Putting the pieces together eliminates puzzling documentation, paperwork
Hospital streamlines several functions into unified model
Case managers at St. Thomas Hospital in Nashville, TN, have consolidated a disjointed, service-line case management approach into a comprehensive, unified program in just six months. The project is centered on standardized critical paths, the addition of an outcomes tracking tool, and increased collaboration with the hospital's database staff for variance analysis, explains Susan M. Coles, RN, MSN, OCN, a clinical nurse specialist and case manager for the hospital's surgical patient care units. Coles is one of the originators of the revised case management program.
Prior to the consolidation, the cardiac nurses had developed their own case management system, the surgical staff had a separate approach, and the vascular staff had yet another method for handling case management, explains Coles. Pathways and other documentation tools varied greatly.
"If you looked at all of our documents without the hospital's name on them, you would swear the documents all came from different institutions," she tells Hospital Case Management.
St. Thomas, which employs six case managers and four case managers/ clinical nurse specialists, began standardizing its case management program in October 1995.
While department-specific case management programs are advantageous for meeting highly specific patient needs, St. Thomas found that a unified program provides more benefits in terms of having comprehensive, consistent data collection for outcomes management purposes. Plus, a unified data collection system eliminates the need to retrain nurses who transfer from other departments.
The case managers started their efforts by developing a team to standardize the critical path format. The reason for redesigning the paths is that "the documents with which we started were case manager-oriented and didn't have much staff input," Coles says.
The revised, uniform documents then were used by staff during a three-month pilot program. This first redesign attempt, however, was met with strong resistance from the staff nurses. Although they liked the pathway concept, they said the documents they were given were not user-friendly, Coles says.
"We made the mistake of saying, 'This is the new system; this is what you are going to be using.' What we were hearing back was, 'I don't like them; they are not user-friendly.' Pathway projects need to have input from medical staff and staff nurses," she says.
In fact, case management leaders at St. Thomas quickly learned that integrating a disjointed case management department requires staff buy-in, education, and integration of existing supporting tools. (To see how St. Thomas is developing a staff education program on the new case management effort, see related story below.)
At this point, Coles and her colleagues enlisted the help of two staff nurses, who sat on the development committee. The pathways were further refined to make them more user-friendly. One concern was that the paths include a place for noting the multidisciplinary needs assessment, and that was included in the second draft. As the case managers begin to analyze variances and other outcomes data, the pathways may be revised again, as needed.
Also during the pilot test phase, the case managers worked to eliminate duplicative paperwork. Pathways now are used for documentation by the staff nurses, says Coles. Staff nurses also record variances and patient progress toward outcomes on the pathways. Numerous charting documents were eliminated as a result.
"Perhaps the best thing we have done as a result of the pilot program is include an outcomes tracking tool as part of the care map document," Coles adds. "This way, if the outcome says that the patient should be able to ambulate the length of the hall three times a day, and the patient cannot meet that outcome, then we can go to our tracking tool and determine why the patient cannot meet that standard."
Case managers are only called in to handle patients who vary from the expected plan of care. "The case managers basically pick up the variances. A patient who goes through a path right on cue and meets every single outcome doesn't need a case manager," explains Coles.
Variances analyzed by database team
The hospital's database staff members are beginning to work with the case managers to analyze variances. The database staff, which includes computer programmers and data analysts, are responsible for entering data into the hospital's computer information system and generating reports.
Many details of how the final outcomes management system will work still are being tested because the hospital is just now concluding the implementation of the critical paths and case management portions of the program, says Coles.
Case managers already have begun meeting with the database staff weekly with the goal of using the information that eventually will be gleaned from the spreadsheet-style reports for making improvements to pathways and other elements of the case management program. *
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