Critical Path Network: Pathways to success: Standardizing care throughout a diverse health care system

CareMaps allow targeting of improvement efforts

How to establish and maintain a high standard of care, promote consistency across 18 diverse health care facilities, and develop a culture of quality throughout the system was the challenge that confronted the North Shore Long Island Jewish Health System (NS-LIJHS) in Great Neck, NY. But by developing a comprehensive quality management methodology, which included championing CareMaps with variance analysis, Yosef D. Dlugacz, PhD, senior vice president quality management, was able to create databases of care practices that convinced clinical and administrative leadership that the use of guidelines would help to meet this challenge.

Over the past decade, the quality management department has developed and implemented more than 170 CareMaps. "These tools help manage and organize the complex care patients receive," says Karen Nelson, assistant vice president quality management for NS-LIJHS, who oversees the CareMap program. An episode of illness involves coordinating care from many disciplines, and information needs to be communicated from pre-hospitalization through discharge. This difficult task is efficiently and effectively promoted via the implementation of the CareMap methodology.

"One of the many advantages of being part of a large health care system is that we can use the expertise and resources from all our facilities to develop best practices and benchmarks for a specific disease process," Nelson explained. "We knew it was important to get stakeholder buy-in, for the people involved in the care delivery to have input into the plan of care."

The system took great pains to develop the CareMaps for maximum utility. Multidisciplinary teams researched current literature and used clinical expertise to establish the standard of care. "It is important to remember that a CareMap is not set in stone once it is developed. On the contrary, as information increases and becomes available, the CareMaps have to be revised and kept continuously up to date. The CareMap, which is part of the medical record, is individualized, based on the patient’s needs. It has to be a dynamic and ongoing process," asserts Nelson.

"One of the great advantages of CareMaps and of the use of guidelines is that information provided from the guidelines allows us to target specific performance improvement efforts," Nelson explains. "Our variance database enables us to track whether or not key interventions have been met or unmet, as well as being able to track the reason and source of key outcomes." Such information can be cycled back to the provider, the unit, the floor, the service, or the hospital for performance improvement and educational efforts.

Not only do the CareMaps identify interventions and outcomes for a plan of care, but the database that Dlugacz developed for the system is the source of a tremendous amount of information. "The goal is to reduce variation through measurement, to foster efficient resource utilization, to identify opportunities for improvement, as we increase the care provider’s knowledge," Dlugacz explains. In addition, communication among caregivers is improved. This is key to improving patient safety, he adds.

Staff complete two forms, the CareMap and the variance form, which are scanned by the system’s quality management analysts. Data are aggregated to identify trends. For example, if the congestive heart failure (CHF) patients are not receiving ACE inhibitors on the first day, it’s important to know why not and where in the hospital this is failing to happen. The database allows care to be analyzed from the system level down to the individual physician. This information helps leadership prioritize improvement efforts and assists the clinicians with comparative data for education. Without being able to assess the care being delivered across the system, the management of patient care would be isolated in individual silos. "That’s not ideal," asserts Dlugacz. "Health care delivery is far too complex for us not to learn from one another and share information."

Professional staff are educated about the CareMaps through various forums: inservices, rounds, conferences, and a train-the-trainer program that is approved for continuing education credits. Once the physicians realize that they are not promoting cookie-cutter medicine but instead are communicating information about the current standards of care, they get on board and see the value of collecting and analyzing these important data, Dlugacz and Nelson agree.

Before CareMaps, inappropriate length of stay signaled that there was a problem to be addressed. With the CareMap methodology, NS-LIJHS provides a proactive rather than responsive approach to the delivery of care. Because the information comes in on a continuous basis, the system can manage problems as they occur. This is a great advantage, both for the patient and for the system.

The NS-LIJHS also has developed "patient-friendly" CareMaps that outline, in lay language accessible to patients, what patients can expect from their hospitalization. Allowing patients to be educated and to be partners in their own care is a great advantage, Nelson explains. With the information they have on their CareMaps, they better understand such things as their medication regime, the rationale for the tests they undergo, the importance of diet and nutrition, how to manage their pain, their expected length of stay, and their discharge orders. Patient satisfaction has greatly increased, she says.

By providing information to caregivers about the expected standard of care, and by helping patients understand the management of their disease, CareMaps have aided in the standardization of care throughout the system. Ongoing analysis of variance data allows for immediate feedback to care providers. This methodology has been used to define, measure, and monitor best practices for optimal patient outcomes. When there is a suboptimal outcome, the source can be targeted right away through the database. This is an invaluable tool, according to Dlugacz.

The CareMap methodology has helped the system reduce day-to-day variation in resource and treatment patterns, while at the same time providing a framework for building a highly efficient outcome-focused care delivery system. (For a sample CareMap, click here.)

[Editor’s note: For more information, contact Karen Nelson, RN, assistant vice president, quality management, North Shore-Long Island Jewish Health System, 150 Community Drive, Great Neck, NY 11021. Telephone: (516) 465-8054. Fax: (516) 465-8376. E-mail:]