Four Michigan hospitals make community health their business
QI managers compile data; give baselines, tools
Lee Holmberg, MA, CPHQ, was interested to hear that one of the overriding goals of the community health improvement project sponsored by his hospital and three others in Macomb County, MI, was to prevent bicycle and roller-blading injuries. He wondered out loud to his counterpart at another hospital how project organizers were going to know if the number or severity of injuries grew or shrank, or if the efforts of the hospitals, dozens of community leaders, and 168 businesses made any difference.
"We had a real problem because we didn't know how the baselines [of measures] were going to be created," says Holmberg, administrative director of quality and resource management at Mount Clemens (MI) General Hospital. "We talked to the project director, whose background was in medical records, about addressing some baseline measurements, which they had never thought of when [project organizers] were establishing the goals."
Baseline measures are vital to any improvement project because they give organizers a starting point for comparison.
Holmberg's department and the quality management departments from the other hospitals -- St. Joseph's Mercy of Macomb Hospital and Health Services in Clinton Township, Bi-County Community Hospital, and Macomb Hospital Center, both in Warren -- decided to lend their skills to turn the good intentions of the community effort, called Creating a Healthier Macomb, into a true improvement project.
"If someone is talking about doing [a community project], they need to make sure the quality management people are in tune with it," says Joyce Hennigan, CPHQ, clinical decision support analyst for St. Joseph's Mercy. "I can't stress that enough, because we lost a lot of time having the project roll out and then [the quality management departments] finding out about it vs. being the people who are involved in it from the beginning."
The Creating a Healthier Macomb project began in the summer of 1994 as a result of a conversation between the CEOs of two of the participating hospitals. Starting small by collaborating on a mobile health care clinic, the two hospitals were joined by the remaining two hospitals in the county, along with members of the community, including business and community leaders, and local government officials. By May 1995, the group had 150 community health goals, which were later trimmed to 50. (See sample of goals, p. 67.) Once those goals were set, the quality departments had the task of developing measurement systems to ensure the project remained on track.
Better coding, better data
Realizing the need for better statistical control, members of the four quality management departments met under the auspices of the Michigan Association for Healthcare Quality to see where their expertise could best be used. They immediately identified coding inconsistencies among their institutions regarding bicycle and roller-blading, or in-line skating, accidents.
"We were identifying the fractures and the traumas as they came through the emergency rooms, but we did not identify them as related to bicycle and in-line skating issues," Holmberg says. "Most hospitals don't code for the E-codes that can occur. . . . From a quality management perspective, it can help you figure out where things are happening. But [E-coding] doesn't happen uniformly."
E-codes represent situations that are external to the delivery of health care, such as a fractured arm resulting from the external event of in-line skating.
The group looked at all the ICD-9 codes and came up with several groupings related to bicycle and in-line skating injuries. They took primary diagnoses codes of 800.00 through 804.90 and 872.00 through 873.90, and added E-codes E813.60 and E826.00 through E826.9, which identify bicycle-related injuries.
"We did not have a code for in-line skating because [those skates] weren't around when the ICD-9 system was developed," Holmberg says. "So, we made up a code number that we would all use consistently." That mock code is only used among the four hospitals in the county.
Starting Jan. 1, 1996, the four hospitals started using this coding system and created a database. They also conducted a medical records review of 1995 using the ICD-9 codes to estimate the number of injuries occurring from bicycle and in-line skating accidents. Since the cause could not be determined for all the injuries, Holmberg admits the baseline data will have a low confidence level. The data, however, will offer a starting point to measure against the more accurate data collected in 1996.
Pediatricians in the county also have asked to participate and have started using the coding methods and similar data collection forms.
The quality departments developed a data collection form for emergency department nurses. When someone comes into the emergency department with a bicycle or in-line skating injury, the form asks what type of protective equipment the patient wore. The goal of this question is to assess the effectiveness of community safety education.
"This is all very exciting because it has forced us to collaborate on a major outcome," Holmberg says. "We will be able to provide this information to the people that are doing the intervention."
The intervention Holmberg speaks about is a series of bicycle and in-line skating safety clinics sponsored by the American Automobile Association of Michigan and local businesses to heighten awareness of proper use of the equipment and the importance of protective gear. Not only will they be able to see over time how effective their education efforts are, but they will also more immediately see what types of safety messages they should be presenting. For instance, if the coding data shows a trend toward increasing wrist injuries, then the education messages could be updated to emphasize the importance of wrist braces. That makes the communication campaigns more data-driven.
Education plays a large part in Creating a Healthier Macomb, far beyond issues of recreational safety. Here are two examples:
* Advance directives: Current projects include increasing the number of people with written advance directives regarding medical care by 5% over the 1995 level by the end of 1996. The quality management departments are examining the process of how those directives are filed and accessed. Patient representatives and older-adult service providers are explaining the value of advanced directives to community members. "No one in the community should feel that when they enter the health care system that they are stripped of their right to make decisions," Holmberg says.
* Violence prevention: Through its nursing educator department, Mount Clemens General Hospital is lending a hand to county school systems by offering health education services. Social services in the hospital are providing violence prevention education. "Our goal is that 75% of all schools districts will teach age-appropriate objectives to resolve conflicts," Holmberg says. Once again, the quality management departments will determine baselines and appropriate measurements to monitor progress and indicate where program changes should be made.
Projects serve dual purposes
In May 1995, Creating a Healthier Macomb had its first summit and issued a report with 50 Community Health Goals that were broken into seven categories. A second summit is scheduled for May 1996. Each hospital has contributed $100,000 to support the project. That display of commitment has led to an additional $600,000 in grant money.
None of the money has gone to increase hospital staffing. The increased workload has been shouldered by the quality staff and other hospital departments using existing resources. That has been a strain, but commitment to this project is widespread in health care quality management circles and throughout all the hospitals, say Holmberg and Hennigan. (See how to gain the backing of hospital leaders, this page.)
While the workload has increased, Hennigan has found ways to get more mileage out of her efforts and tap into other resources for help. Following are some examples:
* Data and analyses for the community project will be used again as preparation for her hospital's survey by the Joint Commission on Accreditation of Healthcare Organizations. For example, the Joint Commission, in its standards on information management, requires organizations to identify community health care needs and process aggregate data related to those needs. In its chapter on continuum of care, the Joint Commission requires organizations to demonstrate how they extend hospital functions beyond the hospital walls.
* The chores of analyzing the data are shared by the quality management departments in all four hospitals.
That team spirit has an energizing effect that minimizes the amount of work required, Holmberg says. "We look at this as an opportunity to improve internally and improve the community," he says. "We are doing a lot more, but when you have other people involved, such as the nurses, the ER, the physician offices, and they all see the common good, everyone is willing to stretch. I find that exciting." *
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