Innovation in Waste Reduction Improves Patient Care Quality

Concurrent and Retrospective Chart Review, Performance Reporting, and Other Support Significantly Improve Adherence to Core Measures in Four Clinical Areas

Innovation in Waste Reduction Improves Patient Care Quality
Tamra Minnier, RN, MSN, FACHE
Chief Quality Officer for the University of Pittsburgh Medical Center (UPMC)
Member, AHRQ Health Care Innovations Exchange Editorial Board

Waste occurs in health care settings when staff, resources, and technology are used inefficiently and the patient is not provided the highest level of service. Waste occurs in many forms, including duplication of information, clinical tests, and prescribing brand name medications instead of generic medications that have been shown to be just as effective.

Inefficient processes in hospitals waste staff time that should be spent with patients. Examples from the manufacturing industry that apply to hospitals include the movement of goods without a plan, unnecessary steps and movement of employees, and employees standing idly waiting for an activity to be completed.1 Health care staff spend so much time tracking down supplies, medications, orders, and medical records that they have been labeled “hunters and gatherers.” Indeed, one study shows that the average nurse on a unit walks the circumference of half the earth in a year.2

Strategies advocated by the Obama administration to reduce soaring health care costs include using comparative effectiveness to evaluate the cost-effectiveness of new and existing treatments, setting quality standards and measures, and redesigning systems, including the use of electronic medical records.3

The innovation Streamlined Evaluation, Transfer and Admission Processes Significantly Reduce Waiting Times for Emergency Department Patients Awaiting Admission to Psychiatric Facility, illustrates how identifying waste led to process improvements and reduced patient wait times from 10 to 6 hours.

Psychiatric patients admitted to the emergency department at Maine Medical Center often waited for more than 10 hours before they were admitted to Spring Harbor Hospital, the center’s affiliated psychiatric facility. A multidisciplinary team, consisting of staff from both hospitals, identified sources of delays and new strategies to improve care to patients.

For example, the team implemented concurrent rather than sequential processes so patients didn’t have to be cleared by medical staff before they were evaluated by psychiatric staff. The team also standardized the assessments/tools for both facilities which eliminated duplication of effort. Spring Harbor assumed the precertification responsibility from the medical center and expedited its admission process. Patients were transferred earlier in the process from the center, which led to treatment being provided sooner and better patient care.

By using best practices, this innovative program reduced waste in its admission process for psychiatric patients. The only exception was the redesign of the psychiatric area in the emergency department, which improved patient safety and privacy, but didn’t reduce waste and cost money.

This innovation can be generalized to other hospital emergency departments that evaluate and transfer patients to psychiatric facilities. The program could benefit from continuing to reduce patient wait times to be consistent with the national average of 4 hours for emergency departments, and identifying a champion to increase the innovation’s long-term sustainability. A champion, especially if not a leader in the hospital, must have the leadership’s respect and recognition. Ideally, innovators identify a champion early on so he or she can participate in discussions with the senior leadership.

The innovation, Concurrent and Retrospective Chart Review, Performance Reporting, and other Support Significantly Improve Adherence to Core Measure in 4 Clinical Areas, also used an effective waste reduction strategy. St. Mary’s Health Center hired a full-time nurse to review patient charts daily during inpatient stays and postdischarge to ensure adherence to evidence-based processes. A core principle of waste reduction is that it is more efficient for one individual to become an expert through performing a task repetitively than dividing the task among several people who perform it infrequently. The innovation’s use of a full-time nurse enabled her to become an expert in the intricate rules involved with CMS core measures.

St. Mary’s Health Center made other process improvements, including internal and external reporting of performance data, department-specific goal setting and measurement, and a physician-led committee that promotes adherence among doctors. As a result of this innovation, St. Mary’s Health Center achieved near-perfect adherence to CMS core measures with composite scores of 98 percent or higher in 2008.

The program’s major costs were the full-time salary and benefits for the nurse abstractor. This innovation can be generalized to large facilities with a large volume of patients to sustain a full-time nurse abstractor. However, in this cost-cutting economy, another option would be to decentralize the chart review function so it is done by staff involved in routine patient care.

References

1 Campbell RJ, EdD, CPEHR. Thinking Lean in Healthcare. Available at: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_043753.hcsp?dDocName=bok1_043753. Accessed April 6, 2010.

2 Hendrich A, Chow M, Skierczynski BA, et al. A 36-hospital time and motion study: how do medical-surgical nurses spend their time? The Permanente Journal. 2008;12:3. Available at: http://xnet.kp.org/permanentejournal/sum08/time-study.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software.).

3 CCH Aspen Publishers Technical Answer Group, Wolters Kluwer. Waste Reduction Strategies Can Improve Health Care Quality With Reduced Costs. Available at http://hr.cch.com/news/benefits/031209.asp. Accessed April 6, 2010.

Original publication: April 14, 2010.

Last updated: April 14, 2010.

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