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Case managers lead the multidisciplinary team
An enhanced care management program is the keystone of Bon Secours Health System’s systemwide performance improvement initiatives in connection with the Centers for Medicare & Medicaid Services’ pay-for-performance demonstration project.
The 24 hospitals in the Marriotsville, MD-based Bon Secours system are among 278 Premier Inc. member hospitals nationwide that are participating in the project.
The case managers at Bon Secours do concurrent review, tracking standing order sets, and identifying patients who should be receiving the recommended indicators that are part of the project, says William Varani, MD, vice president for quality improvement.
"The case management interventions give us the ability to recognize a patient and a protocol and the compliance with the protocol in real time," he adds. In addition to nurse case managers, the quality improvement team includes a clinical champion, a performance improvement expert, and representatives from other disciplines such as pharmacy and respiratory therapy when appropriate, Varani explains.
"We have spent many years arguing that appropriate incentives for quality would result in quality improvements, health care efficiency, and better outcomes for patients. That is what we are setting out to demonstrate in this demonstration project," he adds.
The hospital system’s performance improvement project includes performance improvement experts and staff who are trained in Six Sigma methodology.
The hospitals examine their own performance and identify areas where improvement is needed. They submit monthly progress reports on the demonstration project’s key measures, including barriers to meeting the goals and plans for improving compliance.
The data go to a web site that is shared by all Bon Secours participants in the project. The hospitals in the Bon Secours system submit monthly progress reports on the demonstration project key measures, including barriers to meeting the goals and their plans for improving the process.
Eventually, the data will allow Bon Secours to identify the best practices and recommend them to all the hospitals in the health system, Varani says.
Bon Secours Health System created a system-wide approach to track clinical effectiveness, length of stay, cost per case, and mortality rate for its 24 acute care hospitals several years ago, he says. "Everybody reports on some variation of similar things, but we couldn’t draw very many conclusions because everybody’s processes and definitions were different and nobody tracked the exact measures."
The Medicare measures and definitions made it easy to standardize processes and to focus on across-the-board improvement, he adds.
Here are some projects that other hospitals in the pay-for-performance demonstration project are trying:
The executive team must be on board to support the process and see that it happens, says Jan McNeilly, RN, CPHQ, CHE, principal for clinical advisor services at Premier Inc.
"If you are talking about discontinuing an antibiotic at 24 hours for hip and knee replacement patients, the pharmacy as well as the surgeon has to be involved," she says.
For instance, if the patient has the first dose before the incision and every eight hours after that, a two-hour delay in the medication could delay meeting the goal of discontinuing it in 24 hours. The pharmacy must be involved to help modify the process to make sure the patient gets the last dose within the 24-hour window.
"Multidisciplinary teams can hit these issues very successfully," McNeilly notes.
For instance, most hospitals have low scores on the smoking cessation indicators during the initial scoring because, even though they have smoking cessation programs in place, they don’t have a standardized way to identify who qualifies for the program and ensure these people get involved.
In these cases, the nursing and respiratory care teams collaborate to make sure the documentation is in the chart identifying the smokers and including details on what the team has done.
In most cases, a nurse or case manager does the rounds. One large hospital has hired a couple of physicians to make rounds in the morning and look at targeted cases, regardless of who the admitting physician is.
For instance, if the patient has congestive heart failure and a recommended drug isn’t ordered, the physician will call the admitting physician, describe the recommended care, and find out if he or she has a reason for not prescribing it. In some cases, the drug may be contraindicated for particular patients. In that case, the hospital should have a note in the chart to explain it.
"They are trying to catch the patient in the hospital and fix it then, rather than gathering retrospective data, which is like shutting the barn door after the horse is out," McNeilly says.
As part of the concurrent rounding, hospital staff check to ensure any condition the patient has is documented. Some have a system in place that sends a flag whenever it may be one of the targeted diseases. For instance, any time an order for lasix is sent to the pharmacy, it raises a flag to trigger the case manager to look at the chart to see if the patient belongs in one of the targeted populations.
In some cases, a patient might be admitted with a diagnosis of shortness of breath that is changed to congestive heart failure as the hospitalization progresses.
"By picking up on the lasix order, the staff can see the potential for congestive heart failure while the patient is in the hospital instead of doing retrospective review and determining the patient didn’t get the recommended ACE inhibitor when it’s too late to do anything about it," she adds.
Instead of generic discharge instructions, many hospitals are tailoring them for a specific population. For instance, congestive heart failure patients receive specific discharge instructions, including information about weighing themselves daily.
The hospitals give these patients logs to record their weight and medications each day, and in some cases, a case manager calls patients after discharge to ask them about their weight and medication.
Most hospitals already had standing orders or are working on them to guide physicians and prompt them to provide the recommended care. Case managers are reviewing the patient files and working with the physicians to document the exclusion criteria if the recommended care was not provided.
"We’re trying to get the physicians to realize that if we are not providing evidence-based care, we need to explain why," McNeilly notes.
The hospitals are determining who is responsible for a certain metric and making them accountable if it is or isn’t done.
For instance, in many hospitals, 80% of the patients come through the emergency department (ED). In that case, ED staff are responsible for starting the antibiotics in the case of pneumonia patients. At the same time, the pharmacy is responsible for sending the drug to the ED in a timely manner.
"We’re looking at the whole accountability issue. Sometimes, we hold people accountable, but we don’t give them data to say how they’re doing," she says.
Many hospitals are providing data to the department that should be involved in each process, showing how they are doing on meeting the quality measures.