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Any hospital with a cardiac program probably has been involved in a benchmarking project focused on clinical outcomes. But to date, no one has looked at both clinical as well as operational issues on any scale. Now the University Hospital Consortium (UHC) based in Oak Brook, IL, is about to do just that.
According to Cathleen Krsek, RN, MSN, assistant director of operations improvement, no one had looked at the processes of caring for patients before. "We had done projects in three areas — coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), and congestive heart failure (CHF). But we hadn’t looked at how clinical and operational issues work together. We still wanted to see the issues from the patient level, but also the organizational level," she explains. "We wanted to see how the organizational end supports the clinical end."
While discussing the need to look at operational issues, many of the UHC’s 84 members wanted to do projects on acute myocardial infarction (MI) and revisit the CABG issue in light of minimally invasive surgery techniques that had grown in popularity since the last study, Krsek says.
"There are a lot of accepted standards of care, like giving aspirin or beta blockers to patients. On the operational side, however, there aren’t those kinds of standards. But we thought that if we could draw some conclusions, based on clinical outcomes, or if we could look at the facilities with the best outcomes and see what operational issues they have in common, then we could make some statements that will help our members and their patients," she adds.
Cindy Abel, RN, MSN, assistant director for clinical process improvement, adds that members wanted to find a way to link efficiency issues to positive outcomes. "We can’t put a best performer in front of members whose costs are twice as much," she explains. "That just shoots us right out of the water."
Not all members are participating in the project. Right now, 43 hospitals are involved in the operational survey, and most of the members are participating in at least one or two of the clinical surveys, says Krsek. For each data point, the facilities involved are providing information on 40 cases. "It’s not a huge number of cases per institution," says Abel. "What makes it so useful is that the data are so rich."
In the operational survey, there are some 90 questions divided into five sections, Krsek explains. The first section covers organizational structure, such as whether a hospital is organized along service lines. The facility must provide an organizational chart and information on reporting relationships, budget management, and who sees financial data.
The patient-flow section asks questions on how patients are managed, particularly in the emergency department. "We want to know when a consult is called, whether the hospital uses pathways, and if they use case management," says Krsek.
A section on the cardiac catheterization lab asks operational questions on the number of rooms and whether they are multipurpose; staffing ratios; and inventory control. The final section is short, Krsek says, asking about patient volumes and staffing numbers.
For the clinical questions, Abel says UHC used some of the ORYX core measures. For acute MI, questions include the rate of aspirin administration, door-to-needle rates for PCI and thrombolytics, rates of aspirin prescription at discharge, rates of beta-blocker administration within 24 hours, length of stay, mortality rates, and complication rates.
For the PCI survey, the questions are less well defined, but some are similar to those in the acute MI section, says Abel. They include door-to-reperfusion rates; administration of aspirin and prescription of aspirin at discharge; complications or rates of patients who have to go on to CABG; and rates of glycoprotein 2b3a inhibitors. "That last one is new, so there is a lot of interest," Abel adds. "We are also looking at the number of patients who get stents vs. those who don’t."
The CABG questions are still under discussion, but many will be similar to those asked in previous studies. Among the factors that will determine best performers are length of stay less than or equal to five days; less than a day spent in ICU; extubation in less than six hours; and lower morbidity and mortality rates, Abel says. "We will also analyze the number of units of blood transfused and the criteria used for transfusion."
Other data collected will likely include infection rates and the timing of antibiotic administration. "We also will probably measure OR time, pump time, whether patients get education on smoking cessation and diet if their lipids are high, and if statin drugs [were] prescribed for high cholesterol," she adds. Participants also will collect data on whether their facilities are doing any minimally invasive procedures to reduce recovery time.
The results from the CABG part of the study will have the added weight of four previous projects in this area, Abel adds. "That will make our comparative analysis really rich."
CHF will largely mimic the past studies, with the addition of core measures from ORYX, data on new pharmacology management, and facilities’ outpatient strategies, says Abel.
One of the facilities that is participating in all the parts of this project is the University of California, Los Angeles (UCLA). Gregg C. Fonarow, MD, associate professor of medicine at the university and director of its cardiomyopathy center, says that with all the chances facilities have to participate in projects that can improve efficiency and quality, he has to be picky about which ones he opts to do.
"We have to choose issues that are of significant volume, significant risk to patients, or significant utilization," explains Fonarow. "Or we have to choose something where we need to improve outcomes."
Working on issues where there are marked differences among institutions in procedures, lengths of stay, outcomes, rehospitalization rates, mortality rates, and medications used provide obvious opportunities for his facility, he adds. "What you often find is that those who provide the best care with lowest mortality and better clinical outcomes often provide that care with less utilization of resources. You can improve processes and still provide better care."
But just because UHC has come up with a good idea to work on doesn’t make participation a slam-dunk, Fonarow says. "For some of these projects, you have to get involved in creating the data collection tool or in doing some of the data analysis. That means having the time to commit. Once the tool is created, you have to find an interested director or nurse practitioner who can do the chart abstractions. Usually, it’s not a large number — maybe 30 patients."
But even if the idea is good and the work minimal, Fonarow explains that there are many other competing projects that have to be completed. There is an endless number of organizations out there that want information: the National Council on Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations, and the Health Care Financing Administration, as well as health maintenance organizations.
"The good news for us is that UHC has a solid strength in linking outcomes back to utilization of resources," Fonarow says. "That makes the data more detailed."
Having that data can help facilities develop best practices, he says. For instance, when UCLA did a CHF project six years ago, there were marked variations among participating hospitals in length of stay and their use of ACE inhibitors. Fonarow says it was shocking that months after studies came out indicating the benefits of ACE inhibitors, there were facilities whose ACE inhibitor use was as low as 30%. Others were as high as 85%.
Fonarow and a multidisciplinary team of nurses, physicians, pharmacists, and lab personnel reviewed the data and the processes of care. Frequently, CHF patients being admitted had volume overload, and diuretics were started at low dosages and gradually increased. ACE inhibitor use started later.
"We were able to come up with some preprinted orders and new procedures that helped. Just those small changes enabled us to initiate therapy earlier, adjust medications more toward what patients would use on discharge, and start the patient education earlier," he says. The upshot was turning CHF from a loss-making DRG to a profitable one.
And even if you are the best performer, he adds, your participation can help other facilities improve by giving them something to aim for.
Neither Abel or Krsek have any expectations about what the data in the latest project will show. But they have been through enough projects that come May when the "knowledge transfer" is scheduled, there are bound to be surprises.
[For more information, contact:
• Gregg C. Fonarow, MD, Associate Professor of Medicine and Director, Ahmanson UCLA Cardiomyopathy Center, 47-123 CHS, 10833 Leconte Ave., Los Angeles, CA 90095. Telephone: (310) 206-9112.
• Cindy Abel, RN, MSN, Assistant Director, Clinical Process Improvement; Cathleen Krsek, RN, MSN, Assistant Director of Operations Improvement, University Hospital Consortium, 2001 Spring Road, Suite 700, Oak Brook, IL 60523. Telephone: (630) 954-1700.]