Where: Mercy Medical Center, a 445-bed acute care hospital in Cedar Rapids, Iowa.
The issue: Incorporating new evidence and guidelines into daily practice.
More than a decade ago, clinicians at Mercy Medical Center recognized that care for patients with heart failure could be improved. “This was before the start of reportable data and core measures,” said Rose Allen, RN, MS, Mercy's senior director of clinical improvement and accreditation.
The hospital launched a care management department, led by Ms. Allen. She was charged with ensuring that care for heart failure patients was in accordance with the latest guidelines and quality requirements. “Over the years, as additional populations were included in the Hospital Quality Alliance, and The Joint Commission's ORYX Core measures, we gradually added staff to oversee the specific patient populations,” said Ms. Allen.
How it works
The department, now titled Clinical Improvement and Accreditation, has expanded to seven advanced practice nurses (APNs), who target different clinical areas, including stroke, acute myocardial infarction (AMI), heart failure, pneumonia, surgery and orthopedics.
Sue Dawson, RN, MA, an APN who focuses on cardiac care, described her efforts to gain recertification for the hospital as a nationally recognized chest pain center as an example project. “The American Heart Association and the American College of Cardiology just released an update in the national guidelines for the care of the heart attack population,” said Ms. Dawson. “I summarize those guidelines and meet with administrators and our medical director of cardiology. We update previously developed tools, such as order sets, to roll out that information to the other physicians and the front-line staff.”
Other projects have included providing self-management education for heart failure patients, bringing in clinical documentation specialists to improve physician documentation, creating an outpatient stroke education center, standardizing order sets for surgical patients, educating cardiologists and cardiac catheterization lab staff on the criteria for an elective cath lab visit, and reducing the time that emergency department patients wait for an electrocardiogram.
Depending on the target of the current project, the APNs may focus their efforts on physicians and/or nurses. “We have a residency program and we do a lot of education with the family practice residents who often will be writing orders,” said Pat O’Donnell, RN, MSN an APN focused on heart failure. “We talk to them about best practice and how they can ensure quality care with order set usage.”
When working with nurses, the APNs may get a little more hands-on. “Most of us are embedded on the unit where we work. We are there not only to share evidence with the nurses, but also to assist with implementation,” said Diane Handler, RN, MSN, an APN and the hospital's stroke coordinator. “We help the nurses problem-solve and explain why the required measures ensure the best patient care. We assist with implementation of measures and try to make their job easier.”
Change can be difficult, even if it makes things easier in the long run. “There can be resistance. It really becomes an issue of competing priorities for front-line staff,” said Ms. Allen.The APNs have tried to ease the process as much as possible by developing innovations to assist in implementing and standardizing evidence-based processes. “The physicians and staff understand you're the one...wading through all those guidelines and developing tools to help the front-line staff,” noted Ms. Dawson.
The department's work has led to measurable improvements. Mercy Medical Center recently celebrated two consecutive years of perfect compliance with door-to-balloon times of less than 90 minutes. Overall, Mercy has improved the percentage of patients who receive 100% of the guideline-recommended care from 70.8% in 2006 to 91.8% in 2010. The hospital also has significantly lower than average readmission rates for certain conditions, including 20.1% for heart failure, 17.2% for heart attack, and 14.9% for pneumonia. These results led to the hospital's selection by the Commonwealth Fund as a high-performing health care organization in March 2011.
The APNs suspect that coming changes toward pay for performance will make their work even more important to Mercy, and encourage other hospitals to follow in their footsteps. “It's definitely a model that other hospitals could use,” said Ms. Allen.