they were going to die" survived and was discharged home and the hospital brought that down to one out of three patients. From its 2009 data, the hospital's rate has further decreased to 0.43. It also improved its "appropriate care score," the percentage of time evidence-based care was used, from just under 80% to just under 85%. The hospital also decreased cost by just more than $1,000 per patient discharged from 2007 to 2008.
Scott says a variety of "drivers" led to the success — "we had implemented a rapid response team, and that's been very effective in recognizing people on the floor, getting them into the ICU sooner. We have intensivists who are staffing our ICUs full time."
In 2007, MUMC's medical staff said all care would be evidence-based. So a new position was created and staffed — evidence-based practice consultants. The three EBPCs report to Scott and are responsible for developing order sets, developing protocols, working with the physicians and clinicians in doing that research, and then ensuring that the new evidence-based care guidelines are implemented and sustained. They "set down the expectation that we're going to deliver those. We're going to deliver those to every patient, every time, and we're going to hold people accountable," Scott says. And if the care is not being used, they will examine if it's a system problem and what can be done to help people deliver the appropriate elements of care.
Scott says the consultants are nurses with a master's degree. Some have an MBA. They work in concert with clinicians. So, for example, he says, if the orthopedic group wanted a new order set for knee replacements, the consultant uses a software program to research that area, find a draft order set, and deliver it back to the orthopedic department. Scott says the consultant would ask the practitioner how the new order set correlated with what he or she already practices.
"You've got to remember that only about 20% of what we truly do is evidence-based. Another about 50-60% is consensus-based. And then there's another 20% or 15-20% that still falls under the art of medicine," Scott says.
"What we look for is that we have the evidence. We have the consensus. And then in those gap areas, does this follow along with the standards, the art of medicine in Savannah? Then we can kind of negotiate, but we're not going to bend where evidence exists. We're not going to bend where strong consensus statements exist. But, in those areas where there's neither strong evidence or a consensus, then that's where we're going to try to make that meet what the group of physicians agree is best practice for Memorial and Savannah."
Sometimes it's the clinicians who ask for help and sometimes it's the quality department that sees an area that could be improved with the use of an evidence-based order set or protocol.
"It's pretty arrogant to think that we can do it in a vacuum all by ourselves. We just push it out to clinicians. You need the buy in and you need them working with you in the process. What we've found is that instead of just starting with a blank piece of paper and saying, 'OK, let's make an order set,' if we can come to them with some of that texture and some of that meat on the bones, it's more productive of everybody's time," Scott says.
MUMC monitors bundle use using random audits. One week they may check central line insertions or monitor the use of a ventilator-associated pneumonia bundle on 25 patients. The hospital uses safety coaches. "These are our onsite safety experts, and they fill out behavior-based modification monitoring tools," Scott says. If the quality department wants to look at reliability or compliance, safety coaches can be the "auditors" or sometimes it might be the clinical nurse specialist or other clinical education staff.
Bringing down the cost
"We were kind of forced into that one," Scott says. In 2006, the hospital had a $58 million loss. That forced them to refocus, Scott says. Looking back, he says, the hospital had a number of FTE expansions and other things that seemed like good ideas, but didn't generate patient volume. "In 2007, 2008, there was a lot of real critical looking at adjusting to staffing ratios based on volume, and that became tracked more rigorously. We had a reduction in force. There was a lot more attention to getting the right people in the right spots based on patient needs," he says. The hospital also examined its supply chain expenses and ways to improve those. "I think the biggest thing," he says, "was really looking at what kind of people and resources do we really need to be focused and be efficient?" There were hard choices, but he says quality is continuing to improve, as well as reliability.