Appropriate utilization of telemetry alone helped leaders reduce costs by $4.8 million each year.
Leaders at Christiana Care Health System, a multihospital system based in Wilmington, Del., understand that quality improvements can deliver financial results. In fact, enhancing quality has helped the organization avoid $100 million in costs during a five-year period.
Ensuring Appropriate Telemetry Use
One of the organization’s greatest successes has been preventing overuse of telemetry outside of the intensive care unit (ICU). This improvement has helped the organization sustain annual savings of approximately $4.8 million, says Robert M. Dressler, MD, Quality and Safety Officer for Academic Affairs. The results of these efforts were highlighted in JAMA Internal Medicine (Dressler R., Dryer M.A., and Coletti, C., “Altering Overuse of Cardiac Telemetry in Non-Intensive Care Unity Settings by Hardwiring the Use of American Heart Association Guidelines,” JAMA Internal Medicine, vol. 174, no. 11).
Reducing this type of waste required some smart IT fixes and new nursing workflows. Leaders learned that nurses and providers were frustrated by chasing down physicians when 72-hour telemetry orders automatically expired and required physician authorizations to discontinue or continue telemetry. To eliminate this problem, a multidisciplinary team—which included nurses, pharmacists, hospitalists, cardiologists, and IT and telemetry experts—designed a clinical decision support tool for both groups of clinicians. For physicians, it was the requirement to order telemetry by clinical indication based upon American Heart Association guidelines. This set the duration for telemetry. For nurses, a clinical decision support tool was integrated into their workflow so nurses could assess if it was safe to discontinue orders or were guided to call a physician to discuss the patient’s clinical condition.
As part of the redesign, leaders at Christiana Care also automated how the central telemetry monitoring station is notified when patients discontinue telemetry, saving nurses valuable time. “Weaving changes in their existing workflows and making it easy for everyone to follow is the real art of this,” Dressler says.
Doing the Right Thing
The telemetry initiative is just one example of how leaders at Christiana Care constantly look to root out waste.
“More is not necessarily better in health care—appropriateness is really important,” says Sharon L. Anderson, RN, senior vice president of quality and patient safety, chief population health officer, and the president of Carelink CareNow at Christiana Care. “We have to build systems that make it easier for people to do the right thing.”
Another example of an initiative following this philosophy was focused on reducing unnecessary daily lab tests in keeping with recommendations from the American Board of Internal Medicine Foundation’s Choosing Wisely campaign. Previously, 90 percent of automatically recurring lab tests ordered by clinicians at Christiana Care did not have designated end dates, which led to unnecessary ost accounting and decision supportblood draws, Dressler says. Stopping these recurring tests from being ordered required modifying the EHR and retraining staff to shift their mindset to assess the clinical needs of their patients daily and order labs accordingly. Their efforts were worth it: In five months, leaders saw a 17 percent decrease in census-adjusted chemistries and complete blood counts. That translates to more than 60,000 unnecessary lab studies eliminated each year.
Another area where leaders improved quality and reduced waste was in blood transfusions. After a clinical team’s pilot, Christiana Care hired a transfusion safety officer who has led efforts across the health system to standardize how much blood is given by procedure. As a result, the health system realized a 56 percent reduction in blood transfused in units greater than seven in the ICU. They also had a 33 percent reduction in overall unit volume in the ICU and a 15 percent reduction for all of Christiana Care after one year. This equates to more than $1 million in savings and helps keep patients safe by reducing unnecessary blood, Anderson says.
Creating an Efficient Culture
At Christiana Care, leaders focus on three main goal areas to create a culture of efficiency: providing optimal care, delivering an exceptional experience, and ensuring organizational vitality (financial sustainability). The board’s quality and safety committee sets new strategic goals in these areas for the organization annually. “Every year, our goals get harder, and we rise to the occasion,” Anderson says.
Anderson also credits Christiana Care’s culture of measurement for the organization’s focus on value and efficiency. Across the health system, leaders track more than 200 metrics, such as falls, skin breakdowns, and antibiotic protocol compliance, which can be viewed on interactive dashboards down to unit and individual patient levels. “It’s really important from a cultural standpoint to drive quality—you can’t just give reports, you actually have to create timely and actionable information,” she says.
Preparing for Population Health
Technology tools also help drive the organization’s culture of efficiency. Six years ago, Christiana Care was awarded a $10 million grant from the Center for Medicare & Medicaid Innovation (CMMI) to establish an IT-enabled care management platform that leverages Delaware’s advanced health information exchange. The Carelink CareNow tool integrates data on hospitalizations, emergency department visits, lab tests, pharmacy fills, and claims, and uses predictive analytics to help primary care physicians identify and manage high-risk populations.
“We thought that if we could harness the power of real-time clinical data and add other information, we could get a 360-degree view of a patient so we could work concurrently, in real time, to change the trajectory of care and reduce costs and improve quality,” Anderson says.
Today that platform, called Carelink CareNow, has become a strategic asset to Christiana Care as the health system prepares to take on more risk. For example, the tool has helped Christiana Care reduce 90-day readmissions by 30 percent among joint replacement patients.
To date, Christiana Care is managing 104,000 lives, including the eBrightHealth ACO (accountable care organization) partnership with 50,000 Medicare beneficiaries as well as an Aetna partnership that includes 29,000 Delaware state employees, spouses, and dependents.
Recently, the tool earned the 2017 John M. Eisenberg Patient Safety and Quality Award from the Joint Commission and the National Quality Forum, as well as the National Patient Safety Foundation’s 2017 Stand Up for Patient Safety Management Award.
Learning Through Experience
Dressler and Anderson offer the following advice for organizations looking to improve quality, reduce waste, and create a culture of efficiency.
Share clinical stories to help facilitate process change buy in. “Everyone had something they wanted to gain by redesigning our telemetry process—bedside nurses, pharmacists, clinicians, cardiologists, and hospitalists,” Dressler says. “We wanted to collect the clinical stories about why this was important.” For example, some clinicians were not aware that telemetry outside the ICU was putting patients at increased risk of tripping over wires and falling. By sharing these stories and seeking to understand each stakeholder’s goals, leaders were able to get buy in early in the process.
Change clinicians’ mindsets. “We are working actively to switch how clinicians think about clinical care,” Dressler says. “We weren’t trained in medical school to be shepherds of resources; we were trained to provide the right care to the right patient. However, that conversation has evolved over the last decade, and we need to be much more mindful of the financial calculus, not solely for each individual patient, but as an aggregate to make sure we are good shepherds of both the institution’s and our community’s resources.” Giving clinicians access to transparent quality and cost data is one way to help facilitate that mindset shift, leaders at Christiana Care say.
Establish a “just culture.” Such a culture aims to promote patient safety by focusing on system improvements rather than an individual’s actions. To build such a culture, leaders need policies and practices that assume good intentions, thereby encouraging staff to speak up when mistakes happen to promote system learning and targeted redesign.
Recognize good work. Fifteen years ago, the organization launched its Christiana Care Way Awards to honor improvements that follow a plan-do-check-act (PDCA) cycle for continuous improvement. Last year, leaders received more than 125 entries and presented 30 awards on areas like financial improvement, reduction of healthcare disparities, nursing, and care process redesign. They also regularly present Good Catch Awards to recognize staff who help prevent patient harm through vigilance and awareness of how the environment affects patient care.
Tying Quality to the Bottom Line
As Christiana Care prepares to take on more risk through its population health efforts, leaders recognize the importance of frequently monitoring the costs of adverse events such as central line-associated blood stream infections or hospital-acquired C. difficile infections and developing strategies to reduce patient harm and improve quality.
“We tend to think of quality as an isolated clinical initiative, but it really does have financial implications,” Anderson says. “It’s an important message. Everyone is looking to reduce costs, and as long as we improve quality, we are going to get there.”
Interviewed for this article:
Robert M. Dressler, MD, quality and safety officer for academic affairs, Christiana Care Health System, Wilmington, Del.
Sharon L. Anderson, RN, BSN, MS, FACHE, is the senior vice president, quality and patient safety, chief population health officer, and president of Carelink CareNow, Christiana Care Health System, Wilmington, Del.