Following the path to improved outcomes
July 1, 2000 4 minutes read
Following the path to improved outcomes
Even the little guys can make use of protocols
(Last month, a story in Healthcare Benchmarks focused on how a five-hospital system was able to implement a clinical pathway program with strong results. But in keeping with a trend to investigate how other kinds of facilities and organizations can adapt tools to their use, HB decided to look at how a small hospital, the 80-bed Valley View Hospital in Glenwood Springs, CO, took on a similar challenge.)
If you work in an 80-bed hospital, you probably have many issues to worry about. Being able to deliver the highest quality of care with more limited resources than colleagues in big city hospitals is one of them. And if you wanted to start a new program designed to improve quality, you might not have the staff to do so. But Valley View Hospital in Glenwood Springs, CO, has started a clinical pathway program that has saved the facility millions of dollars and hundreds of bed days.
Cathy LaBaw, RN, director of performance improvement, worked with clinical pathway coordinator Linn Kight, RN, to develop 22 different paths over the course of four years.
"In 1996 when the effort began, our hospital was financially stable, had good outcomes, did well with regulators, and had high patient satisfaction," says LaBaw. "We had no compelling need to make a radical change. Instead, the initial decision to begin was the result of a grass-roots effort by nursing staff who recognized the value of pathways and managed to convince a particular physician to champion the effort to do a path for community acquired pneumonia."
Kight notes that decreasing resource utilization, though, was always in the back of the minds of those who participated in the program.
Several people who were interested attended a training session on clinical pathway development methodology. The path, after creation, was implemented by a multidisciplinary team of clinical caregivers. "The learning curve was steep and long," LaBaw recalls. "Not only because this was a new process, but because pneumonia was — and remains — a difficult condition to develop practice guidelines for."
That first pathway process, though, helped the group work through some general difficulties. Now, Kight researches new pathways to determine internal and external best practices. Using existing pathways, suggested data goals from various specialty societies, and other published work, she comes up with the basis for a new pathway.
For example, Kight says the Chicago-based American Hospital Association recommends that patients with chest pain get aspirin within 20 minutes. "Our target time is 10 minutes, and right now we are at about 12 minutes," she notes. They are working to further improve that by continuing community education on the importance of taking aspirin if a heart attack is suspected, and working with the local ambulance service to administer the aspirin at the home or en route to the hospital.
"Depending on its focus, the pathway is then assigned to one of three existing Collaborative Care teams: surgery, medicine, or peripeds," LaBaw adds.
The teams meet for four hours every month, with pretty consistent membership. During the meetings, the teams work on new pathways, evaluate data from existing paths, and review older pathways to see if they need any updating, says Kight.
One reason LaBaw thinks the effort has gone smoothly is that the clinical pathway steering committee included people from every area of the hospital. Physicians, clinicians, and administrative staff all participated, she says. "Eventually the data began speaking for itself, and that has sold’ many physicians."
The goal has always been to combine better outcomes while lowering average length of stay and charges. With the 22 pathways, there have been nearly 680 patient days saved, $1.4 million in charges eliminated, and more than $1 million in cost savings. Readmission rates have declined by 43%.
"Additionally, each pathway has two or three dedicated quality outcome indicators, each of which shows improvement or maintenance of satisfactory results," LaBaw says.
Perhaps the most telling evidence of how well the program works, though, is that physicians use it, says LaBaw. "We don’t require them to use the pathways," she says. "But they do it. The orders are written, the process was developed against the standard of care, and it has eased their administrative burdens. They love it."
LaBaw adds that having the pathways in place has helped the hospital in its managed care contract negotiations. "This isn’t a very high managed care area, but we use it when we negotiate, and it does provide leverage."
Data-driven quality improvement
Another measurement of success has been the hospital’s ability to use the data gathered because of the pathways to make further improvements. LaBaw notes that physicians wanted to make sure that patients received preoperative antibiotics within 60 minutes of having the first incision during their surgery.
By looking at data collected from other pathways, she knew they weren’t in that window. "We revised pathways based on that knowledge, and we were able to bring it from an average of 67 minutes prior to the changes to 30 minutes after them," LaBaw says. "Having data often provides us with ideas for improvements. And we analyze the data regularly."
The data are reviewed in the collaborative care team meetings, and also with process improvement teams and among physician groups, says LaBaw. The board also sees data every six months.
Costs can be cut only so much, Kight admits. "Everyone has to work smarter and more efficiently, but this takes a multidisciplinary plan of care and tools that allow everyone to care for patients in a like manner," she says.
Next, Kight adds, is expanding the pathway process throughout the continuum of care. "We are trying to bring it into home health, nursing homes, and even one physician’s office so that wherever patients go we can help them reach a better level of wellness."
[For more information, contact:
• Cathy LaBaw, RN, Director of Performance Improvement, Linn Kight, RN, Clinical Pathway Coordinator, Valley View Hospital, Glenwood Springs, CO. Telephone: (970) 945 3453.] n
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