Multidisciplinary Teams

Developing Interventions – Linking the Improvement Team and Care Team

The role of the Improvement Team is to optimize heart failure care delivery, much of which can be improved through standardization and incorporation of specific practices into routine care delivery.  Why is routine important? Across a population of patients, one of the most common sources of suboptimal care arises from provider inconsistency. For a variety of reasons providers inevitably vary care inappropriately, whether compared to each other or compared to themselves. In fact, a graph that depicts improved system performance over time almost always shows a progressive narrowing of the range of performance data points.

The development of protocols that help to standardize the care delivered are an essential part of improve heart failure care delivery.  The best protocols provide standardization while at the same time preserve the ability of the clinician to customize care for special patient situations or circumstances. In contrast to variation that arises from provider behavior, variation from the protocol because of special patient situations is always acceptable. The protocol should make that clear.

As always, the devil is in the details. An order set/protocol will usually fail unless the team pays attention to these details.

Principle 1
Keep it simple for the end user. There will inevitably be trade-offs between the depth of detail of guidance you want to give providers and the simplicity of the forms and the processes the end users have to go through. Most of the time, simpler is better. Minimize the number of unnecessary steps.

Principle 2
You can’t interrupt the work flow. The proposed intervention needs to fit into the work flow of the care team and cannot worsen efficiency.  Ideally you would like the intervention to improve efficiency and eliminate waste and re-work.  Involve frontline workers to make sure your plans are feasible and that your order sets/protocols are easy to use. Default orders that articulate the starting point for care for most patients are a good place to begin to standardize care.  Get input from frontline staff on how to make implementation go smoothly. Clinicians should want to use your order sets, tools if they are constructed properly.

Principle 3
Design reliability into the process. Human beings are incapable of doing anything reliably 100% of the time in the complicated health care setting. Part of your team’s job is to engineer higher reliability into the processes of heart failure care.  If your protocol relies solely on these traditional methods, you will be disappointed with the results:

• Common equipment and standardized order sets;
• Personal checklists;
• Working harder next time;
• Feedback of information on compliance;
• Awareness and training.

All these methods are helpful (and some are necessary), but they are not sufficient for achieving breakthrough improvement. You must design at least one of the following methods into your interventions to enhance the probability that each patient will receive the correct kind of therapy for his or her particular situation.

High-Reliability Strategies

Examples of these methods as they apply to heart failure care:

• Incorporate retrieval of ejection function data into HF admission order sets set.
• Develop forced functions that require a specific action to be taken or the reason it is not to be documented – such as documentation of why an ACEI or ARB is not administered for patients with heart failure.
• Integrate daily data review into processes for multiple members of the care team.
• Examples of these and much more are presented in later sections, along with specific tips on how to integrate high-reliability design features.

Principle 4
Pilot your protocol/order set on a small scale before attempting wide implementation. Inevitably there will some glitches with your initial order set and/or algorithm. It’s best to “fail faster” by piloting on a small scale, so you can get the glitches out of the way before you implement your protocol more broadly. The pilot can be as simple as a paper algorithm you ask 3–4 doctors to use or trying the order set on one unit or for a set period of time.

Principle 5
Monitor the use of your protocol and order set: expect variation from the protocol and learn from it. Reduce variation from your protocol over time. Rolling out the protocol is really only a beginning. You need to learn from variations in your process. Why isn’t the order set being used in some areas? Can we integrate it into other heavily used order sets? Which service needs our focused educational efforts? Which patients just don’t “fit” with our protocol — can we change the protocol so that it fits more patients and situations? The idea is to squeeze variability out of the process while retaining variation based on tailoring to accommodate the patient.