Clinical Performance Improvement Leaders Zero In on ICU Challenges

March 14, 2018
Last month, leaders at the Charlotte, N.C.-based Premier Inc. released a report on the potential for clinical performance improvement in ICUs in U.S. healthcare, outlining tremendous opportunities for systemic improvement in hospitals

Last month, leaders at the Charlotte, N.C.-based Premier Inc. released a report on the potential for clinical performance improvement in intensive care units (ICUs) in U.S. healthcare. As the health alliance’s Dec. 14 press release noted, Premier leaders had “identified 10 diagnoses with the biggest opportunity to curb variation within the intensive care unit (ICU) and reduce unnecessary length-of-stay. The analysis was published in Premier’s latest Margin of Excellence report, which provides unparalleled, data-driven, evidence-based insights on cost and quality improvement opportunities.”

As Premier executives noted in releasing details from the study, “The Premier report focuses on evidence-based improvement steps in the ICU based on an analysis of 20 million patient discharges across 786 hospitals over a five-year period (2011-2016). According to the analysis, Premier found opportunities to reduce ICU days by 988,111 days overall or nearly 200,000 annually. Overall, patients treated at top-performing hospitals spent 24 percent less time in the ICU. Opportunities were identified by comparing all hospitals in the analysis to peers that utilized the ICU for the same populations in the most efficient manner without compromising quality (metrics examined included inpatient mortality rates and unplanned 30-day readmissions).

Among the study’s findings:

>  Sepsis patients with major complications or comorbidities: Represents 19 percent of the ICU reduction opportunity

> Infectious and parasitic diseases associated with operating room procedures, and major complications or comorbidities: Represents 15 percent of the ICU opportunity

>  Cardiac valve and other major cardiothoracic procedures without cardiac catheterization, but with major complications or comorbidities: Represents 12 percent of the ICU reduction opportunity

>  Coronary bypass without cardiac catheterization, but with major complications or comorbidities: Represents 9.8 percent of the ICU reduction opportunity

>  Respiratory system diagnosis with ventilator support for up to 96 hours: Represents 9.5 percent of the ICU reduction opportunity

> Craniotomy and endovascular intracranial procedures with major complications or comorbidities: Represents 8.9 percent of the ICU reduction opportunity

>  Sepsis patients using a mechanical ventilator >96 hours: Represents 6.8 percent of the ICU reduction opportunity

>  Cardiac valve and other major cardiothoracic procedure with cardiac catheterization and major complications or comorbidities: Represents 6.8 percent of the ICU reduction opportunity

> Cardiac valve and other major cardiothoracic procedure without a cardiac catheterization, but with complications or comorbidities: Represents 6.1 percent of the ICU reduction opportunity

>  Heart failure and shock with major complications or comorbidities: Represents 6 percent of the ICU reduction opportunity

The findings underscore the value of identifying evidence-based improvement opportunities that healthcare leaders are focused on,” Premier executives noted on Dec. 10. “For instance, a recent Premier C-Suite survey found respondents overwhelmingly ranked reducing clinical variation and standardizing the use of products, resources and services as a top cost management priority (96 percent), with more than half ranking it as the top priority when tackling cost inefficiencies. The ICU report can help providers pinpoint areas with the most opportunity to reduce variation.”

Shortly after the release of the study, two Premier executives spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding the implications of the study.

Robin Czajka, R.N. is service line vice president in the cost management division at Premier; Cindy Salyer, R.N., is a director in the Premier Performance Partners consulting arm at the alliance. Czajka is based in St. Charles, Ill., while Salyer is based in Kingsport, Tenn. Below are excerpts from that interview.

What led you and your team members to begin looking at this subject area?

Salyer: What really got us started was that hospitals are dealing with EDs that are totally full; they’re holding patients because they can’t find appropriate beds for them. They’re trying to find ways to become more efficient, and to take unnecessary costs out. How many times are patients undergoing unnecessary tests and procedures, just because that’s how it’s done in a particular unit? And we’re looking to decrease the amount of time patients are exposed to those that might cause problems.

How were the percentages and calculations derived?

Salyer: The Premier database is very robust, and we have 3,900 hospitals participating and contributing to that database, to help us determine the best practices, and determine how patients can get out with good outcomes. And the fact that we can tie the outcomes to lengths of stay, is unique to us. And then we wanted to see what percentage of patients went to ICUs or step-down units, and the outcomes, and the costs, coming out of that? Placing patients in areas that meet their hemodynamic needs. So we wanted to drill down to that detailed level, even to the patient level, and to determine what the differences are, and what the factors are driving those differences.

Were either of you surprised at the rankings of areas of risk, as they were revealed in the findings?

Salyer: I actually was not, because I’m in hospitals every day. It really is what we see day in and day out.

Czajka: The shift from acute to chronic care may be pushing some shifts in terms of the outcomes we’re seeing.

Salyer: The Society of Critical Care Medicine focuses on this also.

What kinds of clinical insights are here that you’d like to discuss?

Salyer: For me, the clinical insights are around how well change in the literature and research, gets implemented. So, how long does it take for knowledge to be accepted, and ingrained and incorporated in how patients are cared for on a day-to-day basis? And being able to communicate to providers how to update order sets and practice patterns.

Czajka: From the perspective of clinicians, for us, it’s getting knowledge that a lot of us have, memorialized, and executed into patient care; that’s the real focus and struggles.

What are the challenges involved in applying the insights revealed in this study, to clinical performance improvement on the ground?

Czajka: From the perspective of someone who’s led service lines, I can say that there are so many things service line leaders, clinical and non-clinical, are compelled to do, from Joint Commission, etc. and so something like this might not get the priority it needs. And you can’t be expecting clinicians at the bedside to immediately be changing everything. So it’s aligning practices, not focusing on getting the price of one widget down.

So you’re talking about clinical transformation and core processes?

That’s right. Everything we do, from the way we document things in the EHR [electronic health record], to the way we move patients through the continuum of care in the hospital, everything involves a major change. So maybe you have to take small bites at a time, over three to five years.

Salyer: I think the competing priorities for people’s time, is huge, as Robin said. So getting people engaged, from the frontline team member, all the way through administration, is important; but so is looking to ask, who will be affected? So that you don’t make a change that positively impacts one unit or group but negatively impacts another. It’s very difficult right now to hardwire these processes, because we’re seeing tremendous turnover, especially among frontline nurses, so you’re having to constantly educate people. Things drift back. And the last thing is, getting support from other departments, including IT. IT is so overwhelmed by the implementation of EHRs. People think it’s going to be a plug-and-play thing, but the IT people are so overwhelmed by requests, that it’s hard to get changes implemented.

The IT professionals in hospitals are overwhelmed right now, yes.

They are, and everyone pushing constantly—it becomes something that they have a hard time knowing what the real priorities are. So, having that leadership in place is essential.

Good project management and clinical practice governance are critical success factors here, too, correct?

Yes, that you don’t want to be making [process] changes countless times. So it’s important to engage in small tests of change, and to incorporate those changes, and expand those out over time; that works very well, but it’s hard for people to see sometimes.

Czajka: Your point about project management and clinical governance is critical to the change management piece. Making sure you have the right people, and a top-down prioritization, and aligning the resources around it, is essential.

One of the things that I’ve been saying for a very long time now is that the readmissions reduction program under the ACA [Affordable Care Act] will continue to advance awareness of the need to transform clinical performance in patient care organizations.

Czajka: Yes, I think you’re spot-on about that.

Salyer: Yes, and that really drives that whole need for thinking outside the hospital walls, which is what we also do. What will this patient need when they go home or to a long-term care facility. What are those community resources, and how do you align those resources, to keep patients at the optimum level of health that they’re able to achieve in the hospital?

What have the nursing leaders’ conversations with IT been like in the hospitals you’ve been working with in this area, including with clinical informaticists?

Czajka: When I was a service line leader working on an EHR buildout, the conversation has to be how we make the EHR a workflow tool that will trigger the right actions at the right time. There have to be the right triggers, the right standing orders. There are a lot of standing orders now that are antiquated and are based on old-fashioned guidelines, that need to be reassessed.

Salyer: And really coming up with a guideline for the nursing leadership and the performance improvement leadership, that can really come up with strong, useful guidelines. And having that true algorithm that can prioritize the requests going to IT, knowing they have limited resources. And every hospital I work with has limited resources. And when something can’t be done, talk about why it can’t, and when it can be done. So there are good communications in both directions about constraints, and about impacts on the patients.

Clinical informaticists are absolutely going to have to be a part of this equation, correct?

Salyer: Absolutely. They have to be, for these efforts to be successful.

Czajka: Yes, they’re going to be critical to success. I’ve done quite a bit of work with physician informaticists who are working to take some of these EMR systems and trying to focus on patient outcomes. We need to focus on what’s best for the population of patients, not for the bottom line or what’s easiest to do, or what the hospital down the road is doing.

Salyer: And it’s essential that they’ve understood what the ‘ask’ was, and how it needs to be at the back end, once the code is written. Has it translated in the way it needed to be? Sometimes, we’re not as clear as we need to be, when trying to articulate what we need, to non-clinical people. So having that group that can say yes, that’s a match.

It’s like at the United Nations sometimes, with the need for multilingual interpreters, in terms of helping to get everyone onto the same page, correct?

Salyer: Yes, it really is!

What should CIOs, CMIOs, and other healthcare IT leaders, take away from this discussion?

Czajka: I would definitely say, that number one, to have a focus on leveraging the systems to look at the data and to partner to enable to help our physician and service line leaders focus on change management. And two, how do we prioritize the work ahead of us, so that we’re putting patient safety and patient outcomes ahead of everything else; that’s how we should prioritize everything.

Salyer: I totally agree with everything Robin’s said. And the last thing, I think, is, to make sure that the clinical informatics team, and whoever’s writing code, to bring things back to the clinicians, and have a discussion so that the performance improvement team—to help guide the clinicians in informatics, and say, you need to be thinking about this, and this could be a barrier. Because everyone needs to sit down together and make it work.

Do you foresee a large number of hospitals joining this initiative and working on this set of issues?

Czajka: That’s our hope, yes. This is information that should be acted on. All of our hospitals are really aligned around patient care concerns. This can really create a pathway to achieve better outcomes. Our hope is that this could create a big push.

Salyer: And with that big push, we really want to be able to help expedite that work, so that everyone isn’t always starting at ground zero; that we can share best practices, to help organizations get jump-started.

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