How to Determine the Best Interventions for Clinical Quality Improvement Projects
Health systems use clinical quality improvement projects as a means to improve patient care, but the real improvement in care can only result from deliberate action by your teams. This action is called an intervention and becomes the solution that addresses your clinical quality improvement goal.
Finding efficient, effective interventions can be a challenge without knowing where to start, but by using an Aim statement, your teams will have a working template for each of their clinical quality improvement projects. The Aim statement is a written, measurable, and time-sensitive goal that moves a clinical quality improvement team steadily toward achieving its objective. (We covered how to develop an Aim statement in a previous post.)
Using Interventions to Achieve Clinical Quality Improvements
Once a workgroup identifies an Aim statement, the clinical quality improvement process begins and moves towards the intervention. Intervention types may be identified as:
- A process intervention
- An outcome measurement intervention
A process intervention often focuses on an activity or aspect of a care-delivery process. An outcome measurement focuses more on results and measures the result of the care impacted. Not all process interventions will have a direct outcome, however, by focusing on processes of care, we can measure the outcome and identify those areas that will have a direct impact on improvement.
Proposals for interventions may come from current practice, clinician ideas or input, or documented best-practice research. The team needs to view the data before selecting the right intervention. A careful review of the literature is also imperative.
Heart Failure Readmission Rate Intervention Example
Heart failure is one of the top five causes of hospital readmissions with 25 percent of heart failure patients being readmitted within 30 days. These high readmission rates lead to billions of dollars in direct medical costs for the patient, health system, and payer. It’s important for health systems to focus on interventions in these areas to realize the greatest opportunity for improvement. Here’s one health system’s story.
After implementing a Late-Binding™ data warehouse, a large medical center finally had access to the data they needed to identify which areas were the most inefficient. To make the necessary improvements, they applied for and received a grant to support a transitional care program for heart failure patients. They used the grant’s objectives to define their long-term AIM statement:
To achieve and sustain a 30 percent reduction in the 30-day and a 15 percent reduction in the 90-day all-cause readmission rates for patients with HF by October 2014 and sustained reduction in readmission rates through 2016.
Using the Aim Statement to Achieve Their Clinical Quality Improvement Goals
To achieve their Aim statement objectives, the medical center’s clinical leaders developed three evidence-based, heart failure-specific best practice interventions, which were rolled out over a few months. Their interventions included:
- Follow-up care scheduled before discharge — Before being discharged, patients were scheduled for follow-up care. Patients with a high risk for readmission were scheduled within seven days when possible. All other patients were scheduled for follow-up care within 14 days.
- Medication reconciliation — A physician reviewed the patient’s medications within 48-hours of discharge and provided instructions on how to take them.
- Follow-up phone calls — A member from the care team called the patients within a specific time frame after the patient’s discharge (again based on the patient’s level of risk for readmission) to assess their condition and ask if they had any questions or concerns about their medications.
After deciding on the best three interventions, an integrated dashboard was created in their Heart Failure Advanced Application for each intervention to make it easy for clinicians and administrators to easily visualize the impact the changes were having on readmissions. They also were able to assess the interventions’ impact on costs and patient satisfaction by using additional integrated data in their advanced application.
Because their focus on reducing readmission rates could have impacted other areas, such as increased emergency department (ED) visits or decreased patient satisfaction scores, the teams added several balance measures, which included the tracking of ED encounters, observation stays, length of stay, and patient satisfaction rates.
Six months after implementing the program, the medical center experienced the following improvements:
- A 63 percent increase in post-discharge physician medication reconciliation within 48 hours
- A 2x increase in the number of phone calls made to patients within 48 hours of discharge
- A 21 percent seasonally adjusted reduction in 30-day HF readmissions
- A 14 percent seasonally adjusted reduction in 90-day HF readmissions
The Secret to Choosing a Successful Intervention: Clinical Dashboards
Interventions are powerful, but how do you know which interventions will provide the clinical quality improvements you need? The secret to selecting the right intervention is this: choose something that offers “gain” or improvement and then provides a means to “sustain that gain.” By picking a heart failure intervention, which provides patients with timely follow-up appointments, that patient is gaining medical surveillance and improved care. At the same time, the site is preventing readmissions and its associated financial effects. Many of our work teams have used custom dashboards to display the key metrics they want to monitor and track the intervention they have selected. Here is an example of a dashboard.
These dashboards provide clinical teams with the ability to initially recognize the gain and then continue to sustain those gains. The dashboards are also helpful for monitoring key metrics, such as percentage of follow-up appointments made and the relationship to readmission rates. Human nature is such that it is easy to “drift” back to previous behaviors. By providing a current view of the team’s goal through an actual visualization of the progress, this drift will be minimized.
For clinical quality improvement projects to work (and keep working), they must be set up for success. Choosing the right Aim statement and associated intervention while considering best practices is key to ensuring the work of the team is not done in vain. Most importantly, the patient benefits by receiving the best care available.
What clinical quality improvement projects have you worked on that would have benefit from using an Aim statement? What interventions do you use to improve patient care?