Interdisciplinary, functional approach to quality review.

Faced with the accreditation changes embodied in the "Agenda for Change" of the Joint Commission on Accreditation of Healthcare Organizations, Elmhurst Hospital Center, Elmhurst, N.Y., formulated a multidisciplinary performance improvement team. This team included representation from medical staff, nursing, social work, pharmacy, dietary, medical records, and quality management. The director of quality management served as facilitator after using continuous quality improvement techniques to familiarize the team with the 1995 JCAHO standards. The team's mission was to "develop a system of quality review incorporating the JCAHO 1994 functionally oriented performance standards and using an interdisciplinary approach."

The team started by taking an inventory of quality management efforts already in place. This revealed an abundance of indicators and significant duplication of efforts. In the prior year, the nursing department had 35 ongoing indicators, reviewing such items as malnutrition, patient education, medication administration, pain management, vital signs, and restraint monitoring. Pharmacy had 16 indicators covering such areas as medication administration and errors, drug usage evaluation, and adverse drug reactions. Medicine was reviewing cardiac catheterization, colonoscopy, bronchoscopy, diabetes, AIDS, breast cancer, and malnutrition.

These three representative areas demonstrate the diversity in directions taken and the lack of interdisciplinary coordination. Duplication of efforts by nursing staff and medical staff for example included aspects of malnutrition and blood utilization. Patient education by nursing, pharmacy, and dietary was not coordinated. Independent satisfaction surveys were undertaken by nursing and the quality management department. Pharmacy and nursing even maintained separate databases for medication errors. This survey demonstrated substantial overlap of data and made it clear to the team that interdisciplinary reviews were the most meaningful way of reviewing data and improving performance.

The team determined that there was compliance with the JCAHO "capability standards" prior to 1994 but only scattered attempts at interdisciplinary overviews of functions. The 1994 JCAHO standards served as the stimulus to expand on this approach. The department of medicine quality management committee was consulted to help prioritize an area of review in this department. The team used a high-risk, high-volume, problem-prone methodology to prioritize its areas of concentration. It was concluded that high-volume DRGs were posing increased length of stay problems and affecting patient care resources. DRG information was requested and reviewed. It was noted that six of the top eight DRGs were related to diseases of cardiac etiology and averaged an increased length of stay of 2.2 days.

In an attempt to further refine a measure of care for review, the team looked at each of the six DRGs and noted that myocardial infarction (MI) was the most significant. It was believed that any progress made with this diagnosis would most likely enhance the other cardiac diagnoses. The team then had to determine how to review this diagnosis while assuring themselves that they were complying with 1995 JCAHO standards. A continuum of care grid was the ultimate outcome of the team's efforts. It was agreed that, in order to view the continuum of care that a patient receives, a skeleton upon which quality efforts could be based would have to be developed. If this was generic it might be applied to multiple services.

The result was a four-tiered framework (see figure below) for the patient's a progression through the health care system. The basic framework was divided into preadmission, admission, discharge, and postdischarge. Three additional columns track service involvement, dimensions of performance, and functional standards. Different treatment approaches in the care of MI patients were considered and compared with existing institutional indicators as identified by the performance improvement team. The continuum grid allowed for identification of participating services and consideration of functional standards and dimensions of performance. It should be noted that dimensions of performance, functions, and service involvement will vary with the diagnosis chosen for review and its inherent processes.

Important processes in each of the four phases need to be prioritized for review in order to improve the performance selected for improvement. The preadmission column can be used to consider the appropriateness, availability, and timeliness of interventions that address the need for admission. In the case of MI, these factors include charge of chest pain, use of thrombolytics, ordering of tests, and availability of previous health information. The admission area can be used to review evaluation and treatment plans implemented during hospitalization. These plans can include ordering appropriate tests and their followup, discharge planning, and availability of medical information and can even be used to address considerations of patient rights.

In the MI diagnosis, we sought to review processes important to the diagnosis and contributing to increased LOS. We believe that patient and family education is an ongoing process from admission to after discharge. Education is emphasized in the discharge column in the case of MI to ensure that complete interdisciplinary educational efforts have been undertaken during the patient's stay. Pharmacy and dietary educate patients on their medications and nutritional status, respectively, once patients are identified as stable. While this education is ongoing during the patient stay, it is reinforced just prior to discharge. Physicians and nurses start education from the initial diagnosis and continue this effort after discharge. A multidisciplinary tool to address this has been developed, is under testing, and will be the subject of a subsequent paper.

The postdischarge column reviews the outcomes of our performance in delivering the patient back to activities of daily living. It can be used to consider the continuity and effectiveness of care delivered. In our model case, our concerns regarded recurrent symptoms and compliance with medication, diet, and return to the clinic.

After the team agreed on the processes to be highlighted in the grid, a nurse manager working with the medical director of CCU was charged with coordination of the project. The team member representing each of the interdisciplinary areas is contacted on a daily basis as new MI patients are admitted. Each member then performs his or her part in the process while sharing information with the rest of the team via the coordinator and at weekly team meetings. The medical staff actively participates on the team and is readily available on a consultative basis. At regular meetings, the interdisciplinary team reviews the use of the tool and continues to refine it.

These meetings demonstrate that the team approach is useful in streamlining process and making meaningful quality efforts. We are presently expanding its use to other clinical services, where, again, teams gather to prioritize areas of review. We believe that this process helps us encourage multiple services that directly or indirectly support patient care to work in concert. Further, we improve performance by decreasing duplicative efforts, increasing crosstalk among services, and ultimately improving patient care. The outcome is an earlier return of the patient to family and domestic surroundings, where the most significant healing occurs.

Joseph J. Skarzynski, MD, was Director, Qualtity Assessment, and Elise I. Gropper, PhD, RN, was Associate Executive Director of Nursing, Elmhurst Hospital Center, Elmhurst, N.Y., at the time this article was written. Dr. Skarzynski is now Associate Medical Center of Brooklyn and Queens, Inc., Jamaica, N.Y. Dr. Gropper is Vice President, Patient Care Services, Miami Heart Institute, Miami Beach, Fla.