This very interesting article appeared a few days ago.
Not by quality metrics alone
November 07, 2011 | John Morrissey
Even the most robust technology itself cannot improve healthcare outcomes, as Vanderbilt University Medical center discovered on its way to lowering ventilator-associated pneumonia rates – saving money
During the last decade, Vanderbilt University Medical Center built into its operations the attention to clinical quality that now figures prominently in health reform, using a level of digital documentation and decision support that anyone seeking meaningful use of health IT would love to have.
The problem: All that effort was falling flat where it really counted.
“We had all of the technology anybody’s talking about,” said William Stead, the Nashville-based medical center’s chief strategy and information officer. “We could show that the percentage of the time we did what we wanted to do with decision support went from, say, 10-30 percent up to 40-60 percent – major improvement. But even so, our performance on summative quality measures such as observed to expected mortality were average or actually below average.”
It wasn’t until informatics pros and clinicians figured out how to calculate and graphically present a spectrum of clinical status measures for immediate action that quality measures became worthwhile and patient-care results dramatically improved.
The lessons learned are relevant for hospitals nationwide as they incorporate into clinical settings the quality metrics typical of the federal value-based purchasing and meaningful-use programs now underway.
Most notably, Vanderbilt found that these standard quality metrics by themselves won’t give front-line clinicians the focused information that’s useful in improving clinical results and increasing healthcare value. Measuring and reporting constitute only the first half of the quality-improvement equation. What’s further needed is a sound way to “force” a set of expeditious responses to feedback that, if done well, leads to improved metrics while lowering clinical costs and preventing inpatient deaths.
The method is in place to prevent certain types of infections in high-risk areas, and Vanderbilt is expanding that to target other patient threats in the hospital environment.
Homing in on a serious risk
Few hospital situations are more life-threatening than a critically ill patient, put on a ventilator in an intensive-care unit, who develops pneumonia. Mortality rates discussed in medical literature vary from 20 percent to more than 50 percent.
Few hospital situations are more life-threatening than a critically ill patient, put on a ventilator in an intensive-care unit, who develops pneumonia. Mortality rates discussed in medical literature vary from 20 percent to more than 50 percent.
With six adult ICUs for burn care, trauma, neurological, cardiovascular, post-surgical and general critical care – combining for about 160 beds – Vanderbilt annually had many hundreds of patients who were spending, collectively, tens of thousands of hours on ventilators in settings that were nearly always full.
Ventilator-associated pneumonia (VAP) rates in the mid-2000s at Vanderbilt were running in some cases two to three times above the national benchmark for inpatient populations, said Devin Carr, administrative director of the surgery and trauma patient care center. In 2004, for example, the rate of VAP per 1,000 ventilator days was 29.3.
In the wake of a national campaign by the Institute for Healthcare Improvement to reduce VAP through consistent ventilator management, Vanderbilt organized a multidisciplinary team of physicians, nurses, pharmacists, respiratory therapists and other clinicians in 2007 to develop a “bundle” of care elements proven to reduce the incidence of pneumonia. Then came the challenge of keeping track of how clinicians were juggling the seven elements of necessary care.
Clinical IT provided the electronic means to document what nurses and others did for patients and assemble quality metrics for such actions as elevating a patient’s head to prevent aspirating back into the lungs, appropriate oral care to prevent a buildup of bacteria, and frequently evaluating whether the patient was ready to breathe independently and get off the ventilator.
But for all the advances in IT at Vanderbilt, the VAP improvement team identified some significant shortcomings, Carr said. For example, various ICU medical teams documented differently in separate areas of the IT system according to how they worked, which complicated the task of drawing out and standardizing the metrics in ways that could be brought together and posted in a timely manner.
There also was no alerting function in the documentation system itself.
Due to the broad range of people and clinical roles that come into daily contact with a patient, Stead said, alerts affecting all those roles would be overwhelming in an already-intense environment.
......
From 18 pneumonia cases per 1,000 ventilator days in calendar 2007, the rate fell to 14 in 2008 and 11 in 2009. But thereafter, it continued falling to 7.5 in 2010 and, in the first three months of 2011, a mere three per 1,000 days.
“What we’re really talking about is how to get people to look at care as a system and use controls and feedback to help you adapt and do the right thing,” Stead said. “If you do that, then you fix the system in a way that will fix many quality indicators.”
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It is interesting that the approach adopted here has two arms. First some excellent systems to record care delivery and second some very easy to understand ways of presenting key summary information that identified where care was falling short of guidelines.
Of course even before this having the systems in place to identify outlier clinical outcomes that need attention is also important! You won’t address problems until you know they exist.
Using a synthetic view of where the patient was situated in terms of required care and then feeding it back to the carers in essentially real time clearly has a dramatic impact on the proportion of needed care that is actually delivered - and guess what the patient outcomes are improved!
It is well worth considering what other problems could be addressed in similar fashion.
David.
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