Improving Health Care through Data Driven Process Redesign

Authors:
Ken Coburn, MD, MPH, CEO & President of Health Quality Partners
Tim Hediger, Director, Improving Systems at Doylestown Hospital

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A community hospital in Pennsylvania has discovered that readily accessible, timely analysis of key clinical processes is both practical and essential for system-wide improvement. The “Improving Systems Information Portal” (ISIP) designed and implemented at Doylestown Hospital using Statit e-QC is part of a comprehensive Improving Systems initiative begun in November 2002. The overarching aims of the Improving Systems initiative are to:

1.	increase the delivery of evidence-based clinical care and
2.	improve patient throughput in order to increase the hospital’s capacity to serve its community.

The ISIP has been an essential resource to this initiative by providing widely accessible, up to date analyses of over 100 unique clinical care processes – making several hundred customizable reports available to users by means of incorporating ‘drill-down’ and dynamic parameter choices. These analyses are used by project teams to guide their process redesign work. In addition to a broad portfolio of statistical process control graphs, Pareto charts and reports, the ISIP provides a single portal to manage and document most aspects of the Improving Systems initiatives, including; meeting schedules, meeting minutes, project updates, clinical guidelines, definitions of reporting metrics, improvement tools for teams to use and educational materials (see Figure 1). One senior executive described the ISIP as a “total quality management system”.

Figure 1 – Screenshot of the ISIP at Doylestown Hospital showing links to a variety of resources supporting the Improving Systems Leadership Team.

Multiple existing data systems used throughout the hospital have been tapped in order to provide an array of data sources for the analysis of quality and system performance. This was initially accomplished using Microsoft Access - inexpensively and without the formal implementation of a data warehouse. After 2 years of effective operation, the shared data analysis repository is now being transitioned to Microsoft SQL Server.

Figure 2 – The eclectic set of data sources used by the Doylestown Hospital ISIP.

The chief architect of the ISIP is Mr. Tim Hediger, the Director of Improving Systems at Doylestown Hospital who has received support for design, implementation, and analysis from Health Quality Partners (HQP), a not for profit health care quality improvement research and development organization in Eastern Pennsylvania.

Organizational Structure for Improving Systems:
The Improving Systems initiative is led by the Improving Systems Leadership Team (ISLT), which meets monthly and is chaired by the hospital CEO, Mr. Rich Reif. Membership includes most of the hospital senior administration, hospital board members, several physician leaders, and selected program directors. The ISLT sets goals, evolves the cultural standards for the organization related to improving systems, and prioritizes projects.

The Improving Systems Implementation Team (ISIT) converts the general direction and prioritized projects defined by the ISLT into practical process designs and implementation strategies. It is a multidisciplinary group which includes representatives from nursing, case management, quality, pharmacy, IT, education, and communication departments. The ISIT also oversees and coordinates the work of many project teams and is chaired by the VP for Patient Services, Ms. Eleanor Wilson.

Group facilitation, executive and staff mentorship, technical support and analysis is provided to both of these groups by the hospital’s internal improving systems resources (under the direction of Mr. Tim Hediger) and Health Quality Partners.

Projects Supported through the Improving Systems initiative:
Currently, 15 improvement projects are supported through the Improving Systems initiative. Examples of projects supported are:

• Acute myocardial infarction (AMI)
• Heart failure (HF)
• Community acquired pneumonia (PN)
• Surgical infection prevention (SIP)
• Case management redesign
• Central line infection prevention
• Rapid response team
• Venous thromboembolism prevention
• Glycemic control for intensive care patients
• Medication reconciliation
• Ventilator-associated pneumonia prevention
  

One very useful management tool developed to identify processes needing additional support or redesign is the ‘Evidence-based Care Composite’. This has been built in Statit e-QC as a p chart in which the denominator is the count of all patients eligible for one or more of a set of evidence-based care protocols (e.g., AMI, HF, PN, SIP). A 0 is added to the numerator if any care component of any evidence-based protocol for which the patient is eligible is not delivered in accordance with established standards (i.e., there is any defect in care). A 1 is added to the numerator only if the patient received every component of every evidence-based protocol (in the set of interest) for which they were eligible on that admission. The protocols for AMI, HF, PN, and SIP collectively have 20 specific components of care. Advantages of this measurement approach include:

• Raising the bar – there is no ‘partial credit’ at the patient level
• Patient centered – perfect care from the patient’s standpoint is defined by whether they received everything they should
• Guides management - Pareto charts derived from the composite analysis alert management to areas needing more support and guidance to achieve the greatest patient benefit
• Broad reporting utility – the same report can be used to measure performance of care provided to patients served by medical-surgical nursing units or physician groups. In this way everyone is looking at the same organizational performance metrics and goals, but their specific Pareto chart helps guide their attention to areas of greatest opportunity within their own unique microsystem within the larger system.

A screenshot of the Doylestown Hospital, Evidence-based Care Composite ‘20’ (EBCC 20) with accompanying Pareto chart is shown in Figure 3.

Figure 3 – EBCC 20

Highlights of Results to Date at Doylestown:
Compared to CY 2003, year to date results for CY 2006 demonstrate the following changes (all statistically significant):

• Average length of stay for medical/surgical admissions has declined 0.38 days (8%) with no change in case mix severity, effectively increasing the capacity of the hospital the equivalent of adding 10 new beds
• The Evidence-Based Care Composite 20 for AMI, HF, PN, and SIP has improved from 44% to 78.5%
• In-hospital Code 9’s (cardiac arrest calls) per 1000 discharges have declined from 5.3 to 2.3 and the percentage of Code 9’s occurring outside of intensive care units has dropped from 61% to 25%
• In-hospital mortality has declined by a third from 2.7% to 1.8%

Conclusion:
A data driven approach to process redesign combined with strong senior leadership and organizational structures supportive of multidisciplinary project teams can yield significant improvement in key system performance metrics in a community hospital. Statit e-QC provides a practical way to deliver the robust analytical and reporting capabilities needed for the success of such an initiative.

For more information contact:

Ken Coburn, MD, MPH	Tim Hediger
CEO & President	Director, Improving Systems
Health Quality Partners	Doylestown Hospital
coburn@hqp.org	thediger@dh.org

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