Collaborative effort sees improvement in LOS

Simultaneous opening of clinic key to QI success

Evergreen Healthcare in Kirkland, WA, has used a combination of collaboration with an outside consultant and a diverse in-house team to achieve dramatic reductions in lengths of stay (LOS) and readmission rates for congestive heart failure (CHF) patients.

The concurrent opening of an outpatient heart failure clinic, along with a CHF expert coming on board, also were key to the success of the initiative.

"Evergreen was putting in a clinical IT system and also wanted to see how to make improvements around quality of care," recalls Linda Lockwood, RN, a director in clinical practice for First Consulting Group (FCG), a Long Beach, CA-based consulting and technology company.

"We did some analysis on their quality and cost data to see where they could have the biggest impact — those DRGs or diagnoses where they had the greatest challenges," she explains.

Lockwood used an FCG-developed methodology, working from Evergreen’s cost data.

"They work with Solucient [for benchmarking data], so we were able to compare their performance with other hospitals," she explains. "Then we’d ask, How much cost opportunity is there for improvement?’"

Among the opportunities identified were CHF, ventilator patients, and care of deliveries (a key issue with the chief nursing officer).

At about the same time, Debra Preller, MD, an Evergreen hospitalist, was involved in setting up a QI project.

"I chose CHF as my project for January 2002," she relates. "The hospital was interested because we were losing money on these patients, and at the same time, they had asked Linda to work on several major DRG issues; and they offered to have her work with me. This was fortuitous, as we were looking at opening an outpatient clinic at the same time and had a CHF expert coming on board."

The effort begins

As the initiative got under way, Preller was clear about what she wanted to achieve.

"Our goals were to decrease readmissions and length of stay, as well as cost per case and, at the same time, improve quality of care," she notes. "We set up metrics at the start to make sure patients did not fall through the cracks."

These metrics were based on the initial goals — cost per case, LOS, readmission rates, and the Joint Commission on Accreditation of Healthcare Organizations’ Core Measures.

"In the outpatient facility, we used the six-minute walking test, Minnesota Quality of Life Survey, and the Beck Depression Scale," Preller adds.

She put together a very large team, which included the heart failure specialist (Mark Vossler, MD), a nurse practitioner, nurse case managers, social workers, a nutritionist, a pharmacist, the nurse managers on the floor who got most of the CHF patients, and the call center nurse managers.

"They were key," Preller observes. "The health line nurses were able to come see the patients while they were still in the hospital, talk about heart failure, diet, meds, and so on. Then, when the patients got a follow-up phone call, it would be from someone they’ve already met; they were plugged into the system early," she explains.

"Many of these patients were older, with lots of comorbidities," Lockwood adds. "I’ve frequently seen in other facilities some very expensive case management, which was really hit or miss.

"This was unique; we insisted up front that the nurses come and meet the patient face to face. They would then call a week after discharge and two weeks after. Then we had an interdisciplinary case conference and talked about these patients — who did not have enough money, who was not following their diet, and what we could we do about it," she continues.

New protocol, clinic induce change

As part of the initiative, a new protocol was created to simplify the process for the physicians. "It’s much better, much simpler, but it needs to be updated regularly; and each time, it’s another difficult step," Preller says.

Also difficult — or at least, not easy — was getting everybody on board.

"We did have some initial resistance on the part of the docs to sending their patients to the clinic," Lockwood notes.

However, that resistance eventually was overcome. "Deb and Dr. Vossler went out and talked to each physician, explained what we were doing, and provided them with literature," says Kathy Schoenrock, director of quality, who joined the team about a year into the project.

"Slowly but surely, almost everyone has come around to see the benefits of the clinic for their patients," she points out.

Vossler sees many of the patients while they still are in the hospital and then follows up in the clinic, Preller explains.

He can follow up within a week," she continues. "He’ll see the nurse practitioner, go over what was done in the hospital, and is actually able to see the patient in a day or two if they are having trouble post-discharge."

The system’s hospice also has been involved, which contributes to the lowering of readmission rates.

"The problem with end-stage CHF," Preller says, "is that the patients may pick up for a day or so, but soon they feel poorly again. The program encourages the hospice RN to come to the home, make sure the patients are getting meds they need, like lasix, without having to spend the last months of their lives in the hospital."

The results have been impressive. The average LOS, which pre-program was about 5.5 days, is now less than three days. Six months into the project, the readmission rate was down from 13% to 11%; it is now less than 10%.

"One thing that’s been really exciting is the performance of the clinic," Schoenrock adds. The readmission rate for the CHF clinic is 2.2%

"The administration realized early on that running a clinic might mean a loss at the start, but they also knew that if we reduced readmissions and improved outcomes, it would pay for itself," Lockwood says.

And in fact, Preller adds, "Our clinic is now running in the black."

Improvement efforts continue

The Evergreen team is not content to rest on its laurels. "We’re starting to go into the nursing homes and educate them, to help prevent future patients from being readmitted," she says.

In addition, one of the original goals was to work with Vossler to make sure all core measures were backed in to the data and they all are automated. To date, that has not happened.

However, according to Schoenrock, "We now have a disease management data tracking system installing as we speak; it’s just moments away."

Another critical ongoing effort, she continues, is the CHF report card sent to the physicians. "It’s very comprehensive, and the doctors can use it to measure themselves against their peers," adds Schoenrock.

Both Lockwood and Preller underscore the benefits of their collaboration in this successful initiative.

"The skills I brought to the table were guiding principles, bringing folks together and project managing," Lockwood says. "I was the one constant, keeping focus, bringing people together, doing a lot of groundwork, and helping to analyze the data."

"The other thing is, [Lockwood] was really able to bring her experiences from other places to help us sell the project to administration, to convince them to put in the money and the staff time necessary to make the project successful," Preller adds.

Lockwood previously worked for Delmarva Foundation, which is the peer review organization that manages Medicare and Medicaid in the Washington, DC, and Maryland region.

"She could tell them that from her previous outside experience, this was worthwhile. She was also able to help focus us, and to make sure the right people did the right jobs," Preller notes.

Need More Information?

For more information, contact:

• Linda Lockwood, RN, Director, Clinical Practice, First Consulting Group, 111 W. Ocean Blvd., 4th Floor, Long Beach, CA 90802. Phone: (800) 345-0957 or (562) 624-5200. Web site: E-mail:

• Debra Preller, MD, Hospitalist, Evergreen Healthcare, 12040 N.E. 128th St., Kirkland, WA 98034. Phone: (425) 899-1000. E-mail:

• Kathy Schoenrock, Director of Quality, Evergreen Healthcare, 12040 N.E. 128th St., Kirkland, WA 98034. Phone: (425) 899-1000. E-mail: