Layer Interventions — Beyond Protocols: Layering Reliability
Consider the following hierarchy of reliability in implementing programs to enhance heart failure 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 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:
- Heart failure 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 heart failure.
Level 2 Average: incomplete order sets/protocols
- Order sets with some but not all information necessary to effectively manage patients with heart failure.
- Detailed guidance is available in stand-alone protocols, but these protocols 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 heart failure vs. secondary diagnosis of heart failure), 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 heart failure diagnosis are identified and heart failure care is optimized across the care continuum.
Guidance from your local algorithms and protocols are 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 on the next page outlines several quality improvement strategies to consider. Most of these other strategies leverage that you now heart failure management protocols in the work flow. Providers, nurses, pharmacists, even patients can refer back to the heart failure protocols for clarity, confidence, or advocacy. With any additional layer(s) to the overall heart failure management 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 the management oversights that inevitably occur. At level 4, 70%–80% of your patients with heart failure may be having their care optimized. Will your team be satisfied with that considerable gain? It depends on whether you are merely pursuing excellence (relative to “industry standards”) or whether you are actually pursuing perfection. Level 5 may be impractical or unsustainable without an electronic-reporting mechanism and proper metrics, which we reviewed in Section III.
Armamentarium of QI Strategies
QI strategies |
Specific ideas for heart failure management
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Provider education |
Didactic sessions on heart failure care (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, etc.).
Intranet or Web-based educational programs. |
Provider reminder systems |
Prompts nested within paper admission/transfer/post-op order sets supported by guides for insulin ordering (insulin protocol).
Prompts within CPOE to follow heart failure 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 heart failure carel or patients not on recommended therapies). |
Audit and feedback on performance to providers |
Feedback on core measure performance, readmission rate, 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 post-discharge period) and other materials (eg, pamphlets, physician or nurse teaching patient or caregiver, closed-circuit TV program in patient rooms, etc.) . |
Organizational or
operational change |
Administrative support personnel dedicated to ensuring preview of tools and patient education materials developed
Clinical support personnel dedicated to collecting data and creating useful reports on heart failure management (see Metrics section).
Hospital-wide (or unit- or service-specific) teams or individuals with regular responsibility to focus on heart failure management. |
Incentives, regulation,
and policy |
Provider directed:
Honor recognition of highest performers each month or quarter.
Financial incentives based on achievement of heart failure 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 heart failure management protocols and order sets (e.g patient cannot be discharged without having appropriate HF instructions) |
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 heart failure 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 of reliability, you will be pioneers. If your solutions can be adopted readily by other institutions, you will utterly transform hospital care.
Plan Do Study Act
Action-Oriented Learning: Plan–Do–Study–Act
No plan survives its first contact with reality, particularly if it aims high. And especially in a complex environment like a hospital, there will always be unforeseen glitches when trying something new. But you can start small and scale up quickly by using rapid cycles of action-oriented learning. A great way to do this is by using the popular plan do study act (PDSA) model.
Start by planning (plan) your intervention and then test (do) it. The next step (study) is critical. Observe the test yourself, paying close attention to competing demands and physical space. Most important, ask those involved in the test what worked and what did not, and listen carefully. Ask them for alternative ideas, pitch your own, and talk it out. The idea is to get a read on what could or should be done differently from how your team originally planned it. The last step is to set things up to do better next time (act).
The following table highlights the advantages of PDSA and provides principles for doing it well.
Advantages of PDSA and Principles for Success
Advantages of PDSA
- Allows valuable modifications to improve effectiveness or preserve productivity.
- Allows “failures” to come to light without undermining performance and momentum.
- Identifies areas of resistance that might undermine the plan and spread to other units.
- Allows costs and side effects of the change to be assessed.
- Increases certainty that change will result in improvement.
- Allows for detailed documentation of improvement.
- Allows for detailed documentation of improvement.
Principles for Success
- Start new changes on the smallest possible scale, such as one patient, one nurse, one doctor.
- Run just as many PDSA cycles as necessary to gain confidence in a change, then spread incrementally.
- Spread incrementally to more patients, then more nurses, then more doctors, and finally more units.
- Balance changes in the overall system to ensure other processes are not adversely stressed.
- Pay special attention to preserving productivity and work flow.
Whoever observes and studies the test should record lessons and the suggested tweaks. These should be shared at the next multidisciplinary team meeting.
The IHI has a preprinted PDSA Work Sheet you may find helpful to download.
Plan Do Study Act Work Sheet for Testing Changes
- Aim
- Describe the aim of this project.
- Every aim will require multiple smaller tests of change.
- Describe your first (or next) test of change.
- Person Responsible.
- When to be done.
- Where to be done.
- Plan
- List the tasks needed to set up this test of change.
- Person Responsible.
- When to be done.
- Where to be done.
- Predict what will happen when the test is carried out.
- Measures to determine if prediction succeeds.
- Do
- Describe what actually happened when you ran the test.
- Study
- Describe the measured results and how they compared to the predictions.
- Act
- Describe what modifications to the plan will be made for the next cycle from what you learned.
On to Specific Interventions
As we continue this section, we will assist you in constructing a series of interventions that will support you efforts. Return to these introductory sections on interventions periodically to make sure you are leveraging the algorithms and protocols to the fullest extent possible.
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