New clinical tool could be just what the doctor orders
July 1, 1999 4 minutes read
New clinical tool could be just what the doctor orders
When benchmarks and pathways converge
The first goal of benchmarking should be refocusing the attention of care providers, according to Robert Kane, MD.
"We spend a huge amount of time doing routine things," he says. "What you really want to do is move attention away from the routine things and on to the ones that are early indications of problems, so you can catch them before they become catastrophes." Kane, professor and director of clinical outcomes research at the University of Minnesota at Minneapolis and author of Understanding Health Care Outcomes Research (Gaithersburg, MD: Aspen; 1997) began benchmarking when he and his research group at the University of Utah originally developed a benchmarking system for nursing home care in the early 1970s.
Designed to allow nurses’ aides to track the clinical course of patients, the system was based on a series of structured observations and used a manual in which nurses’ aides could look up what to observe, how often to observe it, and the different levels of response when a pattern of change was observed.
"That was what we originally described as benchmarking," Kane recalls. "More recently, we talk about clinical guide paths, which are ways of tracking specific parameters for a given problem and predicting the expected path for that problem and using management by exception to intervene when the patient’s course deviates from that path. Pathways tend to be written around dichotomous responses because you’re working with a yes-no’ decision tree. If it’s yes,’ you go one way; if no,’ another. Benchmarks tend to be observations which vary, and what you are looking at are patterns of those observations over time. They’re related, but different."
Benchmarks might differ for the same type of wound under different conditions, creating a need for multiple pathways that vary with the underlying condition of the patient. As Kane points out, "If you have a young, healthy patient recovering from a wound, you might need to make different observations than if the patient is old and frail and has multiple chronic conditions."
Kane says when people try to put together pathways based on research, they find that in most cases there is no hard evidence to support the decisions. His guide paths begin with the choice of one or two salient parameters for the problem, followed by systematic observation of those parameters. When the pattern that’s been developed differs from the one expected, caregivers know to take action. "People get very nervous when there are 15 different versions of a pathway for the same problem, and it’s particularly frustrating if different organizations or different payers require different pathways," he says.
At Dartmouth University in Hanover, NH, Julie Mohr, MSPH, and three of her colleagues have designed the Clinical Value Compass (CVC) model to facilitate the benchmarking process. Named to reflect its similarity to a directional compass, the CVC has the following four cardinal points: functional status, risk status, and well-being; costs; satisfaction with health care and perceived benefit; and clinical outcomes. The CVC approach assumes that if providers wish to manage and improve the services they provide, they must: measure the value of care for similar populations; analyze the internal delivery processes that contribute significantly to the current levels of measured outcomes and costs; test the changed delivery processes; and determine if the changes made led to better outcomes and lower costs.1
Mohr emphasizes that the process produces the results, so the only way to know what you need to change is to examine your own process. "You can compare your results to somebody else’s, but unless you understand what it is you’re doing in producing those results and you understand what the other person is doing to produce results, you don’t know what to change. You can’t just have a number as a goal you strive to reach and say, OK, we’re going to do better,’" he explains.
Mohr says this helps you to be very specific when you begin a benchmarking relationship with others. "I think learning from each other should be a goal of benchmarking. You really need to be able to talk about what it is you do, what you’re going to change and try. I think the whole point is not just to make yourself feel good that you have a good number, but to improve what you’re doing."
When the American College of Nurse Midwives contacted Mohr to help benchmark nurse-midwifery care, they decided what to measure and looked at the process of midwifery care. "They knew intuitively that the care they provide is very good, and how it’s different from obstetrical care, but they wanted to make sure that they could document that. They found they were often being compared to obstetricians, and the argument was, If you need a physician to be there in case of medical emergency, then why do we need nurse midwives?’ They had been collecting data at a national level and are now doing their pilot test of the benchmarking process." Mohr says this has been a very long and involved process. "It’s taken awhile to figure out what they should measure and then refine that after they started collecting data. They had to be very specific, making sure everyone was measuring the same thing the same way."
To see illustrations of the Clinical Value Compass, access the Best Practices Web site, www.best4health.org.
Reference
1. Nelson E, Mohr J, Batalden P, et al. Improving health care: The Clinical Value Compass. Jt Comm J Qual Improv 1996; 22:243-255.
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