Layer Interventions — Beyond Protocols: Layering Reliability
Consider the following hierarchy of reliability in implementing programs to enhance ACS care. Keep in mind that you are creating several linked protocols and order sets and that these levels pertain to each protocol and order set and to the transitions you build into them to go from one protocol to the next. Focusing on only one aspect (such as risk stratification occurring in the ED) will result in suboptimal care as patients flow from one setting to the next.
Level 1 State of nature (sometimes chaos)
The institution has no standardized order sets or protocols. Reliance on individual expertise and experience is the only strategy to achieve quality care. Expect:
- ACS core measure performance to be uneven across measures and/or across time.
- Uneven training/knowledge by providers.
- High rates of preventable readmissions.
- Dissatisfaction of patients with the care they receive for their ACS.
Level 2 Average: incomplete order sets/protocols
- Order sets with some but not all information necessary to effectively manage patients with ACS.
- Detailed guidance is available in stand-alone protocols, but these are not well integrated into the order sets or work flow.
Level 3 Integrated order sets/protocols
Level 3 is the entry point for most serious QI efforts; some would term this method “indication-based order sets,” meaning each order set is for a specific purpose (primary diagnosis of ACS versus secondary diagnosis of ACS), and some guidance for proper ordering, administration, and monitoring is integrated into it. Aids for decision making created by the multidisciplinary team are available to support decision making at the point of care or in the order sets. However, clinicians may be frustrated in having to enter multiple order sets and work through redundant information.
Remember that providers should always retain the freedom to deviate from the protocol specifically to meet the needs of a given patient. Eventually, with successive refinements, the protocol should drive management choices for the great majority of patients.
Level 4
The general order sets and protocols are supported by more detailed, comprehensive, institution-specific algorithms and protocols that promote a standardized approach, and additional performance-improvement strategies are used. Furthermore, patients with either a primary or secondary ACS diagnosis are identified, and ACS care is optimized across the care continuum.
Guidance from your local algorithms and protocols is reinforced at the point of care whenever possible. Remember, some tradeoffs are inherent to this more guided and algorithmic methodology. As you integrate more and more of your preferred algorithm and regimens into your order set, you reduce not only variability in ordering but also the choices available to your prescribers and patients. Also, education must continue, as always, because health care providers must understand the rationale for the protocol in order to know when to wisely deviate from it.
The table below outlines several quality improvement strategies to consider, most of which leverage having ACS management protocols in the work flow. Providers pharmacists, nurses, even patients can refer to the ACS protocols for clarity, confidence, or advocacy. With additional layers to the overall ACS effort, include at least one high-reliability mechanism in the design.
Level 5 Oversights “identified and mitigated” *
Level 5 represents a profound leap in quality. At this level you will improve care by a whole order of magnitude, a rare achievement in health care. All the conditions of level 4 exist, plus there is now a strategy to identify and address management oversights that inevitably occur. At level 4, the care of 70%–80% of your patients with ACS may be optimized. Will your team be satisfied with that considerable gain? It depends on whether you are merely pursuing excellence (relative to “industry standards”) or are actually pursuing perfection. Level 5 may be impractical or unsustainable without an electronic-reporting mechanism and proper metrics, which we reviewed in Track Performance.
*Nolan T, Resar R, Haraaden C, Griffin F. White Paper: Improving the reliability of health care. Institute for Healthcare Improvement. Innovation Series 2004. Available at: http://www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliabilityofHealthCare.htm.
Accessed December 1, 2006.
Armamentarium of QI Strategies |
| QI strategies | Specific ideas for management |
| Provider education |
- Didactic sessions on ACS (eg, noon conference, grand rounds, etc.) or, better yet, comprehensive educational programs with mandatory participation and performance (certification).
- Distributed educational materials (eg, pocket cards, handbooks).
- Intranet or Web-based educational programs.
|
| Provider reminder systems |
- Prompts nested within paper admission/transfer/postop order sets supported by guides for insulin ordering (insulin protocol).
- Prompts within CPOE to follow ACS care recommendations.
- Stickers on charts or posters in order-writing areas.
|
Facilitated relay of
clinical data to providers |
- Alerts to physicians by means other than the medical record (eg, page, electronic alert, phone call, e-mail to provider about patients with gaps in ACS care or patients not on recommended therapies).
|
| Audit and feedback on performance to providers |
- Feedback on core measure performance, readmission rate, and mortality to individual providers or groups of providers (with or without benchmarking top performers).
|
| Patient education |
- Programs dedicated to assessing the learner, teaching “survival skills” (especially in the immediate postdischarge period), and other materials (eg, pamphlets, physician or nurse teaching patient or caregiver, closed-circuit TV program in patient rooms).
|
Organizational or
operational change |
|
Incentives, regulation,
and policy |
Provider directed:
- Honor recognition of highest performers each month or quarter.
- Financial incentives based on achievement of ACS management goals.
- Punitive actions for failure to meet minimum performance or to cooperate with improvement efforts (suspension of privileges, stockade in town square, etc.)
Health system directed:
- Enforced policy mandating use of ACS management protocols and order sets (eg, patient cannot be discharged without having appropriate HF instructions)
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Source: adapted from Shojania KG, McDonald KM, Wachter RM, Owens DK. Series Overview and Methodology. 2004. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies; Vol. 1. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/qualgap1/qualgap1.pdf.
Level 6 Achieving true excellence
As in level 5, almost all patients receive ACS care and other testing/therapy per protocol, and every patient not addressed by the protocol is channeled through the identify-and-mitigate strategy. In level 6 the efficacy of mitigation itself is immediately judged, and its own failures are immediately remedied. Most important, the failure modes of mitigation are systematically analyzed and eliminated. If your team achieves this level, you will be pioneers. If your solutions can be adopted readily by other institutions, you will utterly transform hospital care.
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