John A. Kueven
At North Mississippi Medical Center, standardization of wound care processes and products led to improved healing rates and a $300,000 annual reduction in supply expenses.
At a Glance
North Mississippi Medical Center learned four important lessons in its effort to standardize wound care products and processes of care:
- Designate clinical champions.
- Limit the number of vendors that provide products for a specialty.
- Reduce the number of similar-function wound care products that are available for use, with decisions guided by clinicians.
- Provide transparent information related to cost, the intentions of the initiative, usage patterns, and the criteria for evaluation.
Across the country, healthcare organizations are exploring the relationship between cost and quality of care. Many healthcare professionals have long believed that reducing the costs of providing care would also reduce quality. However, in recent years, prevailing thoughts regarding the relationship between cost and quality have been challenged, and new ideas have been suggested regarding the appropriate focus for quality of care efforts.
A common view is that healthcare organizations should focus on maintaining the same quality of care, but at a lower cost to the organization. A more optimistic view is that the focus should be on producing better outcomes at an equal cost. Some propose, however, that the ideal focus should be on producing better outcomes at a lower cost.
Case Study: Wound Care at NMMC
North Mississippi Medical Center (NMMC) in Tupelo, Miss., is an example of one organization that has achieved significant results with this ideal focus in the area of wound care. NMMC, the largest nongovernmental hospital in Mississippi and the largest rural hospital in the United States, began a process of standardizing advanced wound care products just two years ago.
Why advanced wound care products?
First, NMMC recognized that wound care can be extremely costly. In a study of 9,822 patients with wounds of varying etiologies, wound care costs averaged more than $5,000 per patient (Walker, D., The Cost of Outpatient Wound Care in Today's Wound Clinic, HMP Communications, July/August 2009). In extreme cases, costs exceeded $100,000. NMMC's analysis of its own wound care costs disclosed that it was incurring $620,000 per year, on average, on purchases of advanced wound care products alone.
Second, NMMC observed that multiple wound care products were being used to perform the same clinical function, resulting in a large volume of product usage. Such patterns are indicative of excessive costs and can result in poor clinical outcomes.
Third, NMMC realized that its goal of implementing evidence-based practices would be difficult to achieve if products were not standardized, and its leaders knew clinicians would support standardization. Clinical outcomes associated with standardizing wound assessment and practices provide a benchmark for judging outcomes in a specific institution (Bolton, L., McNees, P., & van Rijswijk, L., "Wound Healing Outcomes Using Standardized Assessment and Care in Clinical Practice," Journal of Wound, Ostomy and Continence Nursing, 2004).
Ultimately, standardization of wound care processes and products at NMMC led to a nearly 40 percent improvement in healing rates, a $300,000 annual reduction in supply expenses, enhanced efficiency, and reduced waste.
The Importance of Value Analysis in Standardizing Care
Prior to standardization, both wound care processes and the use of wound care products at NMMC varied within the wound care department and across the organization. Nine vendors supplied 68 advanced wound care products. Vendor-supported education for use of these products varied, resulting in considerable variation in product selection and protocols.
Additionally, the organization's use of antimicrobial dressings was not appropriate when considered against the relative rate of infections. Fewer than 50 percent of wounds healed within 16 weeks, a less-than-desired clinical outcome. A more detailed breakdown of advanced wound care product use and cost can be viewed in the exhibit below left.
As the first step in developing an effective strategy for advanced wound care standardization, NMMC created a value analysis committee whose charge was to identify why variability in wound care products and processes existed and then to work toward a solution. The committee comprised members from multiple departments across the organization, including clinical champions with advanced wound care expertise who were chosen to participate on a subcommittee that could provide clinical guidance for standardization of wound care products and processes. These champions were drawn from inpatient wound care, outpatient wound care, home health, and rehabilitation services.
NMMC also redefined protocols for testing new products and for providing education to staff regarding use of wound care products. To standardize wound care products, the value analysis committee performed an inventory analysis to list all wound care products used by NMMC. The clinical champions then selected four vendors that were considered viable candidates for product standardization, based on the suitability and quality of their products and their ability to meet the organization's service needs. The vendors cross referenced their products and provided pricing based on an assumption of gaining 80 percent of NMMC's wound product business.
Among the four vendors, the one with not only the lowest pricing but also highly perceived product quality and service capability was awarded the first trial conducted in each care area. Specific nurses and patients were targeted to create a controlled trial over a one-month period. The clinical champions were asked to report on the selected products' performance and evidence of positive outcomes resulting from use of the products.
Specific evaluation factors included:
- Antimicrobial performance
- Ease of use
- Minimization of pain upon removal of dressings
- Ability of the dressing to perform as indicated
- Adequacy of dressing wear times
- Evidence of an acceptable progression of wound healing
Based on the results of these trials, NMMC established a primary relationship with a single vendor. Two secondary vendors provided products that the primary vendor did not offer.
NMMC also recognized that in-service education and training were essential for standardizing clinical wound care practice. Therefore, the primary vendor, with the assistance of the clinical champions, instituted a process over several weeks to deliver in-service education to every service area throughout the care continuum and to address concerns. The constant support of the vendor and clinicians provided during this time helped to ensure that all staff would consistently follow appropriate processes and select appropriate products.
The initiative achieved four categories of results.
Process-related outcomes. The standardization of advanced wound care products throughout NMMC reduced the number of vendors from nine to one primary vendor and two secondary vendors. This change led to enhanced communication between clinicians and supply chain personnel. Standardization also resulted in more timely and efficient product trials, which could now be completed in one to six months, rather than nine to 12 months.
Patient/clinical related outcomes. Wound-healing rates were recorded eight months before and after standardization to allow for comparison. Standardization of wound care products and practices resulted in a significant improvement in 16-week healing rates-from 48.4 percent before the initiative to 87.5 percent afterward, almost doubling the percentage of wounds healing within the 16-week time frame. Patient satisfaction scores among wound care patients rose by 13 percent, and satisfaction among clinicians increased as well.
Product-related outcomes. As wound care products were standardized, NMMC reduced the types of wound care products used by the organization by 50 percent, from 68 products to 34. NMMC also reduced the number of units of these products by more than half, from 113,812 units per annum to 55,394, due to more standardized use of these products by clinicians.
The use and cost distribution for advanced wound care products shifted substantially after standardization, with the most notable shift occurring in a movement from a mixed formulary of foams and dressings from various product categories to a simplified and clinically effective formulary of foam and antimicrobial dressings.
Cost/fiscal outcomes. The annual expense for wound care products was reduced by $300,000, from $620,000 to $320,000. Reductions in necessary inventory on hand resulted in an estimated additional $25,000 per month being freed up for the health system ($51,667 versus $26,667).
Additional benefits of standardization include the following.
Continuous quality improvement. Practice standards systematically improved across the continuum of care. Clinicians now use dressings from the specific product groups for particular types of wounds across the continuum of care. Wound-related infection outcomes improved as advanced antimicrobial dressing usage increased from 6.6 percent of the total dressing volume to 20.5 percent of the total volume.
A decrease in product education hours. Because multiple products are no longer being used to accomplish identical tasks, the number of hours clinicians spend learning how to use specific wound care products has decreased.
Improved pricing. By moving 80 percent or more of NMMC's wound care product business to one advanced wound care product vendor, the organization gained the leverage to drive better pricing through volume.
Fewer recall opportunities. By reducing both the number of different products used and the number of vendors, fewer products used by the organization had the potential to be recalled by vendors.
It is noteworthy that the $300,000 savings reported in this study does not include other financial benefits. Standardization of wound care enabled NMMC to avoid costs associated with potential wound complications by improving healing rates. The enhanced outcomes resulting from this initiative also reduced the potential liability risk associated with wound care.
The benefits of standardizing wound care practices at NMMC were substantial and varied. These findings seem to dispel the myth that lower costs necessarily result in lower quality of care. To the contrary, these results indicate that the ideal of improved outcomes at a lower cost can be realized.
Moreover, several lessons can be drawn from a consideration of the various factors that led to NMMC's dramatic improvements in clinical outcomes for advanced wound care and cost reductions related to wound care products and care.
Designate clinical champions for the initiative. When clinical champions drive the standardization of advanced wound care products and care processes, formulary compliance improves and clinical practice protocols are more routinely followed. NMMC's ability to improve quality and enhance wound-healing outcomes was largely due to the leadership of clinical champions.
Limit the number of vendors that provide products for a care specialty. Selecting a primary vendor and two secondary vendors for wound care products allowed vendor support at NMMC for this specialty area to become tailored and more focused, resulting in consistent, more effective, and less costly education for clinicians and patients. NMMC also increased its purchasing power by shifting more of its wound care product business to fewer vendors. Vendors of choice should be capable and willing to provide ongoing educational and in-service support necessary to support standardization.
Reduce the number of similar-function wound care products that are available for use by clinicians, with decisions guided by clinicians. At NMMC, this approach helped to reduce investment in inventory on hand. The creation of a "continuum of care" for wound care practices at NMMC also reduced product usage.
Provide transparent information to those involved in the initiative to secure buy-in. At minimum, this information should include cost, the intentions of the initiative, usage patterns, and the criteria for evaluation.
Patrick McNees, PhD, is professor and associate dean for research and enterprise development, University of Alabama at Birmingham, Birmingham, Ala. (firstname.lastname@example.org).
John A. Kueven, RN, MSHA, is clinical resource manager, North Mississippi Medical Center, Tupelo, Miss. (John.Kueven@childrens.harvard.edu).
Editor's note: Research and writing of this article was supported with an educational grant funded by Mölnlycke Health Care.
About North Mississippi Medical Center
North Mississippi Medical Center (NMMC) is part of an integrated delivery system that includes six hospitals, four nursing homes, 33 clinics, a surgery center, and a variety of ancillary services and clinics. The organization covers a service area of 24 counties representing more than 700,000 people. NMMC is a Baldrige National Quality Award recipient and has received numerous other awards.
How Standardization Can Help Achieve Improved Value
Achieving better outcomes at a lower cost requires not only commitment, but also acceptance of some basic tenets. One such tenet is that improving quality while lowering costs is difficult to achieve without standardizing processes, products, and education. Another tenet is that achieving standardization is difficult without moving toward the use of a single-source vendor.
Today's healthcare environment calls for new efficiencies, and such efficiencies are often the result of standardization efforts. The importance of standardization has been articulated by possibly the most important figure in quality improvement efforts in the past three-quarters of a century: Edwards Deming.
Deming is known for his seminal role in creating systematic approaches to product and service quality (Walton, M., The Deming Management Method, Putnam Publishing Group, 1988). Those
following Deming suggested that standardization is central to the value chain sequence:a
Improved quality > decreased costs > improved productivity > capture market > stay in business > provide more jobs
Job creation or preservation may not be typically viewed as a primary objective for controlling supply costs. However, a primary objective of every healthcare provider should be to keep clinicians at the bedside. Because supply costs are easier to control than labor costs, product standardization is a key contributor for job preservation and creation.
To produce better outcomes at a lower cost, at least three areas must be standardized: processes, products, and education.
By standardizing processes, education, and products, hospitals can achieve benefits such as an improved care continuum for patients; less required education for clinicians regarding products and processes; fewer types of similar products; better pricing; fewer recall opportunities; ongoing process improvements, resulting in continuous quality improvement; and reduced waste.
Processes. A standardized process is a process that is followed the same way every time it is performed. The consequences of using variable processes typically include lower quality at higher costs-the least favorable of all ideals. In the absence of a structured educational and support system, the team will likely revert to old, inconsistent habits.
Education. In many organizations, two factors complicate educational efforts: too many vendors (resulting in too many products that are similar to each other) and compartmentalization across the healthcare system. The number of vendors and products has a direct bearing on challenges in standardizing clinical education. Multiple products available for a single purpose translate into multiple training needs. Education for clinicians also varies according to which vendor is providing the training. Compartmentalization-when departments act autonomously and select different products for the same purpose-further exacerbates the effects of
Products. Although Deming speaks to an array of issues regarding standardization, his most profound views may be those focused on standardizing products. He argues that product variability necessarily results in quality reductions. Although there can be many contributing sources to variability, the number of vendors is directly related to product variability. More precisely stated: The greater the number of vendors, the greater the product variability and the lower the quality. To address this phenomenon, Deming suggests moving toward single-source vendors (Deming, W. E., Out of the Crisis, MIT Press, 1986).
For years, the relative merits of single-source vendors versus multisource vendors have been discussed and argued. However, discussions to date have tended to focus on price. At least six outcomes indicate the advantages of a single-source, long-term vendor relationship:
- Improved economy
- Increased innovation
- Enhanced operational performance
- Lower investment costs
- Less total inventory
- Improved quality
a. Porter, M.E., "What Is Strategy?", Harvard Business Review, November-December 1996.
Publication Date: Tuesday, March 01, 2011