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By Billie Whitehurst, MS, RN
Vice President, Solution Line Manager,
Chief Nursing Officer
McKesson Provider Technologies
Clinically Driven Financial Success
Those of us who have made healthcare our career can usually trace the decision to enter this honorable profession to a family tradition, a calling, a personal experience with illness or even a medical error that changed the course of our lives. Whatever we originally envisioned, today we are all squarely in the business of caring. The prolonged economic downturn and continued cuts to reimbursement have escalated the need to understand the relationship between quality and cost on a micro level.
Given so many variables we can't do much to control, it's important to focus on the ones we can — beginning with Hospital-Acquired Conditions (HACs). Spearheading the effort to reduce them was the Centers for Medicare & Medicaid Services, which in October 2008, began withholding payment for additional care associated with eight "reasonably preventable" medical conditions that were not present on admission (POA). Numerous private payors quickly followed suit.
In September 2009, Health Affairs published a study concluding that the payment reductions resulting from the policy were negligible. However, the study failed to emphasize that the cost of treating such conditions substantially erodes profits. Therefore, hospitals are well advised not only to accelerate efforts to annihilate HACs but also to thoroughly document conditions that are present on admission. The key is for leaders to create a culture of engagement and accountability, measure frontline compliance with evidence-based guidelines and monitor care outcomes.
Hardwiring Best Practices
Hardwiring hundreds of best practices into clinical workflow requires IT:
 Electronic documentation can mandate within the nursing workflow that all appropriate POA
assessments are thoroughly completed and usable for coding purposes.
POA assessment findings, such as high scores on the Braden Scale for Predicting Pressure Sore
Risk and Morse Fall Scale, can trigger alerts tied to computerized provider order entry (CPOE)
and the electronic care plan so appropriate orders, interventions and target outcomes can
be selected.
High scores can also trigger indicators on enterprise tracking boards that help increase unit
awareness of at-risk patients and remind nurses when patients need to be turned or
checked on.
Should a vital sign, lab result or assessment indicate that a hospital-acquired condition has
developed, alerts tied to these solutions enable the care team to take immediate action.
Translating Hospital Priorities into Staff Ownership
The capstone of any performance improvement project is analytics, for two reasons:
To know where to focus efforts, you must be able to combine the data produced as a
byproduct of patient care with financial data. Turning data from disparate HIT systems into
actionable information requires both a data warehouse and powerful, healthcare-specific
business intelligence.
Translating multiple HAC-reduction priorities into staff ownership and ensuring ongoing
compliance requires creating a metric-driven culture that thrives on knowing its targets and
beating them.
For example, analytics can help prevent catheter-related urinary tract infections (UTIs). A recent University of Michigan report says that almost half of hospitals do not keep track of who gets catheters and that less than 10% conduct daily checks to determine patients' need for ongoing catheter use.
McKesson's Hospital-Acquired Conditions scorecard enables stakeholders to drill down to see how many cases included HACs over a given period, broken down by payor and cost. Honing in on UTIs, the scorecard enables organizations to identify outlier units or clinicians and drill down to review Foley catheter documentation and compliance with daily care protocols. When combined with education and positive reinforcement, posting scorecards on units helps motivate staff to track and improve their performance.
Getting to Zero
You need look no further than IHI to see that a critical mass of organizations is adopting proven approaches to preventing harm. The reasons we entered healthcare may be couched in financial terms, but in so many ways patients are better off. That's a very good thing.
Billie Whitehurst, MS, RN, is CNO and solution line manager for MPT clinical and workforce management solutions. She leads the company's strategic direction and business development efforts for clinical solutions that cross care settings. She also leads multiple nursing-focused forums, including the McKesson Nursing Advisory Council, the CNO Strategic Summit and the annual Nursing Leadership Congress. Whitehurst became CNO following 10 years of product management and strategy development leadership for much of MPT's clinical information technology for the acute-care and homecare settings.
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An organization's leaders set and reinforce its culture and are positioned to drive improvements. For this reason, The Joint Commission has issued a Sentinel Event Alert that urges health leaders to adopt the zero-defect approach to preventing errors in a healthcare setting. This approach is used in other high-risk industries such as aviation and nuclear energy.
To improve patient safety, the alert recommends that leaders at healthcare organizations take a series of 14 specific steps, including the following:
Define and establish an organization-wide safety culture with a code of conduct
for all employees
Institute an organization-wide policy of transparency that sheds light on all adverse
events and patient safety issues
Make overall safety performance a key, measurable part of the evaluation of the
CEO and all leadership
Ensure that caregivers involved in adverse events that result in unintentional patient
harm receive attention that is just, respectful, compassionate, supportive and timely
Create and communicate a policy that defines behaviors that are to be referred for
disciplinary action and a time frame for that action to take place
Add a human element to safety improvement by having patients communicate
their experiences and perceptions to leadership
Reward and recognize staff whose efforts contribute to safety
The recommendations are in addition to those provided in the Leadership section of the Joint Commission's accreditation standards to improve patient safety.
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