Quality, case managers collaborate for better care
Hospital earned Franklin Award of Distinction
At Sacred Heart Hospital in Allentown, PA, patient-centered collaboration between the case management department and other areas, such as quality, nursing, inpatient and outpatient providers, the residency program, and the legal and finance departments, has had a dramatic impact on quality.
The hospital was awarded the American Case Management Association and Joint Commission's Franklin Award of Distinction for these performance improvement initiatives, which give timely, individualized care to patients.
The ability to have automatic orders for congestive heart failure (CHF) education, smoking cessation counseling, acute myocardial infarction (AMI) education, and stroke team and home care orders had a big impact.
"The medical staff agreed to these, and it allows nursing and case management to facilitate timely interventions," says Joanne Lee, RN, BA, CPHQ, director of case management and quality improvement. A multidisciplinary approach is used for the education teams, with nursing, dietary, and pharmacy involved in the CHF education process.
Teams including case managers and social workers developed and implemented the pre-printed orders for CHF, AMI, stroke, and bariatrics.
"We worked with nursing and respiratory to establish the smoking cessation counseling process," says Lee. "They were also members of our multidisciplinary DRG cluster teams that looked at specific diagnoses from a management and discharge perspective."
As a result of these changes, length of stay for Medicare patients dropped from 5.2 days in fiscal year 2002 to 4.93 days in fiscal year 2005. During the same time period, overall length of stay went from 4.19 to 4.08 days, and the organization's insurance denial rate dropped from 7.1% to 2.35%.
Quality nurses are responsible for investigating all referred quality concerns, as well as facilitating root cause analyses and failure modes and effects analyses to improve processes. They also work with case managers to ensure compliance with core measures. While data collection by the case managers is concurrent, the quality improvement nurses collect data retrospectively but before submission.
"The CHF education team has been a real success," says Lee. "Not only does it perform timely education, the process also includes a discharge education packet for the patient and an automatic home care referral."
Additionally, a referral is made to a telephone triage area staffed by critical-care trained nurses. The nurses provide a minimum of a five-week telephone follow-up that includes a pre- and post-survey that measures the impact of CHF on quality of life.
"Other successes have been the education of the nurses to perform initial swallowing assessments on the stroke patients," says Lee.
All incident reports are given to quality managers to review case by case and follow the peer review process, a process initiated and tracked by the quality manager. If it is determined that a process was the reason for a questionable outcome, the quality team would follow the process step by step to see what could have been done differently or should be changed, if applicable.
A form is completed by case managers for any issue, to give more information as needed for any of the following indicators: delay in OR, delay in consult, delay in diagnostic study, delay in discharge, no history & physical at 24 hours, no progress note by physician, alteration in documentation, unexpected mortality or mortality within 24 hours of admission or OR, returns to the OR, intraoperative event, unplanned admit from outpatient area, unexpected transfer to higher level of care, patient injury, and management of case issue.
The form is completed upon discharge of the patient or on the day of the incident if urgent, and given to the appropriate follow-up personnel, such as the surgical, medical or nursing quality improvement manager.
Quality managers follow up with multiple concerns, such as tracking readmissions within 31 days. When patients are readmitted within 31 days of their last stay, a readmission team works to discern if there was something missed during the previous stay and answers these questions:
- Should visiting nurses have been provided?
- Did nurses make sure the physician follow-up plan was clear to the patient?
- Was the patient given all the medications he or she needed?
- What could be done differently this time to prevent a readmission?
- Was there a delay in any care that could have impacted patient outcomes or length of stay? For instance, could the patient have gone to the OR earlier than he or she did?
- Were there delays in consults or studies?
"These items are trended and reported to the appropriate personnel for their follow-up," says Maureen Miletics, RN, BSN, case manager.
At Sacred Heart Hospital in Allentown, PA, patient-centered collaboration between the case management department and other areas, such as quality, nursing, inpatient and outpatient providers, the residency program, and the legal and finance departments, has had a dramatic impact on quality.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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