by Laurale Cross, APRN, NNP-BC; and Shana Foley, RN, BSN, CEN
Featured in the January-February 2020 Colorado Medicine Colorado Medicine.
The Transforming Clinical Practice Initiative (TCPi), which worked with close to 200 practices during its four-year time frame, submitted about 20 “exemplar practice” stories to the Centers for Medicare and Medicaid Services directory. TCPi is a federally funded, governor’s office initiative that ended Sept. 30, 2019. The following is an edited version of the story that illustrates some of the work Valley View Emergency Department did to earn the “exemplar” designation.
Valley View Emergency Department (ED), which is part of the Valley View health care system in Glenwood Springs, Colo., strives to be the destination of choice for all who aspire to heal and be healed. By focusing on what is best for patients, the team has improved patient satisfaction and experience scores, saved hundreds of thousands of dollars and achieved high quality, safety and cost efficiency/cost savings.
The emergency services practice team is made up of 13 physicians and a staff of 31, which sees an average of 13,000 encounters, with 17 percent of those being admissions. The site is a level-3 trauma center that averages 2,800 patient visits per year for trauma-related care.
There is a new, dynamic leadership group for the trauma program that has reached out to the local schools to teach programs like “Stop the Bleed,” which gives high school students knowledge about basic hemorrhage control through education and hands-on training. The team has completed training with 800 students to date and is planning to teach clinical and non-clinical hospital staff. The Trauma Team is attending staff meetings all over the hospital to train additional instructors who will in turn spread this vital education to our community.
Another high school initiative is the “Seatbelt Challenge,” which stresses the importance of always wearing a seatbelt and resulted in 15 percent more students wearing seatbelts during the six-week challenge. This was validated by direct observation as students entered the parking lot.
The team also attends health fairs throughout the valley, reminding community members to wear helmets when skiing and biking, which are common activities in the area, and distributes free helmets to those who don’t have one.
A patient-focused approach
Katelyn Kulacz, a nurse resident, initiated a new process for patient callbacks in 2017 that illustrates how focusing on patients benefits the entire team. A team member calls each patient the day following hospital discharge to ensure the patient understood all of the instructions and filled prescriptions, and to field questions.
The team is making 20 to 30 patient calls daily and have seen Press Ganey scores for patients’ level of understanding discharge instructions move from 68 percent to 93 percent during a six-month period.
This is especially significant considering the research shows that patients who receive calls from care teams are more satisfied with their care and have fewer readmissions.
The team also improved its referral process. Instead of telling patients to call for a specialty or primary care appointment and handing them a business card, the team sends an official referral request to the recommended practice with pertinent patient information. Staff have worked with local practices to identify contacts for referral requests to expedite the process. During follow-up patient calls, staff ask if the appointment has been scheduled and, if not, they help schedule urgent appointments. These steps help close the loop and make suggestions for care less overwhelming.
The team has sustained Kate’s initial work to reform the referral process and added the ability for doctors to flag patients for special attention during follow-up calls. Staff can attach documentation to a patient’s initial emergency department visit in the electronic medical record, which helps with patients who have repeated visits and unexpected outcomes. Kate’s enthusiasm helped overcome initial obstacles and embed the process in the culture. The team recognized that unnecessary test duplication, which was common with imaging, was wasteful for the system and exposed patients to higher risks and costs. Instead of routinely ordering imaging studies, staff use the health information exchange to check for recent, relevant tests/images to avoid duplicating tests whenever possible.
The team continues to improve processes to see patient care data from a broader perspective instead of limiting that picture to the western Colorado region.
The team appreciates the effect high utilizers of hospital services have on community resources and piloted an intervention with chronic pain patients to see whether the primary driver was lack of primary care and effective care plans. The team met individually with two patients in the pilot (who had accounted for 14 emergency department visits during three months with an average per-visit cost of $3,570) and connected them with a primary care provider who designed a plan to prevent a pain-related crisis. The team also offered acupuncture at no cost.
These patients are now primarily managed outside the emergency department, receiving much simpler protocols such as IV fluids and oral medications such as Zofran, and only come to the ED if these approaches fail. Once a solid plan was in place, both patients were seen just three times in the ED during a three-month period and are satisfied and engaged with their care. Previous to the pilot program both patients were unhappy with their care and engaged in a grievance process.
Their combined ED costs during the three months dropped from about $50,000 to $10,700, which represents $40,000 in cost savings for that time period.
Since then, there have been months when the patients did not visit the ED, which makes the estimated savings from these efforts more than $160,000 per year for these two patients. The next step is to replicate this success with other high ED utilizers. A dashboard allows the team to see the number of patient visits and identify opportunities for intervention. It’s a long-term project and will require many resources to meet patients’ needs.
The hospital invested in Tableau, a powerful data repository that allows the team to pull large amounts of data from multiple sources. “Heat maps” demonstrate how busy the department was (by color ranging from green, yellow, orange, red) according to real data instead of guesses, which also helps with taking action to improve satisfaction and experience scores.
During the past year we have given staff meaningful and timely feedback regarding performance, Press Ganey survey comments, chart audits, etc. By establishing open and honest lines of communication and being straightforward with expectations, staff are meeting expectations. Providers are also receiving immediate feedback regarding patient grievances/complaints. Whenever possible this feedback is given directly by patients via emails and phone messages, which is more powerful than a second- or third-hand conversation from leadership. The power of the patient’s voice was illustrated with one provider, who had four active grievances from patients during a six-week period in 2018. After changing our process, it has been almost a full year without a single complaint regarding that provider.
The patient voice
Along with many improvement efforts, patient satisfaction has improved. The overall Press Ganey score increased from 72 in January 2017 to 82 by October 2018. One area we are still working to improve is keeping patients apprised of wait times. We encourage the use of white boards in each room for the nurse to note timing of tests and what is next with a patient’s plan of care. As we round on patients, we notice the boards are being used more regularly and expect this score to improve in the near future.
In September 2018, we implemented supply software that keeps real time counts on department supplies and allowed us to charge patients for supplies we use for their care. It was a big learning curve and adjustment for nurses, techs and doctors to log in and pull supplies this way, but the reward is also big. We are saving thousands of dollars each month. Monthly supply cost went from around $3,000 to $300, due to reducing charges to patients and department waste. The savings from the latter allowed us to reinstate a position by demonstrating revenue capture. We now have a department secretary who answers calls during peak activity times and assists patients with discharge planning and referral appointments.
During 2018 we saw alarming medication errors in the ED that were attributed to inaccurate patient weights. We discovered that the accepted practice was to use “stated weights” obtained from patients or their families. One medication error for a critical anticoagulant resulted in under-dosing of Lovenox, which required transfer to a higher level of care. Another case was related to an inaccurate weight that was used to calculate weight-based antibiotics for a case of severe pneumonia.
The team uses Tableau to create a report that shows the data source for weights. In the initial data collection, 75 percent of patient weights were based on stated weight and only 25 percent on actual weights. Today the “stated weight” rate has decreased to less than 2 percent and actual weights are at 98 percent by weighing incoming patients as part of their triage assessment and using three new stretchers that weigh patients in bed.
A new pediatric scale shows weight in kilograms, which also decreases room for error. The team continues to strive for zero stated weights in the ED.
Valley View’s goal is to improve patients’ pain management and return them to a maximum quality of life while controlling the inherent risks of prescribing highly addictive medications like opioids. The Colorado ALTO Project is an initiative based on the successful Colorado Hospital Association (CHA) Opioid Safety Pilot in which a cohort of 10 hospital EDs decreased the prescriptions for opioids by 36 percent while increasing the use of alternatives to opioids (ALTOs). The ED at Valley View was one of the first EDs beyond the initial 10 pilot sites to test reproducibility of the initial results in October 2017. Recent data show success.
The VVH team is also working to reduce opioids prescribed at discharge. We can report provider-specific patterns and show a significant reduction in discharge opioids prescribed by providers as a group and by provider.
Due to the success of the efforts described in this article, change is now common in the VVH ED and providers and support staff are familiar with quality improvement. As a result, resistance to change has been significantly decreased. Small, successful changes and celebrations of these wins are powerful motivators for future improvements. The team will continue to focus on controlling costs and providing value to patients. Success in the ED most likely translates to fewer visits with cost savings to the community.
Decreased patient visits will also result in less revenue for the department and the team is looking at ways to be leaner. Much of our work aligns with value-based payments. TCPi participation has provided us with resources and opportunities that we were not aware of previously and have helped support transformation efforts.
This is the first of a series of articles that highlights the work practices engaged in TCPi do to earn “exemplar” status with the federal CMS.
Learn more about this federally funded, governor’s office initiative at www.co.gov/healthinnovation/tcpi, a website that will be maintained as an archive through July 2020.