Step-by-Step Medicine

The Hospitalist. 2010 January;2010(01):

January 1, 2010 | The Hospitalist

Studies are published every month demonstrating that physicians who implement national guidelines at the local level improve such patient outcomes as mortality, length of stay, and time to clinical stability. Dr. Corrigan notes that there are abundant examples of guideline adherence boosting quality outcomes, and cites as a prime example the AHA’s Get With the Guidelines program (www.american heart.org/presenter.jhtml?identifier=1165), which has documented quality gains in coronary artery disease, stroke, and heart failure patients.

We’re finally shedding light on how to tackle patient handoff and hospital readmission issues. ... If we were to solve just that one piece, we can more easily start implementing other clinical guidelines.

—William T. Ford, MD, FHM, section chief of hospital medicine, Temple University Hospital, Philadelphia

Barriers to Acceptance and Adherence

But there are obstacles to guideline adherence, and widespread practice pattern variation remains a huge national problem. Providers in some regions of the country can use twice the resources as their counterparts in other regions and bring no additional benefit to patients (see “Medicare Fee Inspection,” p. 30). The Dartmouth Atlas of Health Care says unwarranted practice variation is responsible for as much as 30% of wasted healthcare spending in the U.S.—a cost that reformers are anxious to eliminate.

The traditional culture of autonomy in the medical profession is perhaps the most difficult and enduring barrier to reducing unjustified practice variation: clinicians don’t automatically follow guidelines, many treat them more as options than as true standards, and organizations do not sufficiently enforce or reward adherence to guidelines, wrote researchers in a special 2005 issue of Health Affairs focusing on guidelines.2

Care-Transition

Physicians and hospitals can get expert guidance implementing care-transition guidelines. Here are some of the best resources:

Joint Commission Resources (JCR), the educational consulting arm of The Joint Commission, helps organizations assess how they are meeting such core accreditation measures as educating patients about their medication and care plan upon discharge, says Roberta Fruth, PhD, RN, FAAN, JCR/JCI, senior consultant for JCR. In one hospital, for example, implementing patient discharge education checklists and assigning accountability to specific staff members greatly improved discharge-planning performance. “Hospitalists have been leading many workflow improvement projects like these,” Dr. Fruth says.
The Joint Commission recently launched its Center for Transforming Healthcare, tasked with identifying and implementing consistent best practices that address quality and safety challenges facing healthcare organizations, and sharing proven solutions with the more than 17,000 organizations it accredits. The center first addressed hand hygiene to prevent the spread of infections, and is focusing on effective handoff communications.
SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) translates consensus guidelines for effective hospital discharge planning into clear, achievable intervention steps that specific institutions can customize and implement. The program offers training sessions, as well as yearlong mentoring programs in which expert coaches provide hands-on facilitation to help hospitals implement best practices for safe and effective discharge of elderly patients from the hospital, says Tina Budnitz, MPH, Project BOOST’s director and SHM senior advisor.

The project aims to reduce 30-day readmission rates, improve information flow between sending and receiving physicians, ensure that high-risk patients receive follow-up calls within 72 hours of discharge, and improve patient and family education practices to encourage use of the teach-back process around risk-specific issues such as medication compliance. SHM is collecting data from the program’s mentoring activities at 30 hospital sites. “We’re meeting with legislators to encourage the adoption of Project BOOST demonstration projects in their healthcare reform bills, as a means to lower preventable hospital readmission rates,” Budnitz says.

IHI synthesizes guideline literature and has been working with a number of hospitals over the past two years to advise front-line-care teams how to improve care transitions and lower preventable hospital readmission rates.
SHM has launched a series of leadership training programs for its members, focusing on topics including protocol implementation, interdisciplinary team-building, and communication strategies for conflict resolution among clinicians. “Our programs help hospitalists and other clinicians change processes to better prepare their patients to go home, or to strengthen their relationship with primary-care physicians in the community after their patient is discharged,” Budnitz says.
SHM is leading the development of care-transition measures for the Physician Consortium for Performance Improvement (PCPI), an AMA-convened organization that is developing performance measures to be used for outcome measurement, quality reporting, and pay-for-performance incentive programs, says Joseph A. Miller, SHM executive advisor to the CEO. The measures could soon be included in Medicare’s Physician Quality Reporting Initiative (PQRI).—CG

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