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Restructuring fosters better communication
Improvements result in prestigious award
While not always easy to achieve, effective communications can be critical to the success of any quality initiative. For Sutter Health Sacramento (CA) Sierra Region, it not only meant improved performance but the receipt of a prestigious award.
The American Case Management Association (ACMA) in Little Rock, AR, and the Joint Commission on Accreditation of Healthcare Organizations have named Sutter the inaugural winner of the Franklin Award of Distinction.
Sutter Health was recognized for its work to improve quality and specifically for the efforts of its Continuum Case Management Department, which has worked with physicians and nurses to define and implement clinical practice guidelines.
Sutter Sacramento Sierra is a not-for-profit integrated health care delivery system, with four hospitals on five campuses, two aligned medical groups, and one independent physician’s association.
"The Continuum Case Management Department has been in place since the early 1980s," says Linda Van Allen, RN, BSN, utilization management executive, who joined Sutter about four years ago. "At that time, each hospital had their own department, so there were no systematic processes. In 1995, when we saw an opportunity for improvement, we brought in a consulting group and created one regional department with regional governance," she says.
That initial solution brought problems of its own, Van Allen recalls. "At that time, the decision was made to put the department under our TPA [third-party administrator]," she explains. "This was good in that it brought together different structures and was better able to focus on utilization and make improvements, but the staff became disconnected from the hospital structure and began to be seen more as insurance reviewers, rather than as an integral part of caring for the patients in the hospital — a team member, if you will."
So in late 1999, the staff moved back to Sacramento/Sierra regional administration; this involved about 200 nurse case managers, social workers, and support staff. "What this did for us was to put us more in the hospital structure than in the third-party payer structure," Van Allen explains. "Each case manager now not only reports to me but also functionally reports to nurse executives in the hospital; they became partners again."
At the same time, additional interfaces were put in place. For example, Van Allen’s counterpart at Sutter is a quality executive. "We both report to the same physician leader, who is our CMO [chief medical officer] and vice president for integrated quality," she notes. "In early 2000, quality, case management, and nursing leadership met together and decided what our priorities and goals would be."
In "Promoting Quality Care Along the Continuum," Sutter determined to address key areas:
Leadership began its work together by addressing pathways for the top DRGs, to align all their processes and systems around the same priority objectives.
"We decided whose job is what piece of the pathway, such as nurses making sure the patient gets started on the pathway at admission; this can be a challenge by admission diagnosis," Van Allen observes. "Case management’s role was to ensure the patients were on the pathway concurrently and, once on the pathway, that things were happening that should be happening. Quality folks reviewed care retrospectively and reported back through the main quality committees."
This was done in the hospital settings and the alliances for the top DRGs, which generally were identified by a physician champion. "We’d start with a guideline, for example from Milliman [USA], and the physicians would modify them to fit our practice here," Van Allen explains. "Then each hospital could take it and tweak it as needed, so that guideline development was really done only once rather than five times."
One area where new ground was broken is outpatient care, she says. "We developed a modified gatekeeping system, eliminating authorizations for services that we never or rarely denied. We also implemented a focused review program. In the outpatient arena, we worked to define what the role of primary care was and when patients should be referred to a specialist."
They began with GI and cardiology, again using Milliman USA care guidelines. "We determined what should be done before referral and when the patient should be referred," Van Allen explains. "The guidelines were made available electronically. They told the primary care doc what to do if they wanted to refer a patient, what work-up needed to be done, and described the package that had to be sent to the specialist. Before this, the patient would go to a specialist who would not know what work-ups had been done and would not always be clear what the patient was being referred for."
Now every referral has to go through a focus review nurse, to make sure the primary care physician has followed the guidelines. "If they haven’t, the nurse will call the office to make sure the package is completed properly," she continues. "If the case does not seem to meet the criteria, the medical director for the group will contact the doctor and either refine the package or drop the referral."
Performance is tracked annually on report cards. "We saw a statistically significant improvement in utilization of GI referrals," Van Allen notes. "We had a more difficult time measuring the quality piece of the packaging — for example, how much redundancy did we reduce?
As for the pathways, as far as length of stay, Sutter met "with varied success," she says.
"Overall lengths of stay were not reduced, but they were cut for the hospitalists. That’s because they are much more likely to use the pathways," Van Allen says.
One of the biggest successes was the reduced emergency department (ED) visits. "California has had huge ED congestion," she notes. Our interventions have been very successful.
Need More Information?
For more information, contact:
• Linda Van Allen, RN, Utilization Management Executive, Sutter Health Sacramento Sierra Region. Telephone: (916) 454-6691. Fax: (916) 454-6987. E-mail: VanAllL@sutterhealth.org.