Evidence-based medicine is an increasingly effective modality for improving clinical quality outcomes. The challenge is convincing caregivers to adopt proven, standardized procedures rather than follow their personal preferences. Michael Connelly, MA, JD, FACHE, president and CEO of Catholic Health Partners, discusses five ways to standardize processes in the pursuit of great patient care.
1. Write down everyone's role. If you expect caregivers to effectively work together to improve quality, enhance patient safety and reduce cost, each person must understand his or her role and how they function as part of a team in that effort, Mr. Connelly says. The simplest way to help caregivers understand their roles is to clearly define expectations in their job descriptions or employment contracts. "A job description or contract is an opportunity to clarify each person's role," he says. "For example, previously, our contracts with ER physicians did not include quality outcome expectations or role clarification, and now these are spelled out very clearly." A contract should include details about compensation and if compensation is tied to patient satisfaction and adherence to evidence-based medicine. The caregiver should be able to look at his or her contract and see those requirements clearly defined, including how they will be measured.
Contracts can also help persuade more hesitant caregivers who may be unconvinced about the efficacy of a proven, standardized best practice. Catholic Health Partners realized that in the obstetrics department, different caregivers had different interpretations of the fetal monitor strip. "In order to assure consistent, accurate readings, we required that everyone in OB charged with reading a fetal monitor strip be certified by the appropriate national organization," he says. "In some cases, we made it part of credentialing." If your hospital writes down specific role requirements and responsibilities in a caregiver's contract, you will likely achieve greater compliance because providers understand and appreciate the standard's benefit, he says.
2. Challenge providers to question their traditional practices. There are many nuances involved in creating best practices, Mr. Connelly says. In some cases, caregivers are able to make an exception to the "rule"; in others, standardization is clearly in the patients' best interests. "One of the things we rely on is using evidence. We really challenge people with the evidence and say, 'If the evidence says this works, maybe your perception [of the proper approach is flawed]," he says. In some cases, evidence will point to a certain practice that your caregivers may not be following. For example, at Catholic Health Partners, physicians follow evidence that shows a baby should not be delivered before 39 weeks unless an emergency occurs. "Routinely, families and physicians schedule deliveries at 37 and 38 weeks, but data shows that in those cases, babies can incur high-risk complications 200 percent more often."
Mr. Connelly says when the system first attempted to standardize its practices, caregivers were hesitant to accept the evidence. "They would say, 'I've been doing this for 30 years and I've never had a problem.' My answer was that just because I've been driving a car for 30 years doesn't mean I don't wear a seatbelt," he says. He encourages clinical quality leaders to show caregivers hard data that demonstrates the benefit of a particular practice.
3. Target physicians who serve as the "portal of entry." Catholic Health Partners targeted three physician specialties that act as the portal of entry for nearly all care: primary care physicians, hospitalist physicians and emergency room physicians. "We want to have those physicians on our team, most likely employed, following a model of care backed by clinical evidence," he says. "That means they all have the same medical record so they can easily communicate with each other." Facilitating communication through a standardized electronic health record can ensure that the three portals of entry are in constant communication. If a patient enters the system through a primary care physician, hospitalists and emergency room physicians are also able to acquire information on the patient and receive alerts if the PCP needs to hand the patient off.
Mr. Connelly says CHP is working to standardize processes such as hand-offs between caregivers. For example, data indicates that patients are more likely to experience complications or dissatisfaction if they don't communicate with a primary care physician within seven days of discharge. Hospitals can prevent this kind of problem by standardizing a time to contact patients and then holding caregivers accountable for achieving a proven best practice. Because integrated physicians are often more amenable to this kind of standardization, Catholic Health Partners has worked to grow its integrated physician base by 40 percent over the last year, increasing its numbers from 450 to 800 physicians and mid-level clinicians.
4. Simulate a crisis. When CHP holds simulation training in an obstetrics department, for example, the system simulates a medical crisis and then films the team's reaction. "If you haven't practiced teamwork and [don't] understand how you react under certain circumstances, it's easy to make a mistake and misunderstand another person," he says. If a team has been trained on a set of standardized procedures and evidence-based best practices, every event should be met with an appropriate reaction, rather than certain caregivers reacting out of panic because they have never encountered a situation with these particular colleagues. After the simulation is over, the team watches the video to learn from its mistakes.
5. Hold leaders accountable. If caregivers are following evidence-based best practices, improved quality outcome results should be fairly predictable, excepting the occasional outlier. Catholic Health Partners uses a variety of quality measures to garner accountability to proven best practices. "We annually agree on about 10 measures that are benchmarked nationally for top results," he says. These measures include readmissions and mortality rates. While a health system will always run into some situations that cannot be planned for, mortality rates should decrease over time if your system implements practices that have been shown to lower mortality. The same is true for readmissions; if caregivers standardize the way they hand-off and discharge patients, you should see clear reductions in readmission rates.
Learn more about Catholic Health Partners.
Read more on evidence-based medicine:
-The Fight Against Hospital-Acquired Infections: Q&A With Dr. Rabih Darouiche of Baylor College of Medicine
-First Step to Hospital-Physician Integration: Physician-Physician Integration
1. Write down everyone's role. If you expect caregivers to effectively work together to improve quality, enhance patient safety and reduce cost, each person must understand his or her role and how they function as part of a team in that effort, Mr. Connelly says. The simplest way to help caregivers understand their roles is to clearly define expectations in their job descriptions or employment contracts. "A job description or contract is an opportunity to clarify each person's role," he says. "For example, previously, our contracts with ER physicians did not include quality outcome expectations or role clarification, and now these are spelled out very clearly." A contract should include details about compensation and if compensation is tied to patient satisfaction and adherence to evidence-based medicine. The caregiver should be able to look at his or her contract and see those requirements clearly defined, including how they will be measured.
Contracts can also help persuade more hesitant caregivers who may be unconvinced about the efficacy of a proven, standardized best practice. Catholic Health Partners realized that in the obstetrics department, different caregivers had different interpretations of the fetal monitor strip. "In order to assure consistent, accurate readings, we required that everyone in OB charged with reading a fetal monitor strip be certified by the appropriate national organization," he says. "In some cases, we made it part of credentialing." If your hospital writes down specific role requirements and responsibilities in a caregiver's contract, you will likely achieve greater compliance because providers understand and appreciate the standard's benefit, he says.
2. Challenge providers to question their traditional practices. There are many nuances involved in creating best practices, Mr. Connelly says. In some cases, caregivers are able to make an exception to the "rule"; in others, standardization is clearly in the patients' best interests. "One of the things we rely on is using evidence. We really challenge people with the evidence and say, 'If the evidence says this works, maybe your perception [of the proper approach is flawed]," he says. In some cases, evidence will point to a certain practice that your caregivers may not be following. For example, at Catholic Health Partners, physicians follow evidence that shows a baby should not be delivered before 39 weeks unless an emergency occurs. "Routinely, families and physicians schedule deliveries at 37 and 38 weeks, but data shows that in those cases, babies can incur high-risk complications 200 percent more often."
Mr. Connelly says when the system first attempted to standardize its practices, caregivers were hesitant to accept the evidence. "They would say, 'I've been doing this for 30 years and I've never had a problem.' My answer was that just because I've been driving a car for 30 years doesn't mean I don't wear a seatbelt," he says. He encourages clinical quality leaders to show caregivers hard data that demonstrates the benefit of a particular practice.
3. Target physicians who serve as the "portal of entry." Catholic Health Partners targeted three physician specialties that act as the portal of entry for nearly all care: primary care physicians, hospitalist physicians and emergency room physicians. "We want to have those physicians on our team, most likely employed, following a model of care backed by clinical evidence," he says. "That means they all have the same medical record so they can easily communicate with each other." Facilitating communication through a standardized electronic health record can ensure that the three portals of entry are in constant communication. If a patient enters the system through a primary care physician, hospitalists and emergency room physicians are also able to acquire information on the patient and receive alerts if the PCP needs to hand the patient off.
Mr. Connelly says CHP is working to standardize processes such as hand-offs between caregivers. For example, data indicates that patients are more likely to experience complications or dissatisfaction if they don't communicate with a primary care physician within seven days of discharge. Hospitals can prevent this kind of problem by standardizing a time to contact patients and then holding caregivers accountable for achieving a proven best practice. Because integrated physicians are often more amenable to this kind of standardization, Catholic Health Partners has worked to grow its integrated physician base by 40 percent over the last year, increasing its numbers from 450 to 800 physicians and mid-level clinicians.
4. Simulate a crisis. When CHP holds simulation training in an obstetrics department, for example, the system simulates a medical crisis and then films the team's reaction. "If you haven't practiced teamwork and [don't] understand how you react under certain circumstances, it's easy to make a mistake and misunderstand another person," he says. If a team has been trained on a set of standardized procedures and evidence-based best practices, every event should be met with an appropriate reaction, rather than certain caregivers reacting out of panic because they have never encountered a situation with these particular colleagues. After the simulation is over, the team watches the video to learn from its mistakes.
5. Hold leaders accountable. If caregivers are following evidence-based best practices, improved quality outcome results should be fairly predictable, excepting the occasional outlier. Catholic Health Partners uses a variety of quality measures to garner accountability to proven best practices. "We annually agree on about 10 measures that are benchmarked nationally for top results," he says. These measures include readmissions and mortality rates. While a health system will always run into some situations that cannot be planned for, mortality rates should decrease over time if your system implements practices that have been shown to lower mortality. The same is true for readmissions; if caregivers standardize the way they hand-off and discharge patients, you should see clear reductions in readmission rates.
Learn more about Catholic Health Partners.
Read more on evidence-based medicine:
-The Fight Against Hospital-Acquired Infections: Q&A With Dr. Rabih Darouiche of Baylor College of Medicine
-First Step to Hospital-Physician Integration: Physician-Physician Integration