In its landmark 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century
, the Institute of Medicine (IOM) identified an enormous gap between the care that Americans should receive and the care that is actually delivered. One reason for this gap, according to the IOM, is the growing volume and complexity of medical knowledge. “Health care today is characterized by more to know, more to manage, more to watch, more to do, and more people involved in doing it than at any time in the nation’s history,” the report said.
Leaders at Hackensack University Medical Center (HUMC) are very familiar with these challenges and their consequences. “Nationally, something like 100 percent of doctors know that patients who have had heart attacks should get beta blockers. Then why are only 30 percent doing it?” asks Charles Riccobono, MD. Riccobono is Vice Chairman of the Department of Internal Medicine, Chief of the Division of Digestive Disease and Nutrition, as well as Chief Quality Officer at HUMC.
Riccobono and his colleagues know that, for a variety of reasons, the old models of care are largely responsible for this disconnect. So starting in 2002 they began experimenting with new models of care in an effort to close the gap between “what we know and what we do.”
The Background: Hackensack University Medical Center is a 683-bed, not-for-profit, tertiary-care, teaching and research hospital located in Hackensack, New Jersey. Situated just seven miles west of New York City, with more than 70,000 admissions and two million outpatient visits a year, HUMC is New Jersey’s largest provider of inpatient and outpatient services, and one of the busiest hospitals in the nation.
The Situation: With Pursuing Perfection as a catalyst, HUMC has undertaken a wide range of quality initiatives, from delivering more effective care to heart attack patients, to instituting programs that improve medication safety. Through this work, they have learned that changing ingrained behavior can be challenging, and requires more than simple exhortation. Changing behavior requires intervention.
To address the shortcomings of the “old” system of care in which the physician is required to know and remember everything relevant to caring for patients, HUMC leaders now know just how big a role information technology can play. “One of the major supports for delivering perfect care is the timely and accurate capture and exchange of information,” says Regina Berman, RN, MA, HUMC’s Director of Performance Improvement.
Having guidelines or other sources of clinical support at the point of care is an essential element of good care, and HUMC is on the cutting-edge in this regard. Its powerful computerized clinical information system includes electronic medical records that can be accessed from any PC or hand-held computer, and computerized physician order entry (CPOE) enables physicians to electronically order diagnostic tests, medications, lab work, or treatments such as physical therapy. This not only eliminates the possibility of errors based on handwriting misinterpretations, but often speeds up the care process.
But having access to information is not the same as using it effectively to care for patients. “We wanted to change the actual process of care to make it easier for doctors to do the right thing and harder to do the wrong thing,” says Riccobono. This is where new models of care — such as multidisciplinary rounds — come in.
The Solution: Multidisciplinary rounds
(MDR) bring together a team of caregivers who make daily visits to patients — one by one — on specified medical units. With the patient’s care plan and a checklist of quality indicators as a guide, the team reviews the diagnosis, discusses any pending issues such as new symptoms or further testing needed, checks on documentation, and looks over discharge plans.
The nurses participate in rounds and keep careful notes, making them available to all who will be caring for the patient that day. Kept on a card, color-coded by diagnosis (and soon to be computerized), the information is clinically comprehensive and also indicates such things as whether or not smokers have been counseled to quit or whether patients are at risk for falling.
Two specific features of HUMC’s culture have made implementing MDRs both natural and challenging.
First, HUMC is noted for its strong support of nurses, through professional education and development opportunities, mentoring, and nursing participation on important hospital committees. Multidisciplinary rounds are a natural outgrowth of the collaborative approach to care that has been the hospital’s hallmark for years.
Second, many — but not all — of the patients at HUMC are clustered by diagnosis. For example, orthopedic and cardiac surgery patients are admitted to designated units, as are cardiology and oncology patients. By contrast, pulmonology and neurology patients, among others, can be scattered throughout the hospital. Clustered and mixed-patient units present different challenges for the MDR teams.
“Multidisciplinary rounds work wonderfully on the clustered units,” says Regina Berman. “There is repetition, the staff gain expertise quickly, and it is easier to deploy evidence-based care reliably.” Duplicating that success on a unit where patients have many different diagnoses has been a greater challenge.
At the same time the hospital has been testing MDRs, it has been experimenting with ways to deploy nurses to improve performance. Nursing leadership at HUMC is organized into “collegial triads” consisting of a nurse manager, a nursing educator, and an advance practice nurse (APN) who work together as management teams. This triad strengthens unit nurses by providing leadership, coaching, mentoring, and role-modeling.
In what HUMC calls the “APN care model,” APNs play a key role in ensuring that evidence-based practice guidelines are followed for each patient. Some APNs have a disease-specific focus — working on clustered units or with patients throughout the hospital who have the same condition — and some are assigned “geographically” to work on a mixed-patient unit.
Even with APNs assigned to virtually all units and patients, the average length of stay on clustered units is lower than on mixed-patient units. “On the mixed units, our thought was to transmit the expertise of the disease-specific APNs to the unit-based nursing staff,” says HUMC’s Dr. Riccobono. But caring for patients on a clustered unit allows for efficiencies and reduced variation that are not as easily achieved on a mixed-patient unit.
“Our goal is to figure out how to make the mixed med-surg units operate at the same level as the clustered units,” says Riccobono. He and his colleagues believe that, in addition to the APN care model, instituting multidisciplinary rounds is part of the answer to their search for the ideal care team. Typically, MDR teams at HUMC consist of an in-house physician, an APN, a nurse manager, a staff nurse, a social worker, and a case manager. Sometimes a pharmacist and staff from other appropriate ancillary departments join the team.
“The PharmD [Doctor of Pharmacy] is a great addition to the team,” says Riccobono. “The literature shows that physicians are willing to defer to the judgment of pharmacists when it comes to medications.” This speaks to another challenge in implementing MDRs: the cultural shift required of physicians to work more collaboratively than ever before.
Louis Teichholz, MD, HUMC Chief of Cardiology and Medical Director of Cardiac Services, says the complexity of providing care today requires this shift. “In the old days, doctors rowed their own boats. Now, care gets so complicated that it’s like an ocean liner, and you need a whole crew working together to steer it.” Still, he says, “The doctor needs to be the captain of the ship.” Teichholz says that use of MDRs has figured prominently in HUMC’s improvement in the care of heart attack patients.
Riccobono says that motivating physicians to change their way of working is easier when there are data to demonstrate the value of the new approach. “It is hard to tease out the factors that contribute to better outcomes. That’s difficult data to generate,” he says.
But Riccobono says that most doctors understand intuitively the value of MDRs. “They know that doctors are increasingly under pressure and under scrutiny, and that MDRs help them make good decisions. Practicing high-quality medicine is a plus from so many perspectives,” he says. “From a practical perspective, people will want to come to our hospital, our patient volume will remain high, and doctors understand the value of that very well.”
Moreover, says Riccobono, most doctors grow to like MDRs. “Even the people who were skeptical early on are standing up in meetings and saying how happy they are that some burdens of care have been lifted from their shoulders,” he says. Physician satisfaction at HUMC is in the 92nd percentile nationally, according to The Jackson Organization, a market research firm based in Columbia, Maryland.
The Results: It is difficult to measure and quantify the impact of multidisciplinary rounds on patient outcomes. However, HUMC asked participating physicians on five different units to use a point scale to evaluate MDRs in three specific categories: membership (attendance and participation/effectiveness within the team); process (use of rounding tools, communication, issue resolution, resiliency); and barriers (role definitions and knowledge deficit).
Out of a possible 26 points, indicating all elements are perfect, physicians rated the experience a “17” on average, across all five units, with a range from 9 to 24. Not surprisingly, the more patients the group saw together, the higher the scores. MDRs on clustered units were also rated more favorably.
“We are using these evaluations to try to determine what works best,” says Regina Berman. “The scores show the importance of clearly defined roles and the use of standardized tools and reliable processes. These are areas we’ve focused on and have given us our most impressive results.”
In terms of their clinical impact, MDRs have been integral to the care delivered to patients with several diagnoses, including heart attack, heart failure and coronary artery bypass grafts. These are three of the five conditions included in the CMS/Premier demonstration project in which HUMC is participating.
“Our best results are from working well together,” says Dr. Riccobono.
What Team Members Say: “The results from the demonstration project give us a glimpse into the power of a focused team and a definable process.” — Charles Riccobono, MD, Vice Chairman of the Department of Internal Medicine, Chief of the Division of Digestive Disease and Nutrition, and Chief Quality Officer
“The roots of this work began with Pursuing Perfection. Through our work with IHI and other hospitals contending with the same problems, we have learned to organize our work flows and processes around the IOM dimensions of quality and fully support the provision of defect-free care” — Regina Berman, RN, MA, Director of Performance Improvement