Clear information ensures physician cooperation
Graphical presentations make understanding easy
The medical director at Salinas Valley Hospital in Salinas, CA, takes a minimalist approach to getting physicians involved in quality improvement efforts. Instead of "beating them over the head" with quality concerns, he says, he just hands out two or three pages of "teaser" comparative data at department or section meetings, then sits back and waits.
The trick is to give the doctors interesting graphical illustrations like scattergrams and bar charts that allow them to see how the hospital compares to others in the state, says Ralph Keill, MD, assistant administrator and medical director at Salinas Valley. Their curiosity is peaked when they see a DRG in their specialty in which the hospital is below state averages for length of stay (LOS), charges, complication rates, or mortality.
By the time Keill finishes telling them he can dig deeper and provide more detailed data, as well as physician-specific data, they’ve gotten out their date books to schedule the next performance improvement meeting.
"Physicians like it much better when they get the graphical pictures," Keill says. "You have to sift through numbers. A scattergram or bar graph shows the relativity of things."
A scattergram is a graphing methodology using a central vertical and a central horizontal axis. For example, the vertical axis can be LOS, the horizontal axis, charges. (See scattergram, p. 6.) Each hospital in the peer group is a point on the diagram. Anything to the right of the vertical axis indicates a longer LOS than expected, and anything above the horizontal line, a greater charge than expected. When Salinas Valley s performance appears somewhere around the edges, the physicians get concerned.
Off-the-shelf software provides solutions
Keill uses Iameter severity-adjusted data and a new Iameter Windows-compatible product, Sherlock 2.0, to generate the graphical reports. Iameter is a San Mateo, CA, consulting firm that provides severity-adjusted comparative data for benchmarking and QI purposes.
He also uses a Baltimore research and data firm, HCIA, which can provide comparisons of Salinas Valley against national averages and local hospitals. The hospital’s Meditech system, which currently runs 25 applications from payroll and accounting to abstracting and order entry, also provides Keill with valuable data. "We can get a lot of information out of the abstracting application and can write specific reports that allow us to pull specific information, all without ever looking at a chart. For example, Keill recently was able to generate a report within an hour that allowed him to monitor whether patients who were restrained had an order for the restraint on their charts. Another report allowed him to see when outpatients had to be admitted.
"I’m a big believer that physicians will respond to accurate data, so we really try to give them accurate information and then trust that they will improve in areas where they need to improve," Keill says. He uses transurethral resection of the prostrate (TURP) as an example: "We were about $1,000 higher and a day longer than the state average. Just by giving that information to our urologists that’s all I did the LOS has shortened by 2.7 days, and the average charges have come down by $3,000 between 1994 and 1996. We’re now below state averages." (See bar chart, p. 6.)
Salinas Valley orthopedics are now working with Keill’s data. He provided them with graphs on all major orthopedic procedures. They decided to zero in on knee replacement because it was the highest volume area, and any improvements there would have the profoundest effects.
Keill used Sherlock 2.0 to produce a scattergram using individual patients as the data points. "We didn’t worry so much about the patients clustered in the middle, but decided to look into and abstract about 40 charts of the patients who did the best and the patients who did the worst using LOS and charges as the scattergram’s horizontal and vertical axes."
Keill says he didn’t throw complications into this mix because complications would show up as longer LOS and higher charges anyway. When Keill sees a red flag on any DRG’s complication rates, he looks at the charts to see if he can find a root cause. (For a discussion of the pitfalls in relying on complication rates, see story, above.)
In the chart review, a team representing all fields involved in knee replacements from preadmission to discharge planning searched for the differences in ways the two groups of patients were treated. Their goal is to develop recommendations for treatment guidelines or care maps that will "smooth the passage of these patients" through the system.
"The Joint Commission [on Accreditation of Health Care Organizations] really wants you to be doing some benchmarking to some database," Keill says. "I think it’s valuable to see how you compare; otherwise, if you’re just looking at yourself, how do you know how you’re doing?"
[For more information, contact Ralph Keill, MD, assistant administrator and medical director, Salinas Valley Hospital, 450 E. Romie Lane, Salinas, CA 93901. Telephone: (408) 755-0798.]
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