Clinical Process Improvement Research Articles

Clinical process improvement: reduction of pneumothorax and mortality in high-risk preterm infants.

To develop multidisciplinary clinical process improvement methods using evidence-based medicine to decrease the incidence of pneumothorax in a NICU. All inborn infants <28 weeks' gestation (n=79) served as the historical baseline group. A prospective protocol, using evidence-based medicine and a rapid-cycle, multidisciplinary clinical process improvement method, was designed to measure changes in the incidence of pneumothorax in subsequent infants of similar gestational ages. Sixty consecutive inborn infants <28 weeks' gestational age comprised the study group. In comparison to the historical control group, there was a significant reduction in the incidence of pneumothorax (from 26.6% to 10%, p=0.018) and in mortality (36.7% to 15%, p=0.007) without adversely affecting any other measured outcome variable. Introduction of multidisciplinary clinical process improvement methods can significantly decrease the incidence of adverse outcomes in neonatal intensive care units.

An anticoagulation pathway for quality management

p ERIOPERATIVE ANTICOAGULATION REQUIREMENTS increase the complexity of managing surgical patients. Postponement of surgery, a preoperative admission, increase in postoperative length of stay (LOS) for dosage titration, or development of postoperative complications can occur in the surgical patient requiring anticoagulation. Significant increases in cost, patient safety, and delays in patients returning to their prior preoperative functional baseline can result. Although outpatient warfarin (Coumadin) management and algorithms have been available for a long time (Vadher, Patterson, & Leaning, 1995; Wenger, 1996; Wilt, Gums, Osman, & Moore, 1995), they do not easily translate to the inpatient setting where hospitalization and invasive interventions create dosing interruptions. An ultimate solution to this problem, after two studies, was the creation of an pathway. This pathway addresses the anticoagulation process for both hepafin and Coumadin guiding practice from preintervention through discharge. The studies described in this article were conducted as part of the medical center's clinical process improvement program for quality improvement purposes and were deemed exempt from informed consent by the medical center's Institutional Board of Research Associates (IRBA). The information was recorded in a manner such that subjects could not be identified and was used solely to create a clinical pathway to improve the quality of patient care. BACKGROUND

Financial Incentives for Ambulatory Care Performance Improvement

Measuring and improving the quality of care while curtailing costs are essential objectives in capitated care. As patient care moves from the hospital to outpatient settings, quality management resources must be shifted to ambulatory care process improvement. The Quality Improvement and Efficiency Financial Incentives Program at Stanford University Medical Center was adopted to increase quality improvement efforts and contain costs. THE INCENTIVE PROGRAM: Each department's budget for care of capitated patients was reduced by 5% from the previous year. Return of a reserve fund (10% of payments for specialty care) required completion of substantive quality improvement projects and containing costs. Successful departments were also eligible for bonus funds. Implementation strategies included endorsement by clinical leaders, physician education, use of administrative data to identify project topics and support measurement of quality and cost variables, project templates and time lines, and the availability of clinical quality managers with special expertise in clinical process improvement. Eight of 13 clinical departments developed and implemented 19 ambulatory quality improvement projects to varying degrees. Success in the program was roughly correlated with the potential impact of the incentive on revenues and the status of the lead person selected by the department to spearhead their efforts. Only 5 departments achieved their cost containment goals. Financial incentives are one method of encouraging physicians to use clinical process improvement methods. Endorsement by clinical leaders and selection of realistic beginning projects enhance chances for success. The capitated population has attributes that make it an attractive focus for initial quality improvement efforts.

Clinical Process Improvement As a Means of Facilitating Health Care System Integration

In recent years many health care providers, physicians, hospitals, and managed care organizations have undergone significant reorganization in both delivery and financing systems. This has created new organizations called integrated or organized delivery systems. Sentara Health System (Norfolk, Va), one of these new integrated entities, developed a unified strategy for clinical process improvement for the entire organization. This system-wide approach had unanticipated problems and benefits. The Sentara Health System created a team responsible for coordinating clinical process improvement activities across its hospitals and ambulatory physician sites. A steering committee directed this team to improve the organization and delivery of care for specific high-cost, high-volume, or problem-prone disease for physicians to manage. A standardized approach aimed at coordinating care across sites was the cornerstone of these activities. Significant improvements in patient outcomes and a concomitant decrease in costs of care were accomplished for multiple diseases and procedures. These projects uncovered unanticipated barriers to implementing improvement projects in a complex health care system which make implementing these activities far more difficult than for an individual hospital with its medical staff. Coordinating clinical improvement activities across multiple hospitals and other sites of care in a complex integrated delivery system serves important purposes in addition to improving patient care. These projects were an important cultural change agent to transform the individual components of the system into one that is capable of delivering care continuously across multiple sites. Standardization of care practices, policies, and procedures is considerably enhanced by coordinating these activities across the entire system.

A method to the madness in the treatment of asthma

B etter asthma management as a result of clinical process improvement was one of the many topics discussed during The Second Annual Disease Management Congress, entitled ‘Outcomes Measurement & Quality Improvement’ [ California, US; February 1998 ]. Dr Sally Wenzel from National Jewish Medical and Research Center, Denver, US, described a case study of management methodologies for patients with severe asthma at National Jewish, and described outcomes information on patient functional status and quality of care delivered. During the same session, Dr Samy Suissa from McGill University, Montreal, Canada, discussed how to use databases to monitor the quality of asthma care delivered to a large population in Canada.

The role of strategic alliances in ensuring health care quality: a health care system perspective

The Chronic Illness Management Research and Development Project (CIMRDP) was created as part of an effort to implement clinical process improvements in HealthSystems Minnesota, a vertically integrated care system in Minneapolis. CIMRDP's objective is to introduce sustainable improvements in the management of chronic illness. These types of quality improvement efforts require fundamental change at the organizational level, which often does not occur, and the programs do not continue beyond the initial stage. Using CIMRDP as a model for a sustainable chronic illness management program, this paper explores the process of implementing clinical guidelines for the management of chronic illness and contending with the complex problem of initiating change at an organizational level. It reviews factors critical to the success of such a program, including the use of focus groups to ensure a patient-centered approach, the advantage of hiring an outside consultant, the question of whether to accept external funding, and an evaluation outline of the six main tasks the program requires. Methods for marketing and integration are also presented.

An industrial process view of information delivery to support clinical decision making: implications for systems design and process measures.

Clinical decision making is driven by information in the form of patient data and clinical knowledge. Currently prevalent systems used to store and retrieve this information have high failure rates, which can be traced to well-established system constraints. The authors use an industrial process model of clinical decision making to expose the role of these constraints in increasing variability in the delivery of relevant clinical knowledge and patient data to decision-making clinicians. When combined with nonmodifiable human cognitive and memory constraints, this variability in information delivery is largely responsible for the high variability of decision outcomes. The model also highlights the supply characteristics of information, a view that supports the application of industrial inventory management concepts to clinical decision support. Finally, the clinical decision support literature is examined from a process-improvement perspective with a focus on decision process components related to information retrieval. Considerable knowledge gaps exist related to clinical decision support process measurement and improvement.

The barriers to electronic medical record systems and how to overcome them.

Institutions all want electronic medical record (EMR) systems. They want them to solve their record movement problems, to improve the quality and coherence of the care process, to automate guidelines and care pathways to assist clinical research, outcomes management, and process improvement. EMRs are very difficult to construct because the existing electronic data sources, e.g., laboratory systems, pharmacy systems, and physician dictation systems, reside on many isolated islands with differing structures, differing levels of granularity, and different code systems. To accelerate EMR deployment we need to focus on the interfaces instead of the EMR system. We have the interface solutions in the form of standards: IP, HL7/ASTM, DICOM, LOINC, SNOMED, and others developed by the medical informatics community. We just have to embrace them. One remaining problem is the efficient capture of physician information in a coded form. Research is still needed to solve this last problem.

Clinical process improvement: engage first, measure later.

The Institute for Clinical Systems Integration (ICSI) is a non-profit quality improvement organization that bridges 20 medical groups and integrated health care systems in the Minneapolis-St. Paul area. Created in 1992 by HealthPartners, HealthSystem Minnesota, and Mayo Clinic as a part of a contract awarded by the Buyers Health Care Action Group, a purchaser coalition, ICSI's aim is collaborative, continual improvement of the clinical care provided by its member institutions. ICSI's main focus is health care guideline developement and implementation. This article describes this process, as well as evidence of program effectiveness and "lessons learned."

Collaborative development of a clinical pathway for congestive heart failure.

Bon Secours Hospital, a 304-bed community hospital in Grosse Pointe, MI, decided to target high-volume and high-cost DRGs for clinical process improvement. Working collaboratively with members of the medical staff, the cardiac team set out to improve outcomes by reducing the non-value-added costs and the variations in the treatment of patients with congestive heart failure (CHF). A comprehensive program of care for these patients, that included the full continuum of care, from prevention to maintenance, is being developed, using a clinical pathway to manage the acute phase of treatment.

Nursing home-acquired pneumonia: outcomes from a clinical process improvement program.

At EHS Christ Hospital and Medical Center, an eight-step process improvement model was developed that incorporates continuous quality improvement concepts for monitoring, evaluating and improving patient care. Nursing home residents admitted with pneumonia were identified as the group having the most influence on mortality and costs associated with treatment of pneumonia at our hospital. A multidisciplinary team evaluated clinical resource use and patient care processes, and identified root causes of various influencing treatment. Clinical guidelines were created and outcomes were defined, resulting in significant improvement in the clinical management of these patients. Average length of stay decreased from 8.6 days in 1992 to 7.6 days in 1993, with a charge reduction of $1830 per patient. The methodologic framework of a process improvement program combines epidemiologic, clinical, and quality improvement sciences. This mix is essential in improving patient care and quantifying outcomes.