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

The scheduling of surgery provides opportunities to orchestrate a wide variety of resources that have a significant impact on both hospitals, physicians, and patients. This article presents the successful development and implementation of a block scheduling system in a large operating room setting. Strategies include process redesign, automation, and physician empowerment to achieve outcomes of improved efficiency, customer satisfaction and physician self-governance.

Our hospital and a nearby multispecialty physician group practice over- came a competitive relationship to become successful partners in meeting the needs of the community.

Simulation modeling provides an efficient means of examining the operation of a system under a variety of alternative conditions. This tool can potentially enhance a benchmarking project by providing a means for evaluating proposed modifications to the system or process under study.

Background: Shawnee Hills, Inc., formally began the transition to critical pathways in January 1996. The goal was to design and implement a service delivery model with clearly defined clinical paths and appropriate and functional technical support systems. No specific goal date for full implementation was designated; however, the intent was to move into the new system in a manner that allowed both consumer and employee participation in the planning process and to accommodate the organization's transition from a fee-for-service to a capitated model of contracting for services. The target date for completion of phase one, research and initial planning, was March 1, 1996. Although there were a number of benefits anticipated in adopting the critical paths method (CPM), the primary rationale was threefold: (1) standardizing the quality of care and treatment, (2) cost containment, and (3) better positioning of the organization for success within a capitated funding environment. A review of the publications indicated that the CPM had proved to be effective in other healthcare fields. In addition, the goals and approaches inherent within the CPM were consistent with the organization's total quality management (TQM) philosophy and operational practices.

Method: By using the approach common to the organization since the adoption of the principles and practices of TQM in early 1992, a team was appointed with the mission of reengineering the clinical services delivery model. Unlike previous instances, however, this team was comprised largely of senior leadership, and two staff members were assigned on a full-time basis. A more detailed review of publications was conducted and, where possible, identification of critical pathways developed within the mental health field in other states were secured. Focus groups were used to address "best" or "preferred" practices for specific populations and age groups. Team members provided an orientation to the process, along with the opportunity to critique proposed pathways and models for service delivery as they were drafted to all employees through participation in ongoing staff development efforts. The center leadership was kept informed and was provided additional opportunities for input through regular presentations to the Quality Council that meets on a weekly basis.

Results: The first phase of the transition, research and initial planning, was completed on March 1, 1996. To date, the team has adopted or developed initial drafts of proposed clinical pathways for frequently occurring diagnoses within adult and child mental health, adult and child substance abuse, and specific to early childhood for the mental retarded or developmentally delayed. A model for clinical pathways was developed incorporating the JCAHO requirements to address assessment, care, and education at the major junctures of service delivery. In addition, the team formulated recommend

Background: Benchmarking is the process used to search for best-in-class, compare results, discover the enablers of superior process performance, and take action to achieve quantum process improvement. It sounds simple, but all too often benchmarking efforts fail. The first obstacle often is failing to understand how work is currently being performed.

Methods: Through linear flow charts, connection charts, and cross-functional flow charts, teams identify each step in a process, see how the people in the process interact, follow the work flow, and label the type of a step. When this is accompanied by supporting documentation, this method provides teams a way to visually see the work flow and know where there are glitches and where things are going well.

Results: Through flow charting, benchmarking teams can understand what they are doing so they know what to look for in a benchmarking partner and how to identify the enablers of a superior performance.

Conclusions: Without flow charting, teams will not get the maximum benefit from benchmarking.

Three common methods of determining optimum pathways and their attendant cost and time requirements will be evaluated. Popular methods used for the development and adaptation of pathways are the use of published guidelines, the creation of pathways within an existing health care system and the use of an automated tool. The cost and time required for each of these methods vary tremendously.

Background: With the advent of managed care, academic medical centers have been challenged to lower costs and to document their claims of high quality outcomes. A successful method to achieve these objectives must not interfere with the academic missions of research and teaching. At M. D. Anderson Cancer Center, we initiated a program that would reduce practice variability and increase quality with a model that was familiar to the faculty.

Methods: Professional staff members were divided into disease site groups that included physicians, nurses, and other allied health staff. Each group developed practice guidelines and Collaborative Care Paths, based on evidence in the publications and on expert opinion. Desired outcomes were prospectively defined during this process. Before implementation, paths and guidelines underwent peer review.

Results: The faculty actively participated in the development and implementation of the program that was viewed as a means of empowerment to deal with managed care. Nearly 1000 patients have been entered on the B8 paths that have been implemented to date.

Conclusion: A physician-driven outcomes management program permits delivery of high quality care and supports outcomes research while decreasing cost in an academic setting.

Background: This investigation outlines an approach for using the physician work relative value units (RVUs) in the Medicare Fee Schedule (MFS) to profile physician clinical activities. These techniques were then used to profile the physician services associated with kidney transplant patients at Emory University System of Health Care.

Methods: All physician services associated with 179 patients who had kidney transplant surgery in 1993 were studied. By using billing data, physician work RVUs were assigned to each service and the results were analyzed by type of service and the hospital department providing the service for physician work RVUs and physician charges.

Results: A mean of 130.4 physician work RVUs were involved in the 179 episodes of care. Surgical services represented 48.7% of the physician work activity in the kidney transplant. Visit and consultative services make up the next highest share with 25.5% of the physician work RVUs, whereas anesthesia makes up 13.3% of physician work RVUs. Physician charges totaled $16,249 for kidney transplants in 1993 dollars. Surgical services accounted for 54.2% of physician charges connected with kidney transplants, whereas visits and consultative services represented 20.6% of physician charges.

Conclusions: Physician work RVUs in the MFS offer a unique and much needed perspective on physician clinical activities. Physician work RVUs are an important new tool for healthcare and researchers and their use needs to be more fully explored and benchmarks developed for all major medical and surgical services.