EVIDENCE-BASED MEDICINE AND HEALTH SYSTEMS LEADERSHIP IMPLEMENTS DISEASE MANAGEMENT GUIDELINES AND REPORTS RESULTS THROUGH A “QUALITY METRIC” August 22 – 25, 2004 Cambridge, MA JCAHO 1999 Ernest A. Codman Award HANYS 2001 & 2004 Pinnacle Award - Honorable Mention Yosef D. Dlugacz, Ph. D. Senior Vice President Copyright © 2004, North Shore – Long. Karen Nelson, R. N. , CPHQ, CPUR Island Jewish Health System Andrea Restifo, R. N. , M. P. A. Vice President Assistant Vice President 0
Objective To define and explain how to implement guidelines based on evidence for all organizations … and why The Challenge To standardize care and change practice across a vast, diverse healthcare System Copyright © North Shore – Long Island Jewish Health System Copyright © 2004, North Shore– Long Island Jewish Health System 1
NORTH SHORE – LONG ISLAND JEWISH HEALTH SYSTEM - HOSPITALS Affiliated Huntington Hospital NSUH at Glen Cove Owned Sponsored NSUH at Syosset System Office Manhattan NSUH - Manhasset NSUH at Plainview Long Island Jewish Med. Ctr. NSUH at Forest Hills Statue of Liberty Southside Hospital Franklin Hospital Med. Ctr. SIUH (Concord) SIUH (North) Eastern Long Island Hosp. SIUH (South) Peninsula Hospital Central Suffolk Hosp. 201. 17 km. Southampton Hosp. 2002 Total Population = 5 Million Copyright © 2004, North Shore – Long Island Jewish Health System 2
Creating Consistent Care Across…. § 5, 670 Hospital & Nursing Home Beds • 3 Tertiary Care Hospitals • 2 Specialty Care Hospitals • 13 Community Hospitals • 4 Long-Term Care Facilities • 1 Children’s Hospital • 1 Psychiatric Hospital • 3 Regional Trauma Centers • 3 Area Trauma Centers • 1 Burn Center § 7 Home Health Agencies § Research Institute § Core Laboratory § Center for Emergency Services Copyright © 2004, North Shore – Long Island Jewish Health System 3
Educating Staff § 32, 000 Employees (largest employer in region) • § 7, 000 Nursing Professionals 7, 000 Active Physicians & Dentists • 800 Full-time § 6, 000 Volunteers & Auxiliary § 1, 200 Residents & Fellows in 89 Accredited Programs § 1, 300 Medical Student Rotations Copyright © 2004, North Shore – Long Island Jewish Health System 4
Evidence-Based Medicine Education Medical Staff Defining the standard of care (CMS) Nursing Changing practice and enhancing competency (Magnet designation) Resident/Fellows Didactic sessions, field experience and projects * Quality Mgmt. Directors Communicating data-driven information. * Clinical Task Forces Developing guidelines Identifying best practices “A Critical Literature Appraisal of Care Pathways and Structured Order Sets in Internal Medicine” Copyright © 2004, North Shore – Long Island Jewish Health System 5
A Critical Literature Appraisal of Care Pathways and Structured Order Sets in Internal Medicine Source: Edward Wu, M. D. Quality Management Rotation Copyright © 2004, North Shore – Long Island Jewish Health System 6
A Critical Literature Appraisal of Care Pathways and Structured Order Sets in Internal Medicine § More randomized controlled studies need to be done particularly studying the incremental effect of structured order sets § Studies are needed which include more education of the care pathway § Order sets are on the horizon and have yet to be studied in detail Source: Edward Wu, M. D. Quality Mgmt. Rotation Copyright © 2004, North Shore – Long Island Jewish Health System 7
Education Across Quality Continuum for Management All Employees Methodologies ü Value of data ü Understanding the variation ü Importance of documentation Trustees Senior Management Managers (480) New Employees Enrichment Courses Copyright © 2004, North Shore – Long Island Jewish Health System 8
Leadership Values Quality Copyright © 2004, North Shore – Long Island Jewish Health System 9
Consistent Quality Patient Care Objective: To become the leader in providing quality healthcare which can be defined and measured. Strategies: ¨ ¨ Create a culture of safety and quality at the bedside. Promote utilization of Care. Maps® as we embrace evidence-based medicine. Focus on processes. Educate future generations of medical and nursing professionals on quality principles. Copyright © 2004, North Shore – Long Island Jewish Health System 10
Top Medical DRGs Jan 2003 -Dec 2003 DRG# Description AVG Evidence-Based Cases L O S Pathway 143 Chest Pain 6, 354 1. 9 127 Heart Failure & Shock 4, 606 6. 3 4, 303 7. 1 183 Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders 3, 662 2. 45 088 Chronic Obstructive Pulmonary Disease 2, 981 6. 1 089 Simple Pneumonia and Pleurisy (Age >17 w/ CC) (excludes: OB/GYN, psych, & rehab) Copyright © 2004, North Shore – Long Island Jewish Health System 11
Top Surgical DRGs Jan 2003 -Dec 2003 Cases AVG LOS Evidence-Based Pathway Percutaneous Cardiovascular Procedures 4, 716 1. 7 209 Joint and Limb Reattachment Procedures of Lower Extremity 2, 772 5. 3 148 Major Small and Large Bowel Procedures w/ CC 1, 572 13. 1 494 Laparoscopic Cholecystectomy w/o C. D. E. w/o CC 1, 424 2. 4 288 O. R. Procedures for Obesity 1, 255 2. 8 DRG# 527 / 517 Description (excludes: OB/GYN population) Copyright © 2004, North Shore – Long Island Jewish Health System 12
Who Wants Evidence-Based Medicine? External Groups Internal Groups § JCAHO § CMS § NPSF § NQF § AHA § Advocacy (Leapfrog) § Nursing- communication § Quality Management – develop measures to define performance and opportunities for improvement and communication § Utilization/Case Management - Care. Map® Copyright © 2004, North Shore – Long Island Jewish Health System 13
Evidence-Based Medicine from Three Perspectives Copyright © 2004, North Shore – Long Island Jewish Health System 14
Analysis of the Variance Between Expected Outcome (Evidence) and Actual Outcome (Practice) Copyright © 2004, North Shore – Long Island Jewish Health System 15
Health System Performance Q 1 2004 Out of 100 indicators (10 hospitals times 10 measures) reported to CMS, 34 exceeded the top 10% level reported by all hospitals. Copyright © 2004, North Shore – Long Island Jewish Health System 16
Performance Improvement Best Practice and Opportunities for Improvement Top Performing Bottom Performing Copyright © 2004, North Shore – Long Island Jewish Health System 17
Public Reporting: Preliminary Hospital Performance Q 3 2003 Green = 13 Q 1 2004 Green = 34 Copyright © 2004, North Shore – Long Island Jewish Health System 18
Public Reporting: Preliminary Indicator Performance Copyright © 2004, North Shore – Long Island Jewish Health System 19
Leadership Developed Quality Metric Desired Direction + = © 2004, North Shore – Long Island Jewish Health System Copyright 20
Physician Profile Copyright © 2004, North Shore – Long Island Jewish Health System 21
Physician Profile Copyright © 2004, North Shore – Long Island Jewish Health System 22
Service and Nursing Unit Performance Copyright © 2004, North Shore – Long Island Jewish Health System 23
NS-LIJHS Quality Management EBM Task Forces § § § Pneumonia Heart Failure Myocardial Infarction Coronary Artery Bypass Graft Surgery Hip and Knee Orthopedic Stroke Bariatric Surgery Pediatric Cardiac Surgery Hyperbaric Wound Treatment Critical Care Skin Care Sterilization § § § § Fall Prevention Health Information Management Infection Prevention Needle Stick Safety Oncology Safe Practices Credentialing Bioethics Perioperative Mental Retardation /Developmental Disabilities Discharge Planning Utilization Management Care. Map®/Variance Copyright © 2004, North Shore – Long Island Jewish Health System 24
NS-LIJHS Quality Management EBM Task Forces Charge Benefits Provide understanding, direction, education and § § § tools to achieve improved § processes/outcomes § § Optimize patient care Standardize measures Share best practices Identify gaps in safe patient care Improve clinical involvement Enhance communication Copyright © 2004, North Shore – Long Island Jewish Health System 25
Results Acute Myocardial Infarction • • • Pilot of standardized admission orders Pilot of rapid diagnostic testing Incorporating CEMS into treatment protocols Heart Failure • • Orthopedic/CABG • Standard protocol for antibiotic administration Pneumonia Development of education module on CD ROM and Intranet Physician champions conduct around the clock educational programs for staff • • Standardized orders for immunizations Educational video for patients Copyright © 2004, North Shore – Long Island Jewish Health System 26
Educating Patients Copyright © 2004, North Shore – Long Island Jewish Health System 27
Evidence-Based Medicine is Used for LOS Management Copyright © 2004, North Shore – Long Island Jewish Health System 28
Example: LOS Management Community Hospital Copyright © 2004, North Shore – Long Island Jewish Health System 29
Continuum of Care Process Description Admission Cycle Pre-Admission Testing Patient Management Admitting Transfers Transition Management Emergency Room Physician Offices • Information Collection • Admission Protocols • Discharge Planning Begins Treatment Cycle Discharge Cycle Service Facilitators Clinicians Ancillary Services Social Work • Case Mgmt. /Floor Nurses • Results Reporting Copyright © 2004, North Shore – Long Island Jewish Health System Discharge Medical Records • Discharge Planning Retrospective Reporting • Restrospective Reporting Billing Documentation • Billing Documentation 30
Result: Care of Pneumonia Profit X Patient Taking PO Meds Misuse/Underuse “ 1 -Day Stays” Costs Clinical Pathway Overuse Costs Quality Lowers Cost Day 1 Day 3 Day 5 Day 7 Underutilization Antibiotic Home Optimum Switch Antibiotics (IV to PO) Plan for Discharge Optimum Implementation of Discharge Overutilization Excess Days Improper Discharge Process Copyright © 2004, North Shore – Long Island Jewish Health System 31
Example: Disease Specific LOS Management Copyright © 2004, North Shore – Long Island Jewish Health System 32
Outcomes Indicators – March 2004 Copyright © 2004, North Shore – Long Island Jewish Health System 33
Case Management Uses EBM Guidelines Across Continuum QUALITY MANAGEMENT Multidisciplinary NURSING PHYSICIANS Patient Centered Care SOCIAL WORK ANCILLARY SERVICES HOME CARE (Case Mgmt. ) • • • Laboratory Nutrition Occupational Therapy Pharmacy Physical Therapy Radiology Respiratory Therapy Speech Therapy Environmental Services Copyright © 2004, North Shore – Long Island Jewish Health System Coordination (Pre, During and Post Discharge) 34
The NS-LIJHS Care. Map® § § § Disease-specific Helps to direct the care towards evidence-based best practices Provides a standard of care for varied patient populations with disciplinespecific goals, focusing on patient and cost outcomes Increases collaboration and efficiency by prospectively planning for care Strengthens accountability by linking assessment and intervention strategies with patient outcomes Copyright © 2004, North Shore – Long Island Jewish Health System 35
Care. Map® Creation Methodology PRIORITIZATION DEVELOPMENT APPROVAL IMPLEMENTATION USE OUTCOME Copyright © 2004, North Shore – Long Island Jewish Health System 36
Care. Maps® Encourage Patient Education Patients partner in their care Patient Friendly Care. Maps® provide patient information on: • • Disease Process Treatment Goals Patient’s Role Tests Medications Diet Activity Discharge Planning Copyright © 2004, North Shore – Long Island Jewish Health System 37
Example of Patient Friendly Heart Failure Care. Map® Heart Failure If you have heart failure that has caused you to be in the hospital, it probably means that your heart muscle has weakened to the point where it has allowed your body to collect too much fluid, causing difficulty breathing and/or a low energy level. Discharge Planning Your discharge plan will be based on your needs. If you need help with care at home, or were receiving home care services, please tell your nurse and ask about home care programs available for patients with heart failure. A Social Worker/ Case Manager may visit you to talk about discharge planning. The Health Care Team will go over your discharge instructions 2004, North Shore – Long Island Jewish Health System or your family may have. If any 38 Copyright © and answer any questions you questions come up after you go home please call your doctor.
Promoting Patient Safety Heart Failure Specific Supplemental Discharge Instructions Data for outpatient care Heart Failure specific home instructions To document our high quality of care Doctor’s signature Nurse’s signature Copyright © 2004, North Shore – Long Island Jewish Health System 39
Sample Page of Care. Map® PT assessment Ejection Fraction Daily weight Smoking cessation Variances ACE-I Fluid guidelines Pt friendly map Reminder for smoke and EF RECORDING Copyright © 2004, North Shore – Long Island Jewish Health System 40
Care. Map® Variance Analysis for Heart Failure Copyright © 2004, North Shore – Long Island Jewish Health System 41
Care. Map® Variance Analysis for Heart Failure Copyright © 2004, North Shore – Long Island Jewish Health System 42
Improving Nursing Decision-Making Quality Management Data Identified Variation in Assessment and Treatment of Pressure Injuries Copyright © 2004, North Shore – Long Island Jewish Health System 43
Involves a Standardized Approach § Nursing Competency § Risk Assessment § Assessment/Reassessment § Treatment § Measure/Benchmarking § Participate in Validation of Data with External Sources Copyright © 2004, North Shore – Long Island Jewish Health System 44
Using Guidelines for Skin Care Achieved Good Outcomes Guidelines Implementation For the year 2002, no payments were made for decubitus ulcer lawsuits for the entire Health System !! Copyright © 2004, North Shore – Long Island Jewish Health System 45
Patient Safety Indicators – March 2004 Copyright © 2004, North Shore – Long Island Jewish Health System 46
STANDARDIZED EVIDENCE-BASED GUIDELINE SKIN ASSESSMENT WITH BRADEN SCALE Copyright © 2004, North Shore – Long Island Jewish Health System Copyright © 2004 North Shore - Long Island Jewish Health System 47 47
Quality Management Databases Developing databases allows Quality Management to share information Copyright © 2004, North Shore – Long Island Jewish Health System 48
Quality Management Lines of Communication Executive Session (Medical Staff Function) System Quality Management Copyright © 2004, North Shore – Long Island Jewish Health System 49 49
Quality Management Databases & Applications Development 2003/2004 Medical Records (19 Elements) Acute Care Table of Measures Ad Hoc Behavioral Health Table of Measures Care. Maps® Core Measures • Excess Days • Case Mix Index • Length-of-Stay Developed Ongoing Network Dashboard Sentinel Events ICU Table of Measures Mortality Data Bariatric Surgery Denials Home. Care Table of Measures Discharge Planning Neurosurgery Ambulatory Services Table of Measures Safety Services Table of Measures ED Table of Measures Copyright © 2004, North Shore – Long Island Jewish Health System 50 50
Setting New Standardized Proactive Approach To Care Education to Clinicians and Patients Safety Measures Compare and Benchmark Performance Evidence-Based Medicine Care. Maps® Patient Friendly Multidisciplinary Databases To Share Information Copyright © 2004, North Shore – Long Island Jewish Health System Quality Structure Accountability Communication Quality Metric System Taskforces Standardized Care Best Practices Lessons Learned 51
Quality Reference “Using guidelines also helps demystify the medical process -- for the patients, the nurses, and the physicians. There is an orderly plan of care for all caregivers to refer to. Specific disease processes can be anticipated to take a certain course, with treatment deliberately informed by expert information. Guidelines help mediate between the art and the science of medicine, between less and more experience. And for the manager, especially, following a clinical pathway or a process guideline can bridge the gap between less and more organized and efficient care. For a new manager, in particular, this is a welcome tool. ” The Quality Handbook for Health Care Organizations, Yosef D. Dlugacz, Andrea Restifo, Alice Greenwood Copyright © 2004, North Shore – Long Island Jewish Health System 52
Скачать презентацию EVIDENCE-BASED MEDICINE AND HEALTH SYSTEMS LEADERSHIP IMPLEMENTS DISEASE
7b5d6065fd8bfe62ce60ab5f70417f8c.ppt