Best practices and benchmarking in healthcare : a practical journal for clinical and management application最新文献

Background: Physicians need prompt results of laboratory tests before early morning rounds or on a stat basis to support time-critical decisions that can impact patient care or length of stay. At The Methodist Hospital, we formed a multidisciplinary performance improvement team that was successful in reducing the length of time between collection of specimen and availability of laboratory test results (turnaround time). Our goals were to have Stat results available in less than 60 minutes, and results for morning blood tests available by 8 AM for acute care units and 7 AM for critical care units.

Methods: Before making changes, we first devised a system of measurement. The most efficient way to obtain data was to query the mainframe laboratory information system for times of specimen collection, times for reception in the laboratory, and times for results verification. We also decided that patient-specific information on specimens that did not meet the goals-exceptions-would be crucial for effective follow-up and corrective action. During several measurement and assessment cycles, we identified opportunities to improve our process.

Results: The percentage of early morning specimens meeting the specified turnaround time improved from 60% in August 1995, to greater than 90% in May 1996. The average turnaround time for early morning specimens takes only 95 minutes rather than 186 minutes. The average turnaround time for a stat specimen declined from 69 minutes to 45 minutes during this process. The volume of stat specimens has also declined significantly.

Conclusion: Laboratory test results turnaround time is impacted by a variety of health-care providers, and a multidisciplinary team can work together to improve prompt availability of test results to support time-critical decisions.

The home medical equipment services industry has started to participate in outcomes measurement and benchmarking. As a result, the industry now will be able to capture and to compare treatment, performance, and outcome data to make informed decisions about the benefit and the value of various options to treat illness or to maintain wellness in the home setting.

In its recent reengineering efforts, the Mount Sinai Hospital developed economic tools to assure that this major restructuring project would reach its predetermined financial objectives. We discuss how these tools were designed and implemented and what impact they had.

Background: As part of a large multidisciplinary project to reduce cost, decrease hospital length of stay, and improve efficiency of patient care at Saint Mary's Hospital, a clinical pathway for pneumonia was developed and implemented.

Methods: After using analysis of severity-adjusted data to determine which conditions would be best targets for improvement, a utilization management steering committee created a multidisciplinary group to develop a clinical pathway for pneumonia. This group was led by physician champions and consisted of representatives from nursing, respiratory therapy, pharmacy, and home healthcare. With information gained from chart abstraction, which identified "best practice" patterns, guidance from the medical literature, and local expertise, this group developed a clinical pathway that included an auxiliary protocol for respiratory care and a detailed educational brochure for patients. Before implementing the clinical pathway, extensive educational activities were undertaken involving the medical staff, house staff, nurses, and other staff. Data collected on consecutive patients discharged after implementation of the pathway were compared with data collected on patients discharged before the pathway in 1994.

Results: For DRG 89, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.45 days (5.84 vs. 7.29 days) and a lower average total charge by $1,453 ($9,511 vs. $10,964). For DRG 90, the patients who were on the pathway in comparison to the control patients from 1994 had a lower average length of stay by 1.83 days (3.45 vs. 5.28 days) and a lower average total charge by $1319 ($5450 vs. $6769).

Conclusions: The pneumonia clinical pathway that was implemented was associated with reductions in the length of stay and total charges. These reductions were seen in relationship to historical controls and to patients cared for concurrently who were not placed on the pathway. Although not fully used on all pneumonia patients, the presence of the pathway probably had some positive effects even on patients not formally on the pathway, through systems changes and educational influences. The pathway also positively influenced other conditions by the use of ancillary algorithms for conditions other than pneumonia, and the more rapid administration of antibiotics for other infectious diseases. Also, lessons learned in the creation of this first pathway have been helpful in streamlining the process of future pathway development.

Managed care challenges physicians to learn to collaborate with healthcare executives to achieve cost containment while enhancing quality of patient care. This report describes specific steps to successful working relationships between physicians and healthcare executives. "Learning the culture," recognizing differences, offering assistance, taking steps toward closer collaboration, and avoiding pitfalls are interpersonal skills and behaviors that allow physicians to become part of the decision process in a managed care environment.

Background: We evaluated a new psychological test (Paindex) for identifying and quantifying psychological factors associated with poor surgical outcome, and predicting the degree of pain relief and return to work.

Method: This test was administered to 120 randomly selected patients before carpal tunnel and laminectomy surgeries.

Results: This test correctly predicted the probability of pain relief and return to work in 46 of the 50 laminectomy patients (92%), and 63 of the 70 carpal tunnel patients (90%). The overall test sensitivity was 86% and the specificity 94%.

Conclusion: These findings indicate that this can be a useful adjunctive test for identifying psychological problems that could have a bearing on the decision to operate and then problems that could occur after surgery, particularly in cases where the extent and degree of pain and disability are judged to be considerably in excess of the objective medical findings.

In mid 1993, administrators and physicians at Bristol Medical Center teams up with HCIA to perform clinical pathway analysis on five diagnosis related groups. The major goal of this project was to establish a partnership between the hospital administration and the medical staff to meet or beat existing benchmarks.

Background: Forty-six academic health centers (AHCs) belonging to the University HealthSystem consortium joined forces to compare the efficiency of their surgical services and to identify best practices. In addition to measures of operational performance, surgeon satisfaction with the surgical services provided was measured by using a standardized questionnaire.

Methods: From hospital records, indicators of the efficiency of surgical services were collected in three main areas: scheduling, preoperative testing and assessment, and the intraoperative process. Responding to a mail questionnaire, a sample of surgeons rated their satisfaction with key aspects of surgical services including scheduling, operating room staff, and equipment/supplies. On the basis of a review of the operational measures and the survey results, high performers were identified. Site visits were made to several of these high performers to uncover the critical factors responsible for their success.

Results: The survey revealed distinct variations in surgeon satisfaction across the participating institutions. Numerical benchmarks were obtained for surgeon satisfaction with each key component of surgical services. Scheduling was the most important component of overall surgeon satisfaction, explaining 71% of the variance in the rating of overall satisfaction with surgical services. High operational efficiency and high surgeon satisfaction were not incompatible. Several of the participating institutions were able to achieve both. These results were disseminated to all of the participants at a national meeting as well as in written form.

Conclusions: The surgeon satisfaction survey allowed the participants to establish benchmarks for surgeon satisfaction for each key component of the surgical services they receive. The site visits revealed several common characteristics of highly efficient surgical services. Taken by themselves, the participating institutions might have been reluctant to consider adopting these best practices for fear of alienating the surgical staff. The availability of data on surgeon satisfaction showed the participants that these best practices can coexist with high levels of surgeon satisfaction. This has helped to promote their adoption by the other participating institutions.

Background: Statistical methods and software can be useful for evaluating clinical outcomes data.

Method: The use of control charts and regression analysis can be particularly helpful in outcomes assessment. Control charts can reveal outlier events and patterns that require additional review leading to changes that improve outcomes. Regression analysis can show factors that affect process characteristics. This article uses examples derived from hospital outcomes assessment activities relating to length of stay, treatment planning, insurance coverage, patient characteristics, and clinical decision making.

Results: Minitab statistical software is used to create control charts and perform regression analysis, and essential Minitab commands are explained.

Conclusion: Through the use of the techniques described the clinical and manager can more effectively evaluate clinical outcomes data to improve healthcare quality.

The National Chronic Care Consortium developed the SASI tool to help health-care networks plan, implement, and measure chronic care integration across their full continuums of care. An integrated network for chronic care can be applied to any care population, and the SASI tool can assist in integration efforts in a variety of circumstances.