Gregory Kutcher, MD, Medical Director and Family Practice Provider
John Haley, MD, FACC, Cardiology Provider
Kevin Cragun, MD, FACC, Cardiology Provider
Nicole Geiger, RN, Cardiovascular Case Manager
Susan Haugh, CNP, Cardiovascular Services
Alice Weydt, RNc, MS, Patient Care Services Director
Katherine Boutchee, LPN, Cardiovascular Services Data Coordinator
Cathleen Ahern, RN, Cardiac Rehabilitation Coordinator
Theresa Mees, RN, MS, Director of Quality Resources
Adam Falkenstein, Statistics Coordinator

To reduce acute myocardial infarction-related mortality by 50 percent.

• Acute myocardial infarction patient mortality
• Percent of patients receiving all possible care

The changes listed below have been part of an ongoing performance improvement initiative that started in our organization in the fourth quarter of 2002. The improvement project was initiated in response to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) ORYX data. A compliance rate of 40 percent to Angiotensin-Converting Enzyme (ACE) inhibitors at discharge and 57 percent compliance to Smoking Cessation Counseling were red flags!

• Formed an interdisciplinary acute myocardial infarction (AMI) Improvement Committee that used the Plan-Do-Study-Act (PDSA) model.
• Developed AMI order sets in an attempt to gather the needed components together.
• Monitored aggregate physician compliance with order set utilization.
• Shared data related to order set compliance with the medical staff.
• Hired one full-time employee as a nicotine counselor.
• Added automatic consult for nicotine counseling to the AMI order sets.
• Implemented Outpatient Heart and Fitness Program.
• Hired two full-time nurse practitioners to work closely with cardiologists to update the four AMI order sets and talked individually with all physicians who treated AMI patients.
• Initiated a Nicotine Rapid Action Team, utilizing the Six Sigma method of improvement, who planned and implemented a Nicotine Protocol.
• Sent members of the Network Quality Committee of the Board to Institute for Healthcare Improvement (IHI) conference.
• Joined IHI 100,000 Lives Campaign.
• Initiated Rapid Action Teams utilizing Six Sigma methodology for improvement for each of the goals linked under the 100,000 Lives Campaign.
• Leadership began a massive communication effort throughout the network and sharing of data via a 100,000 Lives Progress Report which included the key measures for improved care for AMI.
• Combined and implemented AMI order sets from a total of 4 to 2:
  • March 29, 2005: ST Segment Elevation
  • April 27, 2005: Chest Pain Myocardial Infarction
• Regularly monitored and shared with the medical staff the compliance to Core Measure Data through JCAHO.
• Initiated Outpatient Tobacco Cessation Program.
• Assigned accountability for compliance with AMI key components of care to the hospital Medical Director.
• Quality Improvement Committee of the Medical Staff assumed responsibility for all of the 100,000 Lives Campaign initiatives.
• Communicated progress on compliance with AMI key components of care and order set utilization at appropriate committees of the medical staff, and documented progress in the meeting minutes for all to review.
• Monitored and reported individual physician compliance with AMI order sets to the Quality Improvement Committee of the medical staff.
• Developed Medical Staff Communication Tree through Quality Improvement Committee of the medical staff.
• Implemented physician profile for individual Quality Files that are reviewed by the Credentials Committee of the medical staff at the time of the reappointment.

We reduced the number of deaths related to acute myocardial infarction from 15.4 percent in 2002 to 6.4 percent year-to-date in June 2005.

Lessons Learned:

Senior leadership team, physician leadership, and communication are instrumental to creating the charge.

Senior leadership must be a driver for the following:

• Alignment: Leadership assigned several groups and individuals working on parallel paths and made changes so they worked together.
• Communications: Leadership ensured repetitiveness and brought the idea to the medical center in both formal and informational ways (e.g., newsletters, committee meetings, one-on-one's).
• Standardization: Leadership encouraged order set standardization, including both creation and usage of the order set.
• Measurement: Leadership expected and reviewed and standardized the process which improved the credibility of the data. This included regular feedback to the medical center.

Additional lessons:

• Do not assume all medical staff will be excited and responsive to the expectations of the new AMI order sets.
• Anticipate the resistance of medical and nursing personnel to change.
• Expect that decreasing the number of order sets to reach a more standardized approach affects a number of departments.
• Consider utilization of "Process Management" approach.
• Build a system that prevents human error of "forgetting."
• Do not assume that high rates of compliance with each element of the AMI key components of care independently ensures that you are meeting "all possible care" for each patient.

Barriers:

Attitudes toward standardization became a challenge in development as well as implementation of order sets. Things to consider:

• Obtaining buy-in from the medical staff and allied health is critical.
• Include as many "users" as possible in the development phase.
• Provide data so they know a change is crucial to patient outcomes. Show evidenced-based medicine works.
• Put into place a method of holding physicians accountable for not using the order sets.

Next Steps:

• Re-examine ther project objective to lower AMI mortality to an updated future goal.
• Continue to push order set utilization to a higher percentage of physician compliance.
• Implement system in Emergency Room to increase order set utilization for admitted AMI patients.
• Evaluate staffing needs to provide nicotine consultation.
• Ensure documentation reflects current state of compliance. Underlying assumption is: If it’s not documented, it’s not done.

Greg Kutcher, MD, Medical Director and Family Practice Provider
Immanuel St. Joseph’s — Mayo Health System
Email:  Kutcher.gregory@mayo.edu