Hospital uses scan form to integrate pathways and improve quality
August 1, 2002 11 minutes read
Hospital uses scan form to integrate pathways and improve quality
Pathways focus on phases of care
Three years ago, Memorial Health University Medical Center, a teaching hospital in Savannah, GA, relied primarily on Joint Commission on Accreditation of Healthcare Organizations compliance requirements for its performance improvement priorities. "That was the low bar," says Ray Perigard, Memorial’s management engineer. "We were shooting to meet the minimum standard requirements, and that was not going to get us to where we wanted to be."
As part of a major process improvement effort, the hospital decided to integrate all of its medical staff departments and their performance improvement efforts while at the same time integrating clinical and operational performance improvement into a single set of critical success measures based on outcomes.
According to Perigard, this does not mean that compliance is unimportant. Minimum standard requirements such as risk management, patient safety, physician credentialing, various Joint Commission requirements, corporate compliance, ethics, and medical records as well as other federally and locally mandated requirements for accreditation are still important, he says. "However, they are an adjunct to improvement," he says. "They are not the basis for improvement."
The aim of the clinical pathway program was to involve all functions at all levels, Perigard says. "It was not one person’s job or one group’s job," he says. "It was all functions involved in the care of the patient at all levels."
Memorial also wanted to integrate physician-driven improvements with its operational improvements. "We have trouble getting everything aligned," Perigard says. The aim was to shift the focus from department-level improvements that were not integrated or coordinated to improved clinical outcomes based on patient-focused improvements that ultimately would drive department-level improvements as well as operational improvements, he says.
According to Perigard, one of the roadblocks Memorial faced was that it was focused on compliance. "Our performance improvement was focused on meeting the minimum standards, not improving care," he says. "All of our performance improvement activities were isolated individual departmental goals not necessarily supporting an overall direction."
At the time, each operational department had a performance improvement analyst who helped the department analyze what was taking place and develop performance improvement opportunities that fed into the quality management department, he says.
In addition, each clinical medical staff department had a performance improvement committee focused primarily on peer-review activities and morbidity and mortality analysis feeding back to the quality management department. However, there was no integration or communication between the two. "They functioned separately," he says.
According to Perigard, clinical outcomes information and collaborative teams were considered essential for improvement. "We needed to put groups of people together who were taking care of these patients and decide the best way to do that," he says. "We also had to have a way to communicate back to the physicians how they were doing."
One of the functions of his department is to issue physician profiles to all the physicians, Perigard says. Initially, those were limited to cost and length of stay because that was all the information the hospital possessed. For the most part, however, physicians did not respond well to information about cost, he says.
Instead, Memorial wanted to incorporate outcomes data. Unlike indicators of cost, when physicians learn that only 30% of their patients are walking on Day Three compared to 70% of patients for all the other physicians in the hospital, that immediately gets their attention, Perigard says. "We wanted to have a system that could collect the right information, feed it to the right people, and be used to improve the way we give care," he says.
Perigard’s task was to develop a way to gather that information. In the past, Memorial relied on chart review, he says. By the time enough information was collected in a statistically significant format, however, the data were 9 months old.
"Half of the things we wanted to evaluate, there is no way to find in the chart," he says. "We needed a way to capture specific information and be able to use it as quickly as possible."
According to Perigard, the first objective was to create a system that was easy to use. "We could not create a system that was so cumbersome that none of the caregivers would want to even deal with it," he says. "We also had to integrate it with the current documentation system." Otherwise, there would be no compliance.
The system also had to be flexible, Perigard explains, because it included 500 patients, more than 500 DRGs, and numerous disease entities. "We had to be able to collect a broad range of information from a broad range of patients," he says.
Wanted: A comprehensive system
In addition, the system had to be comprehensive. "We did not want something that was only going to collect the 10 most important pieces of information," he says, with the next piece somewhere on the chart. "We wanted something that was going to collect everything we needed at the same time."
Finally, the system had to be automated. "Chart review just took too long," Perigard says. "We did not want something where we had a checklist that someone had to enter all the information," he reports.
That would mean hiring a full-time employee to sit in front on the computer all day and transcribe information into a database. "We felt that if we could automate as much of the process as possible, we could spend our time using the information rather than generating it," he explains.
Memorial also wanted to create a system that was compatible with the future of the hospital’s clinical information system, Perigard says. The hospital uses HBOC, and he knew that there were upgrades and changes coming, including a pathway program in just a few years. "We wanted something so that we would not have to reinvent the wheel when it came time to put in the pathway system" he says. "We wanted something that was immediately integrated."
Memorial implements scan forms
Memorial ultimately decided to use a scan form that came from a piece of software called TeleForm, Perigard says. The software designs a scan form and puts the information wherever the user wants to put it. "It is all-inclusive and does all the work for you in terms of processing the information," he says. "One of the reasons we chose it is that it has a completely flexible layout."
Many scanning software products are available, he notes. But some of them require the user to use their forms, he says. "They have pre-printed forms, and you type in the information," he says. "You are limited to their layout." Perigard says the cost of those forms would have totaled $50,000 a year.
Memorial also wanted a program that used standard paper, he says. "This system used standard copy paper right out of the box and could be set up landscape or portrait and could be photocopied." Master copies are maintained in the administration office, which is open 24 hours a day. "We have a wall with nothing but pathways on it," he says. "They keep a supply of all the pathways there."
The form was laid out with demographic information as well as dates and times and the patient’s room number.
One side of the form has all of the desired outcomes selected for that day. In the center of the page is a simple choice between, "Met," "Unmet," or "Not Applicable," Perigard says. "That is all that the caregiver has to select," he explains. If the outcome was unmet, there is a space for comments where they explain why it was unmet. The back of the form is for nursing notes.
"This pathway and all of its pieces for that given disease entity become the interdisciplinary plan of care for the patient," Perigard says. "It is a permanent part of the medical record."
Perigard points to a sample from Memorial’s open-heart surgery pathway. Each part of the pathway is set up with several different categories for outcomes such as progression, assessment evaluation, diagnostics, treatments, medications, diet, consults, and other case management concerns.
Some additional information, such as what tests have been done, also are included in order to track what is being monitored vs. the outcomes, Perigard reports.
"In this case, we are looking at how quickly the patient was excavated following surgery because we identified that as something critical to quick progression," he says.
The form also allows staff to view what type of antibiotics or pain medication the patient is on and then relate that back to whether the pain is controlled. "We can interrelate all the items on the page to each other," he says.
Karen Watts, RN, MSN, outcomes management specialist at Memorial, says the hospital used Care Maps prior to implementing clinical pathways. She says those large foldout sheets were really "task lists" that staff would have to copy every 24 or 48 hours. They mainly contained basic nursing information rather than best practice information.
"It was supposed to be multidisciplinary, but it was not," she reports. "It was just done because they needed a plan of care of some type."
Each of Memorial’s current pathways is divided into critical time periods called "phases of care," Perigard says. Almost every inpatient pathway is one day per page. However, early in the stay, there may be one for pre-op, one for the operating room, and another for the recovery unit. "We divide it into those phases of care," he says.
For example, for stroke patients, there is one page for the first 30 minutes the patient is in the emergency department because so much is needed in the first 30 minutes, Perigard says. There is another page for the remainder of time spent in the emergency department. "It is very specific to the type of disease," he says.
The caregivers complete their pathway evaluation form for each designated day or phase, he explains. All pages stay together, are combined, and then are put in the medical record. Once the patient is discharged, the medical record goes to the medical record department. When the chart assemblers come across the pathway, they pull it out of the chart and put it on a copier, which is hooked into Memorial’s local area network.
Instead of transferring that image to a piece of paper, it transfers the image through the network to a computer in Perigard’s department. TeleForm reads that image, pulls the data out of the image and immediately puts them into an ACCESS database, he says.
The TeleForm software processes and scans the database each night, and a data analyst verifies the data every morning.
Verifying the data takes about an hour a day, he says. "We process about 500 pages a day because there is one page per patient per day," he says. "It takes about an hour every day to make the corrections necessary to get the data in the database."
Within 24 hours of discharge, Perigard says, he has all of the outcomes required. "I can put out a report tomorrow on all the patients from yesterday and how their outcomes were met," he says. "That gives us the ability to look at the data on an ongoing basis."
Eventually, Memorial would like to have the data available live so that case managers can determine what the objectives were for their patients the day before, Perigard says. "We are not quite there yet."
Memorial has one database for each disease entity, such as a cardiac database and an orthopedic database. "At first, we had them all in one database," he reports. "The database was just too big and grew too quickly to manage."
Each form and field is uniquely identifiable, Perigard adds. Because of that, he can go back and interrelate pain medication to whether or not the pain outcomes were met on the same day or look at pain or ambulation across a continuum. By using the patient ID field, Perigard is able to look at the financial impact of meeting outcomes vs. not meeting outcomes, he points out.
Memorial now has 40 to 45 pathways, Watts reports. While she plans to develop a few more pathways, going much above that number will become unwieldy. The hospital also has generic pathways where it does not have case specific pathways.
Specifically, the hospital has a generic surgery and a generic medicine pathway for adults and for pediatrics, she points out.
Memorial also has two clinical programs and five collaborative teams that are part of the pathway. "I don’t have teams for every pathway," she adds. "Some things I can do without a team."
Watts says she also avoids meetings for the sake of meeting. "I don’t think much comes out of them," she contends.
Team meetings take place quarterly and are focused on data and potential actions, according to Watts. "There must be some action, or we are not going to meet," she says. When meetings do take place, they usually focus on high-volume, high-risk conditions that raise issues such as length of stay, cost, or outcomes, she adds.
Watts says she prefers a programmatic approach to employing pathways. Two examples of that are Memorial’s stroke program and joint replacement program. Part of the latter program includes bringing patients in preoperatively to educate them about pain and mobility.
Performance improvement reports
Memorial also uses performance improvement reports that it issues to specific units. For example, units such as respiratory therapy, pharmacy, and other departments would receive a report on heart patients that included extubation times. The target was to have 75% of those patients extubated within four to six hours, Watts says. In December, roughly 54% reached that target. For the year, that number was 28%. "Obviously, we are making a lot of progress," she says.
Watts also correlates various indicators on the pathway. During the four weeks she spent implementing the pathway for coronary artery bypass graft and watching the progression of these patients, she saw that they were not ambulating enough and their diets were not progressing fast enough.
Watts says she found that you may have to alter the staffing model because the area where heart patients go is staffed only with RNs but no nursing assistants or others to walk these patients. Mobilization is tracked using a report on daily ambulation out of bed and daily ambulation in the hall.
"I want to make sure staff are steadily progressing their mobility their mobility, as an important indicator," she explains.
Another example Watts points to are cesarean patients. "We focused on C-section or vaginal deliveries because we have an extremely high length of stay," she says. One of the things her staff found is that pain was not managed consistently, and diet and ambulation suffered as a result, she reports.
To correct that, anesthesia was encouraged to prescribe Duramorph to help control pain, then pull the epidermal catheter, Watts says.
"That would hold the pain for six to 12 hours, and then they would start on a Toradol protocol to control any breakthrough pains," she says. That improved alertness, diet, and ambulation, she reports.
While teams are much more interested in patient outcomes, Watts says her department also must focus on costs. There will be many competing priorities among departments, but when the results are there, it is difficult to argue against recommended changes in care, she adds.
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