Multidisciplinary plan wows Joint Commission
System pushes teamwork, improves outcomes
Although the original goal of the Catholic Medical Center of Brooklyn and Queens' multidisciplinary care plan (MCP) was to improve collaboration, efficiency, and patient outcomes, it resulted this year in rave reviews and accreditation with commendation from the Joint Commission on Accreditation of Healthcare Organizations.
The MCP combines documentation-by-exception tools with daily patient bed rounds. It was piloted in October 1993 in the medical services department at St. Joseph's Hospital in Flushing, NY, and later applied hospitalwide in all four acute care facilities of the Catholic Medical Center. It is a documentation, assessment, discharge planning, and patient education tool all rolled into one 28-page booklet.
The booklet incorporates a critical path and is used by staff daily in rounds by a multidisciplinary team in each hospital unit, says Jacquelyn R. Paynter, MPH, professional services administrator at St. Joseph's and chairwoman of the Catholic Medical Center's patient assessment master team, the systemwide steering committee for the MCP.
Included in each unit's multidisciplinary team are medical staff and nursing representatives, a pharmacist, a nutritionist, a social worker, a physical therapist, a utilization review case manager, a quality improvement planner, and an administrator. The booklet, similar in format to a critical pathway, contains columns under each day for interventions and treatments by members of the multidisciplinary team. It also provides space for each department's recommendations and treatments for up to eight days of hospitalization.
The booklet includes assessments from each discipline, the expected patient outcomes, a record on the patient's progress, and columns to identify variances from the critical path and the expected outcomes, Paynter says. Additional booklets are added for longer patient stays. Each day, the team goes to each patient's bedside, examines the booklet, which is kept with the patient's chart, and discusses what's going on with the patient. The rounds take about a half-hour per unit, which at full capacity covers 25 to 30 patients.
"Every day, we have a team on the unit that looks at how long the patient has been in the hospital, what's being done for them, and what variances are, meaning what issues need to be addressed and what outcomes we're not meeting. We talk about what we're going to do about the variances, who is going to take on what responsibilities, and every day we look at it and go over it until it's fixed," Paynter says.
Joint Commission takes notice
The MCP was not specifically designed to win praise from the Joint Commission, but it did get the surveyor's attention, says Katie Dolan, MBA, former executive director of St. Joseph's and current director of planning for the Daughters of Charity National Health System's East-Central Region in Evansville, IN.
"The nurse surveyor and the physician surveyor spent almost all their time talking to staff members," Dolan says. "What I suspect impressed them was that staff members knew what the other staff members were doing. When the pharmacist was asked what the dietitian was doing, the pharmacist knew the answer."
Paynter agrees. "During the survey, when the surveyors wanted to look at patient care delivery, we pulled in, at their request, our multidisciplinary team. What the surveyor saw was a working team, working together. They were able to describe their collaboration as it related to the commission's functional standards. They were able to talk about patient rights and continuity of care. This was a team that met every day and talked every day about the variances from expected intervention and outcomes, and they were able to discuss these things with the surveyor."
The teams at all four Catholic Medical Center hospitals were involved in the survey, Paynter notes.
St. Joseph's highlighted the MCP to surveyors during a continuous quality improvement presentation, Dolan says.
"During the survey, there was time devoted to letting individual institutions highlight their accomplishments," Dolan says. "For St. Joseph's, we highlighted our guest relations program and the MCP. With the MCP, we showed the surveyors what specific outcomes came from it." Those outcomes, as of the survey in March 1995, included:
* an overall decrease in the length of stay by 3.5 days, from 12.5 days to under nine days;
* a 40% decrease in nosocomial infections;
* a 70% decrease in patient complaints.
"I think the surveyors were impressed that we got significant changes in outcomes in a relatively short period of time," Dolan says. The MCP had been in place throughout the Catholic Medical Center for about a year before the Joint Commission survey.
The patient satisfaction outcome, measured through a telephone survey done by Picker/ Commonwealth in Boston, also helped in meeting Joint Commission continuum-of-care standards, Dolan says.
When patients were asked whether a doctor or a nurse gave conflicting information, overwhelmingly, patients said no. "And when they were asked whether a test or a treatment was delayed because people were not communicating to each other, they also answered no," Dolan says. "That is attributable to the MCP."
Results -- not theory -- count
The Joint Commission does require a multidisciplinary or interdisciplinary care plan be in place for patients, but it does not mandate the specific form such plans must take, says Richard Scalenghe, RMT, associate director of the department of standards at the Joint Commission. When reviewing such plans, surveyors are interested in performance, not paperwork, Scalenghe adds.
Although he refused to comment on specifics of Catholic Medical Center's survey, he did say the Joint Commission looks for the following when it conducts a review:
* the goals and objectives of the multidisciplinary plans;
* whether those goals and objectives are measurable;
* whether the care plan is truly individualized for the patient;
* whether it guides the staff in care delivery;
* whether it facilitates coordination of care.
So, how important is a multidisciplinary care plan in an accreditation survey? "Probably in the top 20 things we take a look at," Scalenghe says. "When we interview staff and observe what's going on in the unit, and when we interview patients, we're looking for a sense that care is planned and coordinated."
If the hospital looks good on paper, but surveyors get a different story when they are on the unit, that may throw into question how well the facility is implementing its plan. "If I see you're doing a great job in paperwork, and then we go into the unit and see there are some major problems with coordination of care that perhaps would have put patient at risk, then you do have a major problem," Scalenghe says.
In addition to awarding the system accreditation with commendation, one surveyor verbally complimented the MCP during the exit interview. Dolan and Paynter say the positive response from the Joint Commission has had a strong impact on the system, including:
* Validation of the MCP.
"We were getting a sense from pieces of the medical staff that yes, this was the right way to go, and yes, this is a good way to approach patient care, but it wasn't uniform," says Dolan, "Having these positive survey comments definitely made it easier to work with people who were not yet on board," she says.
* Receipt of a $35,000 grant.
Dolan says the MCP's successful outcomes, coupled with the Joint Commission's favorable review, helped Catholic Medical Center win a $35,000 grant from the New York-based United Hospital Fund for developing such plans for ambulatory care patients.
* Good public and interhospital relations.
Paynter says the Catholic Medical Center has received dozens of calls from hospitals interested in the MCP and wanting to learn more about it. She has responded by sending out copies of the plan and inviting hospital officials to join the daily MCP team rounds. *
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