Benchmarking children's hospitals improves asthma home management
Collaborative sought to improve compliance with TJC requirements
Children's hospitals participating in a benchmarking initiative have achieved significant improvement in compliance with home care requirements set forth by The Joint Commission. The Children's Asthma Care (CAC) performance measure set, implemented as a core measure effective with July 1, 2008 discharges, includes three measures:
- CAC — 1: use of relievers for inpatient asthma;
- CAC — 2: use of systemic corticosteroids for inpatient asthma;
- CAC — 3: home management plan of care given to patient/caregiver.
"We first started addressing [CAC] back in April of 2007 [when The Joint Commission first introduced them]," recalls Tina Sacco, RN, BS, clinical quality specialist, Connecticut Children's Medical Center in Hartford. "It was pretty clear from the start that we did fine with the first two measures; but the last measure, related to home management care, needed to improve. The first results were pretty dismal."
In fact, she reports, the baseline figure for her facility's compliance was 20%; today, it's at 90%. That baseline figure was not unusual for the participating hospitals, recalls Sharon Lau, who has been heading the BENCHmarking Effort for Networking Children's Hospitals (BENCH) since 1992 for her Los Angeles-based company, MMP. "It was designed to be a collaborative effort of children's hospitals to share data and knowledge so we'd all get better at what we do," she explains. "After the first couple of data submissions [for this initiative], we called a conference and looked at the data; a number of the hospitals were at the bottom — if they had 1% or 2% compliance, it was a lot."
Addressing shortcomings
Since the CAC home management measure represented a Joint Commission requirement, "Our role was to bring those hospitals together that were part of the BENCH effort, whether they use us as a vendor for health care or not, and share what works and what doesn't work," Lau explains.
And while a number of the hospitals ranked low in terms of compliance, "There were some at the top," says Lau. For example, SSM Cardinal Glennon Children's Medical Center in St. Louis "showed up as being about 80% for the first couple of go-rounds, which was pretty dramatic."
So, during the first conference call, Lau asked them to share with the other facilities just how they did it — how they got buy-in from the organization and how they got the physicians to participate. "What they said was that it was an organizational initiative that they would get to 100% on these measures — period, end of story," Lau shares. "If you have an initiative with expectations that people will be accountable, you generally will have success."
In their first three quarters of addressing the issue, Lau reports, Cardinal Glennon went from 39% compliance to 80%. "It came down to the fact that one person was responsible — she was the accountability person," says Lau. "Whether she did it herself or assigned it to someone else, there was one person in the organization you could go to and ask why things did or did not improve. Also, they reported at the quality improvement council on a monthly basis, so there was 'public' accountability."
So, during the subsequent conference calls, Lau would ask participants where the responsibility resided in their facility. "There are still a couple of organizations where the function is not as central and they're not doing quite as well," she reports. "There's the same correlation with presenting the results in open meetings in the hospital."
On an ongoing basis, Lau collects the performance data from the hospitals and then shows each one where they rank compared to the other participants. "This process gives them access to known hospitals [as opposed, say, to Joint Commission data, which are 'blind'], and allows them to borrow ideas and adapt them for their own purposes," she explains.
Using a task force
At Kosair Children's Hospital in Louisville, KY, a multidisciplinary task force was established in 2007 as the initiative began, recalls Elizabeth VanCleave, RN, BSN, CPN, AE-C, asthma clinician.
Actually, there were two organizations: One, which strictly dealt with core measurements, included VanCleave, a clinical nurse specialist, and a systems analyst. The asthma task force included respiratory therapists, pulmonary specialists, the asthma educator, chief resident, pharmacy, case managers, quality control, and pediatricians from the community.
"We had a home management plan of care," says VanCleave, "But it was not as measurable as The Joint Commission wanted and not as statistically measurable and consistent."
The team actually rewrote its discharge orders to reflect the care plan, says VanCleave, who notes that it had to be approved by the pharmacy, the pulmonary care specialist, and the hospitalist group. It included instructions for patients in the green, yellow (asthma is partially controlled), and red (uncontrolled) zones. "We did it in a format so the nurses can transcribe it into the care plan," says VanCleave. "We worked quite hard to get it into a readable format, and rewrote the care plan to match that since it was going on the computer."
Continuous monitoring
Discharge order sets continue to be reviewed on a monthly basis, even though the facility has improved compliance from 57% to 88%. This ongoing monitoring includes tweaking of the plan to meet core measurements. "Our goal is 90%," says VanCleave.
New residents are familiarized with the plan, and one-on-one training has been conducted with nurses on the floor, with inservices in other units, she adds. "We have written examples with binders to keep on other units," VanCleave notes. "So, for example, in the peds ICU there are step-by-step instructions, in case they want to send a patient home, for example, at 6 a.m."
There is continuous monitoring of compliance and appropriate performance; for example, says VanCleave, a second nurse always has to review and sign off on the discharge plan after the first nurse has done so, to make sure everything is correct.
"If they do not do something correctly, we engage with them one on one," she says. "On occasion, we've done backtracking to make sure the residents tracked what they did correctly. I may go to the computer and see, for example, if the proper drug dosage and frequency had been ordered. We can go to the doctors and point out that something is inappropriate, as well."
In addition, the systems analyst reviews all asthma charts for patients who are 2 years or older. The systems analysis nurse gives VanCleave the names of individuals who "failed," how they failed, and what type of error was made. "I also look at all the patients that come out of the ICU, regardless of age," adds VanCleave. "I do random charts audits — about 30 a month."
Other keys to success, says VanCleave, are teamwork and a strong desire to achieve common goals. "Upper management is really on board; they've opened several doors for us to be able to teach nurses and residents," she says. "They've allowed us to hold monthly meetings with new residents and not just leave it to the upper residents. We go in as nurses and teach, and we also present to the task force a continuing monitoring of the care plan situation."
If someone is not doing what is expected, she adds, "We can even take it to the medical care liaison for our floor, and they will personally review the chart. And when we have a difficult situation, they are on board with us and back us up."
There can be only one
At Connecticut Children's Medical Center, the preferred model was followed: "The most important thing we did was that there was one person dedicated to doing this on daily basis — me," says Sacco.
While that was straightforward, she says, what wasn't so straightforward was getting people to comply with the requirements. "Each day I looked at any child that had been admitted with asthma, reviewed the chart, and determined if the home management plan of care was on it," she shares. "If it wasn't, I'd send an e-mail to the vice president in charge of the hospitalists, and he'd talk to the doctors caring for the child to make sure it was put on there."
The process is currently manual; computerized physician order entry (CPOE) in the facility is electronic, but at present the rest of the chart is not. Accordingly, the process can be time-consuming, "but you have to be vigilant and look at charts on a daily basis to make sure you have all the pieces in place," says Sacco.
In creating the plan, she says, "We got input from pulmonary and respiratory therapists and the vice president of quality, who is also a hospitalist. We looked at the criteria and revised our plan of care to include all those elements."
Once the plan was created, memos went out to the staff to make them aware of the new requirements. "It mostly impacted our pulmonary group and the primary care center, so we focused on them," says Sacco. "We have a large number of pediatricians out in the community who could admit patients, and that was the hardest piece to get."
How did they get the community physicians on board? "We went through their medical director once he was on board; it's a large pediatrics group," Sacco explains. "When he finds a community doctor who's not compliant, he follows up and ensures the necessary improvements are made."
Benchmarking a plus
Both Sacco and VanCleave agree that the benchmarking process made a major contribution to their success. "It was very valuable to see what the other hospitals were doing and to use some of their ideas when we could," Sacco says. "Everyone was very willing to share ideas on what was working and what was not. We had a few conference calls that MMP set up and were able to talk amongst ourselves; we also have a listserv we used with specific questions related to the asthma core measures, and that's been very helpful."
The greatest benefit, she says, came in setting up the actual form. "It was quite interesting to see how the others were doing it, and bounce ideas off each other as we developed them so we could meet [The Joint Commission] criteria," she says. "In fact, we e-mailed our actual forms to each other through Sharon, looked at them, and took what we needed." (A copy of Sacco's form can be found here.)
Benchmarking played a big role in motivating the staff at Kosair, says VanCleave, because "We wanted to meet the benchmark and be at the top, and the push to get it all correct has been huge. It's been a collaboration of what we think works, what system works best, and the analytics nurse pulling the data. I can think that something's good, but if she says no, we have to work on why."
The greatest benefit, adds Lau, is "the ability to really know what works and what doesn't in a known group of people. You can actually talk to them, pick apart your process and theirs, and compare not just data but the knowledge behind the data."
BENCH has a list of characteristics for each hospital contained on an Excel spread sheet, with short answers next to each characteristic. "So, when you look at the data you can see 'yesses' and 'nos' and see if the other hospital said yes to the same questions you did; each answer gives you the opportunity to dig behind the scenes," she explains. "If they said yes and you said no to a specific question, maybe that's the key to the difference in performance."
The question BENCH is now tackling, she continues, is whether the home management plan does what it is designed to do. "And that is to keep kids out of the hospital, to prevent readmissions to the hospital, to prevent ED visits, and so forth."
In a conference call last week "we also discussed whether hospitals are using it as a tool when a child does come into the ED or into the hospital: Do they ask Mom and Dad whether they had followed the tool? Do they ask what parts of the tool they found useful?"
This involves the whole issue of knowledge — what to do about the data when you get them, Lau explains. "When a patient comes back readmitted, is there someone to say to, 'Mom, are you following the discharge plan? How did it work? Did it help you? Did your child avoid triggers?'" she poses. "If not, maybe you should take another look at the plan. You can be 100% compliant, but what is that doing to outcomes?"
[For more information, contact:
Sharon Lau, MMP, BENCHmarking Effort for Networking Children's Hospitals, 2049 Balmer Drive, Los Angeles, CA 90039. Phone: (323) 644-0056. Fax (323) 644-0057. E-mail: [email protected]. Web site: www.mmp-BENCH.com.
Tina Sacco, RN, BS, Clinical Quality Specialist, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106. Phone: (860) 545-9726. E-mail: [email protected].
Elizabeth VanCleave, RN, BSN, CPN, AE-C, Asthma Clinician, Kosair Children's Hospital, Louisville, KY. Phone: (502) 629-8544. E-mail: [email protected].]
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