Peds benchmarking group gathers outcomes data
Members use data to highlight their strengths
Company literature refers to it as a "national child health outcomes conference," but staff members refer to it as the "Halloween Meeting." A group of physicians, pediatric hospital chief executives, and representatives from payers and national quality organizations came together on Oct. 31, 1997, to ask questions and brainstorm about how to develop a mechanism for measuring pediatric outcomes.
Along with a permanent ban on any more meetings held on Halloween, the result of that meeting was the creation of the Child Health Accountability Initiative (CHAI), a pediatric benchmarking consortium based in Overland Park, KS, with more than a dozen member hospitals around the country.
According to Donna Payne, RN, MSN, senior vice president of CHAI, the group was a natural outgrowth of the Child Health Corporation of America (CHCA) and a desire of some of its 38 members to use outcomes data as a way to differentiate themselves from competitors while simultaneously ensuring the best care for patients.
Blair Sadler, CEO of Children’s Hospital and Health Center in San Diego, hand-selected the attendees, says Payne. "He wanted the top hospitals that were interested in pediatric outcomes and pulled the who’s who of leading health care researchers for the meeting."
The initial group was narrowed to three CEOs and a couple of physicians who worked on how to set up the consortium. "The CEO piece of it was a crucial element," Payne recalls. "We come from a CEO-driven organization, CHCA, that has a reputation of being able to get things done." CHCA was asked to run the incipient organization.
Following a series of meetings, the group decided to select eight to 12 hospitals to participate in the first round of benchmarking, she says.
"They would be early adopters who would put resources on the table to support the initiative," says Payne. Those resources included $100,000 as well as in-kind resources that would allow Payne to use existing assets in member hospitals to take care of things such as statistical analyses and data mining.
CHAI and its officers developed a five-part readiness assessment that was sent to each of the 160 children’s hospitals around the country — from large facilities, such as Texas Children’s Hospital in Houston with 425 beds, to small ones. The group also included the pediatric facilities at some large academic medical centers such as Duke University Medical Center in Durham, NC.
The assessment included an administrative section that the hospital CEO had to complete indicating a willingness to contribute both the monetary and staff resources required of the group, says Payne.
The CEO also had to attest to the presence of a physician leader and enumerate the outcomes-related projects the facility was already working on. There was a section on the facilities’ current use of data for clinical performance improvement. Another part looked at clinical issues, including:
how many clinical paths were in operation;
what performance improvement projects the hospital was working on;
what physicians were involved with those projects;
whether the facility used report cards.
In the technical area, hospitals were asked about their technical capabilities including:
what data they could extract from their systems;
how fast they could extract data;
how those systems worked.
The CHAI staff, as well as some from Sadler’s hospital, scored and weighted the questionnaires. "There was an obvious group of hospitals that was ready," Payne recalls. "There were others that were interested, but they knew they weren’t ready to be included in the first round."
Once the hospitals were chosen, CHAI set up a governing group. The chairman was Jonathan Bates, MD, an emergency department pediatrician and president and CEO of Arkansas Childrens Hospital in Little Rock. Sadler was named the vice chairman, and two medical directors were added. Each hospital was required to provide a physician leader who would be a member of the clinical and scientific team that would decide which projects to select.
Initial projects bring positive results
"They wanted issues that we could see results in within 12 months," says Payne. After lengthy discussions "and much hair-pulling on priorities," Bates made the final selection of projects:
1. The first project selected was medication errors.
Nine of the 12 charter members were already working on that project. "It was easy to get our hands around, and important," she says. "And it could easily demonstrate we can work together."
2. The second project was bronchiolitis.
Ten of the 12 hospitals were interested, in part, because bronchiolitis is the most frequent cause of pediatric admissions between November and March, and much of what is done may or may not be appropriate or efficient, says Payne. "We decided a literature-based guideline would work for that."
For the medication errors project, keeping the focus narrow was important, says Payne. "We kept it to prescribing errors in the pediatric intensive care unit [PICU]."
Each physician champion pulled hospital data, and CHAI analyzed more than 20,000 PICU medication orders. The group was able to identify root causes and interventions and reduced the error rate by 21%. The choice was fortuitous: CHAI wrapped up its project in early November 1999, about a week before the Institute of Medicine released its report decrying the number of medical errors that take place in hospitals. "We were the only national collaborative working on that at the time," Payne says proudly.
Although happy to have been ahead of the curve on the medication errors issue, Bates says he is happier to know that the group is on the right track.
The bronchiolitis care was more complex, requiring an extensive literature search to determine what worked and what didn’t. The search turned up some ineffective treatments, such as steroids and inhaled epinephrine, which are used, but are of questionable use, says Bates. "Certain physicians used it from time to time, but by looking at the literature and showing them that it wasn’t effective and that there were better ways to treat bronchiolitis, we could change their behavior."
Recognizing that staff education was central to quicker adoption of new CHAI bronchiolitis guidelines, CHAI developed a comprehensive bronchiolitis tool kit customized for each participating hospital.
The tool kit included:
hospital-specific findings and recommendations summarized on various-sized posters for displaying in medical lounges and other high-traffic areas throughout the hospital;
electronic files containing hospital-specific findings and recommendations (raw data and PowerPoint presentation formats) for use in medical education sessions and meetings;
pocket cards outlining recovery information for use by medical staff in communicating post-discharge expectations for recovery to parents;
electronic files of recovery information for each hospital’s use in customizing existing parent education materials.
The result of the project was an 8% drop in average length of stay, a reduction in unnecessary testing, and a set of defined post-discharge health status measurements.
Since its inception, the group has added two new hospitals to the group and plans to continue adding about that many each year. In addition, CHAI has picked new projects to work on. Continuing the work on medication errors is still viewed as important, and analgesic and sedation are the current targets for improvement in that area.
Bates says that any new project the group looks at must be something where there is wide variation among members. It also must meet the following criteria:
Change has a positive impact on patient care.
Data collection is not overwhelming.
At least three member hospitals are interested.
Some of the ideas being considered:
pain management;
minor and moderate head trauma;
acute asthma in the emergency department;
antibiotic utilization.
"The list of projects we could do is enormous," adds Payne. "But we can pick only one or two each year. Pediatric hospitals are full of physicians who wear many hats and are willing to take on a lot. Part of my job has been to say that we can’t fly the plane while building it. While we want to make rapid decisions, we have to be sure that we don’t take on too much."
"The whole idea is that we want to be demonstrably doing the best possible job for the kids," says Bates. "This is how we demonstrate it to ourselves, and to others — payers, regulators, and the community. Payers sometimes look at us and think we are expensive. But we can show them in a methodical and systematic way that it makes sense for us to be expensive. We are responsible, and medical quality and service quality are our key goals. If you want proof my hospital is good, I have the data to show you."
[For more information, contact:
• Donna Payne, RN, MSN, Senior Vice President, Child Health Accountability Initiative, Overland Park, KS. Telephone: (913) 262-1575.
• Jonathan Bates, MD, President and Chief Execu-tive Officer, Arkansas Childrens Hospital, Little Rock. Telephone: (501) 320-8000.]
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