Continuous benchmarking improves best practices

To stay abreast of best practices and compete more effectively in the cardiac care market, North Carolina Baptist Hospitals (NCBH) in Winston-Salem empowered its myocardial infarction (MI) management team to aggressively participate in internal and external benchmarking programs.

With the help of the National Registry, the hospital filled out quarterly data forms for acute MI clinical practices, presented them to utilization nurses for review, and then sent them to the National Registry’s clinical trials research department to be input and measured against nearly 1,600 participating facilities nationwide.

Each quarter, the facility will use the information to benchmark against state and national averages in similar hospitals on length of stay, procedure times, vascular complications and other MI data.

Data spotlight problems

Despite the relatively short time NCBH has participated in the benchmarking program, the data already have helped the facility recognize areas that need improvement, says Lisa Kiger, RN, MSN, CCRN, clinical nurse specialist in cardiology at NCBH.

"We just started [benchmarking with] the National Registry in January, but we can already tell it’s going to be very beneficial," Kiger explains. "By looking at our first-quarter data and comparing it to like hospitals across the state and across the country, we can see what we’re doing well and what areas we need to work on."

According to the National Registry data, NCBH met or surpassed the national average on timing of angioplasty procedures, length of stay, and most information relating to the administering of medication, but fell slightly below average for timing of thrombolytic therapy and success of smoking cessation programs, Kiger said.

"In our case, thrombolytic therapy is not [performed] frequently, so it takes us a little longer than other hospitals that do it more often. But we’re already looking for ways to improve that timing," she says. They may choose to benchmark some facilities that have good start times for thrombolytic therapy.

"Also, being in the country’s tobacco capital, it’s a continuous challenge for us to get patients to stop smoking. But we won’t stop giving them advice and trying to reach that goal," she explains.

Weak programs stand out

After carefully reviewing all the data, NCBH managers also noticed that its quality improvement (QI) programs needed improvement, so it recruited multidisciplinary QI committees to evaluate and strengthen clinical pathways.

Initially, the QI committees met monthly to discuss the process and coordinate ideas, but eventually they settled on quarterly meetings as team members grew more comfortable with the process.

Although Kiger says the pathway development was "not easy because it took the nurses a while to complete all the documentation and get into the flow of things," the committee is making headway and is confident that the efforts will pay off.

Always room for improvement

In addition to making external hospital comparisons, NCBH plans to use the data to benchmark internally and help set independent goals. By accessing quarterly data, the hospital can look at its own demographics, including length of stay, readmission rates, and how the facility responds to various cardiovascular complications. That way, they hope to improve the processes that produce the outcomes.

The MI management team will then measure the data against the previous quarters’ figures to consistently monitor progress and track various improvement strategies.

"We will really want to see how far we’ve come within our own facility," Kiger explains. "Even if you’re at or above [state and national] averages, you shouldn’t stop there. There is always room for improvement."