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By combining the benefits of the MEDSTAT IMSystem and software from 3M, a 162-bed facility in rural Minnesota has been able to meet not only the Joint Commission on Accreditation of Healthcare Organizations’ ORYX reporting requirements but achieve a significant reduction in the time taken to administer thrombolytics. The ORYX initiative, introduced in 1997, integrates outcomes and other performance measurement data into the accreditation process.
"We were a beta test site for the infection control and medication use indicators in 1992 when the Joint Commission was developing them," recalls Mary Nelson, MPH, quality improvement coordinator for St. Joseph’s Medical Center in Brainerd, MN.
When the test phase ended, the hospital purchased the 3M software, which targeted the initial indicators from the Joint Commission (the hospital began with perioperative and obstetrics). "At that time, we were transmitting data to a repository connected with the Joint Commission," she notes.
It was about eight years ago that St. Joseph’s began using the IMSystem from Ann Arbor, MI-based MEDSTAT Group. Initially, the intent was just to monitor compliance. "We would transmit our data to MEDSTAT, and they would send the ORYX measures to the Joint Commission," notes Nelson.
"As we worked with them they became extremely diligent about cleaning data, and this generated much change," adds Angie Merkel, director of the MEDSTAT Group.
Since the MEDSTAT IMSystem also provides comparative data from all reporting hospitals — more than 1,000 — St. Joseph’s also was able to use it to identify opportunities for improvement. "In our quarterly reports [reviewed with the MEDSTAT account manager], we are given rates for our facility, such as mean time and median time for different processes, as well as numbers of cases," Nelson notes. "But we’re also given comparative times."
Through these reports, St. Joseph’s identified an opportunity for improvement in the area of thrombolytics administration times. "We looked at how long it was taking for patients to be assessed and the drugs given," Nelson observes.
"Part of the solution came from a review of the process — how the patients were assessed and then treated. In the past, patients were assessed by one group of physicians and then the thrombolytics were given by a different group of physicians who would come in specifically for that purpose. We saw that we needed to get closer in the chain of people who treat the patients," she explains.
The 3M software also was a valuable part of the process, notes Nelson, because it could be used to print out times for individual cases. "This lets you pull the chart and identify specific issues," she says.
A multidisciplinary group came up with the solution, and ultimately, emergency department physicians were trained to administer thrombolytic therapy. This decreased the average time between arrival and administration of thrombolytics by 19.6% over a period of about two years. The median time decreased 33% during that same period.
The comparative data also prompted evaluation of ventilator management. "When we compared our rates of ventilator-associated pneumonias with the database, we thought there might be an opportunity for improvement," notes Nelson. "Ultimately, nursing and respiratory therapy evaluated their management of cases and made some changes in equipment. The rates have reflected a significant decrease," she adds.
Perhaps as important as these changes is a significant change in staff mindset, Merkel points out. "We’re now seeing a culture change," she says. "Many of the patient care staff have come to depend on this comparative data throughout the hospital."
• Angie Merkel, The MEDSTAT Group, 777 E. Eisenhower Parkway, Ann Arbor, MI 48108. Telephone: (734) 913-3000. E-mail: MEDSTAT@MEDSTAT.com.
• Mary Nelson, MPH, Quality Improvement Coordinator, St. Joseph’s Medical Center, Brainerd, MN. Telephone: (218) 828-7658.