Culture of quality captures award for TN hospital
Outcomes, finances, satisfaction improve
Sure, major improvements in treating pneumonia and total joint replacements helped, but Middle Tennessee Medical Center's evolving culture of quality has earned the Murfreesboro-based center the Tennessee Quality Achievement Award.
The award, traditionally given to companies in other industries such as manufacturing, is modeled after the Malcolm Baldrige National Quality Award, which recognizes industry leaders for their quality efforts in changing the culture of an organization. The medical center earned a level three award; four is the highest level of achievement.
The award caps off a banner year for the medical center, which scored a 98 on its Joint Commission on Accreditation of Healthcare Organization's survey in 1995.
The medical center's quality improvement process began several years ago, and the results are finally beginning to show up, says Christine Lombardi, RN, BS, CPHQ, director of quality improvement and utilization review.
Some 15 months ago, the hospital's quality team began collecting data and examining patient charts to determine patterns in areas that had good outcomes. "When we'd done well, we looked to see what were the things that happened and how we could replicate that so we could have good outcomes all the time," Lombardi says. "Hospital staff identified pneumonia and total joint replacement as areas where the hospital could improve the process, develop clinical pathways, and decrease length of stay." Average length of stay (LOS) and costs for both areas were higher than the averages for the state.
Advances in total joint replacement
The hospital's biggest success so far has been in total joint replacement, where LOS decreased from 10.2 days to about 6, for a total savings of about $2,500 in hospital costs per case, or nearly $100,000 for the first two quarters of 1995. When the quality team, led by Lisa Pewitt, RN, MSN, examined length of stay, they found that one of the major holdups in discharging patients was locating rehabilitation beds in the community. "We worked closely with the social workers to implement a number of things to facilitate them getting to beds quicker," says Pewitt, patient care director of orthopedics for the hospital.
The core of the pathway's success is a preadmission education session a week or two before surgery. During this session, a social services worker talks to patients about which rehabilitation facility they would like to go to after surgery. To avoid delays, patients are often put on a list for the skilled-rehabilitation facility as early as two weeks before admission to the hospital.
Some patients require only the services of a home health agency instead of a rehabilitation facility. Staffers were reluctant to send patients home because they were not sure which home health service would be used. To combat this problem, the hospital added a physical therapist, a home health employee of an agency associated with the hospital, to the staff.
The therapist developed, with orthopedic surgeons, a protocol for physical therapy so that each surgeon knew what the therapist was doing with all of the patients. The physical therapist worked with the hospital's physical therapy department so that he had a good concept of the patient's physical therapy routine. This therapist's involvement increased physician and patient confidence levels, and resulted in physicians discharging patients sooner, Lombardi says.
Another important component of the quality program in decreasing LOS is preoperative teaching. Patients are taught by the same nurses who will be taking care of them during and after their surgery. The nurses develop a relationship with the patients and review the clinical path with them.
"The patients now know before they come in roughly how many days they will be here and what will happen to them," Pewitt says. "It's something to work toward."
Preadmission courses are conducted in a classroom setting. Friends and relatives are encouraged to attend. It helps patients to know that they are not alone, and they develop relationships with other patients, Pewitt says.
Patients also meet their physical therapist, who introduces them to the exercises they will do after surgery. In addition, blood for lab work is drawn, and an anesthesiologist evaluates the patient. "Because a lot of these patients are in the 65-year-and-up age bracket, we felt like we were not giving them as much as they deserved by giving them all this education and exercises after they had this painful surgery," Pewitt says. "Now they learn a whole lot better and have a much better idea of what to expect. We feel like the patients do a lot better post-op because they have retained the information and are doing the exercises," she says. Ninety-nine percent of patients have rated the preadmission program excellent in exit surveys, Lombardi says.
Patient progress enhanced
What's more, patient progress appears to be improving. The medical center re-evaluates patients within six months of surgery. "In our last report, all of them showed functional improvement," says Lombardi. "Maybe they did not reach their goal, but the results were real positive."
Involving the medical center's orthopedic surgeons in the process was crucial to its success, Lombardi says. "We talked to the doctors and staff to help them structure the program and address problems that they and their patients were having, and that helped us," she says.
The original team for total joint quality improvement had nine members, but eventually swelled to 39. "I think it overwhelmed us when we started; we realized that everything we do impacts on everyone else," Pewitt says. "It became necessary to get these people involved. These patients have so many people to take care of them. It was important to get input from each of the front-line caregivers." The key: "I didn't approach anyone who didn't want to make the process better."
Advances in pneumonia
The medical center has reduced LOS for pneumonia patients from eight days in January 1995 to five days in the quarter ending in September 1995, just a day shy of its goal of four days. Those advances are not quite as stellar as the results in total joint, because total joint operations are scheduled and recovery is predictable, Lombardi says. Most pneumonia patients come in through the emergency department, and treatments vary widely.
The first step was to divide patients into three categories: community-acquired (patient had tried antibiotics but has not responded); respiratory-compromised; and institutionally acquired. A separate set of care plans was drawn up for each category.
The team primarily focused on getting antibiotics to patients faster, ideally within an hour of order time, Lombardi says. "We try to start the antibiotics in the emergency department because that is where 85% to 89% of the patients come in, rather than wait until they get up to a bed, Lombardi says.
Before the program was in place, patients received antibiotics in three hours on average. Now, 85% of patients receive their antibiotics within 60 minutes. To reach this goal, Lombardi and the quality team involved everyone who had a part in delivery of the antibiotic -- the pharmacy, the lab, nurses, and physicians.
Though a finished pneumonia pathway is not yet in place, Lombardi expects to have an initial order sheet in place soon for the medical staff to clarify antibiotic choices, and respiratory-driven protocols for aerosol and oxygen therapy. The idea is to make better use of aerosol and oxygen therapy, and to make sure, for instance, patients are monitored so that if they can maintain their own oxygen, they are not left on it until the day they leave the hospital.
Lombardi and her quality team have made improvements in other areas, as well. In winter of 1995, the coronary care unit experienced recurring shortages of telemetry machines. Rather than automatically assuming the hospital needed to buy additional machines, Lombardi studied the way existing machines were being used. In many cases, she found physicians simply did not notice that patients were hooked up to the machines and were leaving them on longer than was required.
Nurses began attaching stickers to patient charts to remind physicians that the patient had been on the monitor for 72 hours and to ask for a determination of whether it was still required. Since implementing the sticker system, the average number of days patients are on heart monitoring has decreased from 4.5 to 2.5.
Quality improvement touches all
The next areas that Lombardi and her quality teams will tackle are large and small bowel procedures, and chest pain, both of which have higher LOS and costs than regional averages.
Pewitt says she is in the beginning stages of looking at pathways for hysterectomy and back and neck surgery. "Those are things we know we do well, and we want to capture those paths," says Lombardi.
Lombardi emphasizes that the award committee wanted to validate that quality was part of the culture at Middle Tennessee, not just something that is pulled off a shelf when company comes. The committee spoke with a focus group of employees without members of the quality group present.
Committee members also focused on the hospital's supplier relationships. "They wanted to make sure that we applied the same quality standards to our suppliers," Lombardi says. Customer satisfaction was also a factor. The hospital's patient satisfaction surveys, conducted by Press, Ganey Associates, show that more than 91% of patients rate the hospital's services as excellent or good, up from 89% a year ago.
"We started in quality improvement maybe three and a half years ago, and you think it's going to show up the next day," Lombardi says. Of course, results do not happen so fast. "But this award showed all of us that the efforts are paying off." What's more, improvements were made without investing a lot of money, Lombardi says. "We feel like we were pretty typical. You don't have to be at a big teaching hospital to make improvements. It wasn't that we brought in a costly piece of equipment. We tried to do as much as we could with what we had here." *
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