Take those clinical guidelines off the shelf
Improvement plans not academic exercises
It's a scenario that hospital quality planners and administrators know too well: After months of quality improvement data collection, meetings, and plan writing, a new clinical guideline ends up collecting dust, ignored even by staff who invested time and energy in its development.
The key to success clearly lies in defining the issues to be addressed by the process improvement plan, recognizing what obstacles there may be, and taking steps to overcome those obstacles, says Diana Barrett, DBA, MBA, MS, lecturer in management at the Harvard University School of Public Health and partner in the Crimson Group, a provider of specialized education programs for health care organizations, both in Cambridge, MA.
"The problem is that people put these guidelines out there, and they simply assume they're being used. They never really figure out what the issues are they want to address and what the obstacles are to implementation," she says.
Barrett and Jane Roessner, PhD, a research and writing consultant with the Harvard School of Public Health, looked at clinical processes in a variety of hospitals across the country. They wanted to determine how quality improvement panels can ensure their clinical process plans are used and see what lessons could be learned from the providers' experiences. What they found, Barrett says, is that improvement processes must address all of the following issues:
* financial incentives;
* providers' expectations;
* patient education and acceptance;
* human resources and staffing.
For example, one hospital involved in a managed care contract wanted to recommend a clinical process for all its physicians to treat urinary tract infections (UTIs) in women, Barrett says. Originally, UTI patients had to see their physicians, undergo a urinalysis, wait for the results of the test, and finally receive treatment through the physician, usually administration of antibiotics for two or three days. UTIs can be a recurring problem and are easily self-diagnosed by patients who have had such infections previously, Barrett says, but obtaining the antibiotic treatment required several physician visits and a time investment by the patient.
Here's how the new process works: First, the patient contacts the physician's office, and knowing there is a guideline for UTI, the receptionist refers the patient to a nurse practitioner. The nurse practitioner follows a flowchart, and asks the patient questions about the symptoms.
"When it's clear that statistically the chances are high that the patient does have a UTI, because she's had it before and she doesn't fall into any high-risk group, the patient automatically receives a prescription for three days of antibiotics and is told to check in if there is no significant improvement in three days," Barrett says.
While patient acceptance of the new process was high because it provided good treatment promptly, Barrett and Roessner say it did not receive widespread staff acceptance because it failed to do the following:
* Demonstrate consistency with the financial goals of the organization.
"Every time a physician does not see a patient in a fee-for-service system, he does not get money in his pocket," Barrett says. "So, while he can at one level say he knows this guideline is providing better patient care, every time he doesn't see one of these patients, he's losing X amount of dollars." She recommends spelling out any financial incentives for adopting the guideline. (For more on cost issues, see related story, p. 12.)
* Provide consistency with provider expectations, and clarify providers' roles in the new process.
Although nurses were included throughout the UTI process improvement, Barrett says many were unsure of their new role in the patient care process. "Many nurses had a question about what their role really was because, all of a sudden, they thought they were asked to play doctor," she says. The improvement panel "really needed to work with those people and nurture their changing expectations."
Additionally, Roessner says, the financial-incentive question for physicians could have been better managed if the doctors had better understood their role in the new process.
"Doctors really do want the best treatment for their patients," she says. "If they can understand that, in fact, the new process is going to free them up for the kind of patient interventions for which they are really needed, they will have less resistance."
Although a clinical process improvement team may address all the issues, it still can be doomed to failure. Based on their process review, Barrett and Roessner offer the following tips to help ensure good guidelines get used:
* Clearly define the process and compose a team that includes everyone involved in that process.
For example, some physicians do not view the clinical process for hip replacement cases as including post-surgical physical therapy.
"Now we're finding out that if you start working with a patient before surgery and help them understand what physical therapy is all about -- that it is going to be painful -- and give them a vision of what their life will be like after surgery, they will heal faster, get out of the hospital faster, and get into physical therapy better," Barrett says. "So, when you're changing the concept of the process of care, a major pitfall is to see only the issue you are dealing with as the entire episode. Instead, every guideline has to be part of a conveyor belt of care."
Although one hospital did take a broad view of the hip replacement process, defining the process to include care before, during, and after surgery with rehabilitation, Roessner says the guidelines met limited success. "It was the pet project of one orthopedic surgeon who was able to make it work because that's the way he does it," Roessner explains. She says that when it came time for all orthopedic surgeons to handle surgery in the new process, there was resistance because they were not included in its development.
* Avoid mixed messages when charging the team with its work.
One process improvement team tried to limit the number of vendors from which the hospital purchases its hip prostheses, Roessner says.
"They really wanted to control costs, and with good reason," Roessner says. "They were looking at how much these total hip procedures were costing and found one of the big cost factors was the cost of the artificial hip itself. So, what they said when they bought these orthopedic surgeons together was, 'Let's look at these variations and see if we can reduce them.'"
In the end, the team of doctors could not demonstrate why one prosthesis that cost three times as much as another was worth the extra money. "There was a lot of confusion on that team and later resistance because you have doctors feeling bossed around and asking whether the hospital wanted to improve the process or limit the doctors' freedom to choose, which muddied the waters from the beginning," Roessner says.
In this case, if the team had simply been charged with improving the clinical hip replacement process, they probably would have identified the cost issue themselves and worked on solving it, Roessner says.
* Make sure the process improvement team has support, including technical help with data, and a commitment from administration to provide the time needed to do the job.
Roessner says one of the most successful clinical process improvements she and Barrett found involved clinical guidelines for coronary artery bypass grafts. In this case, a doctor read an article about another facility that had extremely short lengths of stay for the procedure and challenged his hospital to do the same.
"It was a grass-roots effort," Roessner says. "This doctor got the team together and included everyone involved in the procedure, and they said, 'If this hospital can get their patients in and out of the hospital in seven days, why can't we?' There was lots of trust and ownership on this team." That attitude, plus strong administrative support, made all the difference, Roessner points out. *
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