In-Depth Analysis of Current Processes and Failures

Performing an Institutional Assessment of Current Care

One of the first steps in improving care is a thorough survey of your current care environment, order sets, methods for assessing and tracking ACS patients, and a variety of other factors. This section provides a framework for such an assessment. Again, you may wish to focus on selected portions of the assessment at first, but eventually, essentially all these items need to be assessed and improved on in order to achieve optimal care. Note: You might find it helpful to use process mapping when you do your assessment of selected areas of interest. The Analyze Care Delivery, Process Flow Mapping section has more information on and examples of process mapping.

Assessment item 1: Institutional support

• Are buy-in from administration and a communication/medical staff committee reporting structure defined and in place? Do you have the resources available for forming a team and supporting its efforts in formulating order sets, protocols, educational programs, and metrics to optimize the care of the inpatient with ACS? Do you have an executive staff sponsor?

A team working on an improvement effort this large requires the recognition by hospital administration and medical staff committees of the importance of improving ACS patient care. If you haven’t already enrolled the administration in your cause, the Obtaining Institutional Support section will assist you in doing so and in defining the medical staff entities your team needs to report to. Because of the importance of ACS quality care measures in the CMS core measures and the PQRI measures, this recognition should be relatively straightforward.

Assessment item 2: Presence of a multidisciplinary team to address issues?

• Have you formed a truly multidisciplinary team or steering committee that works on the front lines of health care delivery, as outlined in Build a Team and Team Rules? If not, do so now! You won’t be able to complete the survey without the knowledge of representatives from all disciplines. Importantly, an appropriate team for the entire spectrum of ACS care will include members who can represent all the areas of a medical center that patients may encounter from the time they enter the emergency department to the moment they are transitioned out of the facility.

Assessment item 3: Reliable data flow and metrics

• What is the dashboard of measures your institution uses to assess its care of patients with acute coronary syndrome?
• What is your method for identifying patients with ACS? Do you only include AMI patients, or do you broaden your catchment to include those patients with other ACSs requiring hospitalization?
• Is the methodology for acquiring and recording ACS measures standardized and reliable?
• Are potential gaps in patient care identified in real time, or is the process retrospective? If it is retrospective, what is the lag time? Is that acceptable?
• How are the data communicated to the front line caregivers?
• Are there any concerns about data integrity and accuracy?

Help on data flow, formulating metrics, and presenting data is available in Track Performance.

Assessment item 4: Standardized order sets for ACS care

• What order sets/protocols for ACS care and monitoring already exist?
• Do your order sets include evidence-based practices such as rapid identification and risk stratification using accepted methods such as TIMI risk scores, identification of patients requiring immediate cardiac catheterization, appropriate assessment of LV function, and stress testing for diagnosis and prognosis?
• Do your order sets include standardized care processes such as monitoring beta-blocker use, aspirin use, ACE inhibitor use, and/ or other medication measures?
• Does your order set help to achieve success in meeting the ACS core measures?

Visit the ACS Resource Room Clinical Tools section for examples of order sets and care maps.

Assessment item 5: Inpatient ACS management

• How is care initiated in the ED and then transitioned to the appropriate inpatient setting and provider? When is the inpatient team notified of the patient?
• Who takes care of most ACS patients? Are there different care strategies depending on the type of coronary artery disease identified (unstable angina, non–ST segment elevation myocardial infarction (NSTEMI), or ST-segment-elevation myocardial infarction (STEMI).
• How is the care coordinated with cardiology? Are specific aspects of ACS care always managed by a cardiologist? How is the care coordinated among hospitalists and other members of the care team?
• Are there specific patients who are always cared for by a specific physician group? Are there criteria for this triage decision?
• Is there a daily review process regarding a patient’s ACS care?
• How well is a patient’s medical regimen managed? What proportion of patients are discharged with aspirin, beta-blocker, or statin therapy?
• How is advance care planning integrated into the inpatient management plan?
• How are patients evaluated for eligibility for devices such as AICDs? Is there a standard approach across providers?
• How are issues related to medications and polypharmacy assessed and managed?

Assessment item 6: Transitions in care

• Do you have a standard approach for transitioning patients from one setting in your medical center to another, for example, from the CCU to the floor?
• What is the readmission rate for patients with ACS?
• What are the most common reasons for readmission?
• What is the relationship between readmission and core measure performance?
• Is follow-up standardized?
• Are there any programs available for self-management after discharge?
• How is care coordinated with the follow-up physician? What information is transmitted to the follow-up physician? Are there specific mechanisms to assure that appropriate information regarding interventions, particularly stent placement, is communicated to the physician(s) responsible for follow-up?
• Is there assurance that the medical regimen on discharge is tailored to the patient, that the patient can afford and understand it, that medications are covered by the patient’s insurance, that the patient has defined follow-up, and that any specific drug monitoring is clearly understood?
• How do you identify patients who need translation of verbal and written instructions?
• How is medication reconciliation handled at these interfaces?

Assessment item 7: Educational issues

• Do you have a comprehensive ACS patient educational process In place?
• Is there a template in place for ordering ACS self-management education materials for patients?
• Who is responsible for the teaching?
• Do you routinely assess the learner as part of the educational process?
• Do you include information on community resources and further outpatient education if needed?
• Is up-to-date and comprehensive written information provided as appropriate?
• Do you have a reliable method to educate the patient whose primary language is other than English?

Staff education and certification

• Do you have a complete educational program in place for care of the inpatient with ACS?
• Is it widely available via intra- or Internet access?
• Is it interactive in the form of learner-based modules?
• Are the modules tailored to the nurses? Tailored to physicians and other providers?
• If yours is a teaching institution, is education appropriately targeted at house staff?
• Does your program address institution-specific order sets as well as general principles?
• Is there mandatory participation by key providers?
• Is the educational program case based?
• Is there any method for tracking participation or competence/understanding of the most important concepts?

Pharmacy issues

• Do pharmacists review the use of medications?
• Have formulary issues between the inpatient and outpatient settings been identified and resolved?
• How has medication reconciliation been integrated into ACS care?

The Comprehensive Educational Programs section is designed to assist you in successfully building, implementing, and tracking the results of a comprehensive educational program. Performing an institutional assessment can be daunting at first. Remember, you don’t have to fix or assess everything at once.

TASK

Perform an institutional assessment of your current practice
Download the task sheet