Doctors react swiftly to evidence of variation

External benchmarks help set targets, protocols

While physicians may be leery of "profiling," they are strongly influenced by data that show they are practicing differently from their colleagues. That contrasts sharply with the common reaction to external benchmarks: "We're different here. Our patients are different."

"I have yet to run across a physician who didn't say that when you used external benchmarks," says Chip Caldwell, FACHE, senior vice president of Premier Performance Services in Charlotte, NC. "Whenever we presented an opportunity to improve a clinical process in which there was substantial internal variation, they were able to drive out the variation very rapidly."

Of course, external benchmarks will still be important markers for quality analysis and standardization.

Internal data matter most

Physicians in Carilion Health Plan developed 13 clinical guidelines covering inpatient care based on scientific evidence from the medical literature as well as their own internal data. Morton Plant Mease Health Care uses external data and medical literature to develop clinical recommendations and standing orders.

Even so, "[physicians'] own data are much more powerful and compelling than anything they can read in the literature," says Janet Niles, RN, director of utilization and quality management at Carilion Health Plans in Roanoke, VA, whose health plan is jointly owned by the physicians and the Carilion Health System.

With guidelines in place, the health plan gained a cost-savings of 25% to 30% for those select conditions and an average reduction of length of stay of two days.

To improve efficiency, the physicians looked at both processes of care and clinical issues. For example, in total hip replacement, patients typically stayed in the hospital for seven or eight days. That has been reduced to three.

In one change, home health personnel began visiting patients before they were hospitalized to discuss such issues as post-surgical exercises and how to use a walker. Patients now know in advance what to expect from their recovery after surgery, says Niles.

"People would sit in the hospital while they were arranging for services," she says. "Now, they arrange the services beforehand."

Team standardizes practices

At Morton Plant Mease, clinical process improvement teams comprising physicians, nurses, and other personnel use total quality management principles to identify areas for change. Team members gather the data on their own, then meet only three or four times to brainstorm, decide on process changes, and implement recommendations.

For example, the team studying pneumonia care found that physicians prescribed 27 different antibiotic combinations, and patients received their first dose anywhere from one hour to 16 hours after coming to the emergency department.

Now, the standard of care at the health system calls for all patients to get their first dose within the first two hours after entering the emergency department, Babka says. The quality improvement team members review a sample of records six months after they issue recommendations and then annually to track progress and consider other process changes, he says.