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Ongoing support allows for impressive results
Are evidence-based guidelines being followed consistently in your organization? If not, you need to "get with the guidelines," says Cindy Waller, RN, MSN, vice president of quality improvement initiatives for the southeast affiliate of the Dallas-based American Heart Association (AHA).
The AHA’s "Get with the Guidelines" program was developed to address a gap between scientific evidence and the care being delivered to coronary artery disease (CAD) patients at the bedside, she says. "Evidence-based guidelines were not being followed consistently." The AHA recently has added modules targeting stroke and heart failure.
Now there are powerful new incentives to follow evidence-based guidelines: public reporting of quality data, pay-for-performance programs, and compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measures.
"There are a lot of external pressures on hospitals. All those pressures have made it much easier for us to get the required resources and additional quality improvement personnel," reports Gray Ellrodt, MD, chief of medicine at Berkshire Medical Center in Pittsfield, MA, which has participated in Get with the Guidelines since it was pilot tested in 2000.
"For us, it was a powerful way to begin clinical quality improvement initiatives," Ellrodt points out. "The support given by this program, and the incentives for regional and national recognition, are very important to a small institution like ourselves."
The program interfaces with patients and families prior to discharge and also serves as a data collection tool. The hospital enters clinical and demographic data and medical therapies for heart attack or stroke and checks these components against the secondary prevention guidelines, with recommendations given at the time of the data entry for what might need to be done differently.
For example, if the patient’s height and weight shows the body mass index is higher than it should be, recommendations will be given instantly. "In addition, there’s a link to our web site which has patient education materials for that particular patient, so they can be printed out at the time of discharge," Waller adds.
If hospitals want to see how they are performing on compliance with core measures, they have the option of using the program’s reporting function, she explains. "The tool will aggregate all the data they have entered and put it in a report format without an lot of extra work involved." Hospitals also can benchmark their performance against other hospitals in the region or country, although the confidentiality of hospital-specific data is maintained.
Collaboration is key
The program has a tiered approach and begins with conducting physician workshops, including cardiologists and emergency department (ED) physicians.
"We educate the physicians and train them, in essence, to be Get with the Guidelines physicians. So we have this group of physicians who understand the value in secondary prevention. They can then give workshops to other physicians in their community," she says.
Next, quality managers, risk managers, and cardiac care staff participate in all-day workshops. "We look at what we can do to help implement the program at their facility, what tools they are currently using and how they are working, and examine barriers to implementation," Waller explains.
The most common barrier identified is, "Who is going to enter all the data, and how much time is it going to take?"
"The data-entry piece is about 20 clicks, and it takes three to five minutes to do it," she adds. "And if the organization chooses, this could be their vehicle for sending data to JCAHO and CMS [Centers for Medicare & Medicaid Services]."
At first, case managers at Berkshire entered all the data for the program, but after significant improvements in smoking counseling and cardiac rehab referrals were demonstrated, quality managers lobbied for additional staff.
"Then our organization started participating in public reporting and the pay-for-performance pilot with CMS and realized there were significant opportunities to improve our payment based on improved quality of care," Ellrodt says.
The AHA’s program ties in perfectly with this goal, he adds. "The beauty is that there is near-perfect alignment between the AHA guidelines, JCAHO, and CMS measures, so you can cross-populate once you have perfected the data," he says. "You have one program to implement, but you are able to report how well you are doing to three or four different databases."
The workshops and collaborative environment were a key factor in rapidly improving patient care for acute myocardial infarction and CAD, Ellrodt notes. The organization then was able to use the same approaches to improve care of stroke, diabetes, and heart failure. "They got us started and very rapidly improved our performance. Now we have sustained improvement over four years and also in other clinical areas," he says.
Collaboration not only allows you to rapidly improve your performance, but equally important, it enables you to sustain those gains, Ellrodt says. He points to his hospital’s increasing the percentage of patients referred for cardiac rehabilitation from 14% to 99%.
"If you look at CMS and JCAHO, there are no collaborative workshops — no one in those programs is helping you get really good," Ellrodt adds. "In those other programs, you don’t get any of that. You can end up reporting lousy data, because there is no one helping you improve your performance."
The organization also got an idea from a participating hospital to improve its smoking cessation counseling, which was being done by a single individual. Although 100% of stroke and CAD patients were getting smoking counseling, only 70% to 80% of heart failure and community-acquired pneumonia patients were receiving this.
"We realized that if this individual was on vacation or out sick, we would miss opportunities to counsel smokers," he says. Another Get with the Guidelines participant suggested doing this through the respiratory therapy department, which is always available. "They are very often trained in tobacco counseling and are often standing with a patient for 10 or 20 minutes helping with a breathing treatment that they need because they were a smoker," adds Ellrodt.
As a result of the change, 100% of all patients now receive smoking-cessation counseling.
The AHA’s Get with the Guidelines second module, for stroke patients, has partnered with JCAHO’s Primary Stroke Center Certification program, which recognizes organizations that make exceptional efforts to foster better outcomes for stroke care. "So if the organization is interested in pursuing stroke-center certification through JCAHO, this tool will aid them in data collection," Waller says.
This allows organizations to be much more efficient with utilization of resources, just as the recent alignment of the CMS and JCAHO quality measures have done, Ellrodt explains.
"Hospitals were going crazy, quite frankly, being up against multiple regulators. Not only were the measures different, but the diseases were different; and even within conditions such as heart attack, the measures were different," he says. "It was very burdensome. Now we can report through a single structure, which allows us to be much more efficient with our utilization of resources."
The hospital is participating in the pilot phase of the stroke module and also participating in a national project with four other states.
"We are very focused on improving stroke care and using this tool to improve our performance," Ellrodt adds. "For a small place like us, to get a national award from the AHA and have our stroke coordinator stand up in front of hundreds of people is pretty special."
When hospitals have achieved 85% compliance on the five key indicators of secondary-prevention guidelines, they receive a quarterly recognition award with a plaque and ceremony at their hospital. If the 85% compliance is maintained over a calendar year, the hospital is recognized at AHA Scientific Sessions.
National recognition from AHA is a public relations boon for any hospital, Ellrodt says. "We can then contact our local newspaper about the award, which is a good reflection on the hospital and very good for our community," he adds.
AHA has just released its third module, targeting patients with heart failure. Some of the key indicators that are measures for heart failure are different than for stroke or CAD, but otherwise, the platform and functionality of the tool is the same, Waller explains.
"Interest in heart failure is growing, so this is very timely. If your organization is submitting heart failure indicators to JCAHO, this tool will help with that," she says.
Heart failure is a key focus for quality professionals at Berkshire, Ellrodt adds. "We had already been working on heart failure before this new module, by entering the heart failure patients who also had CAD in the CAD module."
Some organizations are reluctant to participate in the AHA’s program, arguing that they already are submitting data to other cardiac data programs, Waller notes. "We emphasize that all the other databases are based on AHA scientific guidelines, so they are dependent on the AHA to guide their clinical care. When the guidelines change, the other databases have to be updated. Given the fact that we are an AHA database, the patient management tool is automatically updated at no cost to the facilities."
In addition, most facilities are dependent on the AHA for their patient education materials, so having direct links to this resource is another key benefit, Waller notes.
Real-time reporting is another huge plus for overworked quality managers, she says. "You do not have to take the reports and put them into Excel and develop your report for presentation purposes.
"These reports are real time, and they are presentation ready. If your hospital administrators calls and asks, How we are performing?’ it’s a quick and easy process to run those reports," Waller adds.
[For more on Get with the Guidelines, contact:
• Gray Ellrodt, MD, Chief of Medicine, Berkshire Medical Center, 725 North St., Pittsfield, MA 01201. Phone: (413) 447-2849. E-mail: firstname.lastname@example.org.
• Cindy Waller, RN, MSN, Vice President, Quality Improvement Initiatives, American Heart Association, 1818 Patterson St., Nashville, TN 37130. Phone: (615) 340-4125. Fax: (615) 340-4101. E-mail: Cindy.Waller@heart.org.
• American Heart Association. Web: www.americanheart.org. Click on "Science & Professional," "Get with the Guidelines." A measurement system is available to meet data collection requirements for JCAHO’s Primary Stroke Center Certification. For more information, register at www.outcomesciences.com/gwtg, or contact Outcome Sciences, 201 Broadway, Cambridge, MA 02139. Phone: (617) 621-1600 or (888) 526-6700. Fax: (617) 621-1620. E-mail: email@example.com.]