Effective management of quality improvement initiatives includes leadership, teamwork, planning, and pace setting.
The Institute for Healthcare Improvement has developed a QI Project Management Tool to help health systems and other healthcare organizations implement quality improvement initiatives.
As healthcare organizations seek out greater efficiency and shift their business models from volume to value, quality improvement project management has become an essential capability in operational areas ranging from clinical care to finance to innovation.
The IHI officials who led the effort to create the QI Project Management Tool—Executive Director Karen Baldoza, MSW, and Head of Operation Excellence Christina Gunther-Murphy, MBA—say there are several qualities of successful project team leaders.
Successful team leaders can manage a project such as identifying needed processes and developing workplans, and they can facilitate meetings and conversations, Baldoza and Gunther-Murphy told HealthLeaders this week via email.
They said successful team leaders are also good communicators; adept at bringing out the best in people; committed to subordinates, customers, and results; and willing to take risks.
The core team members of a successful quality improvement project possess a similar set of qualities, Baldoza and Gunther-Murphy said.
"A successful core team represents the key perspectives of the area targeted for improvement and has both process and subject matter expertise; has created a culture of trust and psychological safety where team members can bring their whole-self and contribute thoughts, ideas, experience, and constructive skepticism; is made up of ambassadors for the work; and is action-oriented and willing to try."
The QI Project Management Tool has five elements—each with ideas for project leaders to try.
1. Frontload the work
Planning at the beginning of a project such as gathering baseline data and organizing the project team increases the likelihood of success.
Hold a project kickoff event with planning activities
Establish a checklist of tasks to show the team progress
Set a pause date in case early project milestones are not met
2. Build the project team
Successful quality improvement project teams have the right people doing the right work in the right roles with the right team culture.
Ensure the right people are on the team, or consider changing the project's scope to have better alignment with goals and staffing
Engage the project's sponsor to help push the team beyond the status quo
Get experienced staff members to share past quality improvement efforts that can help the team predict whether initiatives will be successful
3. Set the pace
Maintaining momentum for quality improvement projects requires a time-limited work plan with milestones.
Ensure the project has start dates and end dates
Seize opportunities to quicken the pace such as holding huddles instead of full-fledged meetings
Make sure time is used purposefully to meet project goals
4. Make the project easy
Quality improvement work should be easy, efficient, meaningful, and fun for the team. The beginning of a project should feature learning to propel progress.
Use a standard agenda to keep meetings short
Make team meetings fun and meaningful such as sharing stories about the project's impact
Remain curious and willing to change course
5. Start with the end in mind
Projects should be designed with built-in capabilities for scale growth and sustainability.
Staff who will be involved with an initiative over the long-term should be involved in a project from the onset
Venues should be found where compelling stories about a project can be told
Staff who will be involved in the scaling up of a project should shadow the initiative
Firearm Safety Check features screening for the presence of guns in the home, counseling about safe firearms storage, and distribution of free gun locks.
Firearm safety programs in pediatric primary care such as screening for the presence of guns in the home can serve as an effective youth suicide prevention strategy, recent research indicates.
Suicide is the second leading cause of death for people 10 to 24 years old, and guns are the most common means of these deaths, according to the Centers for Disease Control and Prevention. There is an opportunity to curb youth suicide in the primary care setting—more than three-quarters of youths who commit suicide visit pediatric primary care in the year before their deaths.
Firearm Safety Check—a program that features screening for the presence of guns in the home, counseling about safe firearm storage, and distribution of free firearm locks—can be deployed in pediatric primary care and save lives, researchers wrote recently in Journal of the American Medical Association.
The proposal does not run counter to the National Rifle Association's recent call for physicians to abstain from participating in debates about gun policy, a co-author of the JAMA research told HealthLeaders this week.
"We can all agree to a shared agenda on saving kids' lives. To move the needle on this public health crisis, we need to partner and take multiple approaches toward promoting firearm safety. That includes firearm owners and experts, healthcare clinicians, parents, and other community members. I see Firearm Safety Check as one approach to moving the needle," said Rinad Beidas, PhD, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Stakeholder views
The research team interviewed 58 stakeholders, including parents, physicians, nurses and nurse practitioners, leaders of pediatric primary care practices, behavioral health staff, health system leaders, and payers. The stakeholders, who included gun owners, said firearm safety should be a health system priority.
The stakeholders said most patients and families would have a positive view of Firearm Safety Check
The patients served by the two health systems that participated in the research featured both inner city youth who had firearms in the home for protection as well as suburban and rural youth who had firearms in the home for hunting and recreation
Stakeholders said inner city families could be more receptive to Firearm Safety Check because of the free provision of safety locks
Many stakeholders said U.S. gun culture could impact implementation of Firearm Safety Check, with some families feeling gun ownership screening violates their Second Amendment rights
Implementation strategies
In general, stakeholders suggested implementing Firearm Safety Check in pediatric primary care with medical assistants and nurses screening patients for gun ownership and distributing locks, and physicians counseling gun safety during wellness visits.
Clinician stakeholders had mixed views on Firearm Safety Check implementation, the researchers wrote. "Some clinicians stated they lacked expertise around firearm locks and wanted additional training. While many clinicians said that it was important and within their scope of practice to facilitate conversations about firearms, some reported feeling uncomfortable."
The stakeholders identified six primary implementation strategies.
Stakeholders said Firearm Safety Check should be launched across entire health systems with the support of system leadership to ensure key implementation elements such as funding for gun locks
Screening for gun ownership was called feasible, and stakeholders suggested screening should be brief, done during wellness visits, and incorporated with other screening questions such as bike helmet usage
Clinicians said counseling about safe gun storage would be feasible if the interaction lasted less than 1 minute
Stakeholders said distribution of gun locks was the most problematic element of Firearm Safety Check, with concerns such as financing of free gun locks and clinician apprehension about teaching proper use of the devices
Stakeholders called for integrating Firearm Safety Check into health system EMRs to trigger reminders about screening and for ongoing monitoring
Staff training was recommended to ensure effective management of Firearm Safety Check, with education sessions set for standard sessions such as monthly clinical meetings
Health systems should explore partnerships and other creative approaches to launching and sustaining Firearm Safety Check, the researchers wrote.
"Additional implementation strategies identified included a policy mandate and exploring creative financing. These included partnering with local police, gun shops, and/or firearm safety programs, applying for grants, and working with private payers and insurers to cover the cost of locks."
In the effort to improve quality and save money, IU Health is creating service line-based clinical councils to tap into the problem-solving power of its medical staff.
The Indianapolis-based health system is seeing promising results, in both identifying workable solutions and engaging physicians along the way. The tactic could catch on, especially as systems across the country respond to the industry's business model shifting from volume to value.
Since last year, IU Health has formed 18 clinical councils to identify and pursue value opportunities in areas such as information services, pharmacy, and supplies. Service lines picked for clinical councils include cardiovascular surgery, cardiology, orthopedics, neurosurgery, neurology, medical oncology, emergency medicine, palliative care, and general surgery.
The clinical councils are physician-led, with members selected by IU Health regional presidents and chief medical officers.
"We tell the presidents and CMOs that we are interested in people who are actively practicing in the specialty and who are considered thought leaders in their region. Often, it is somebody who is a medical director or leader by title, but it doesn't have to be that way," says Chris Weaver, MD, MBA, senior vice president of clinical effectiveness at IU Health. "We really want someone who is a thought leader—someone others will follow."
The primary duties of the clinical councils are improving quality through eliminating variation in care and seeking opportunities to lower costs.
"When it comes to variation from region to region and provider to provider, we are able to dig into the data and the processes and see whether there are opportunities to bring everybody up to the best performer," he says.
The clinical councils are well-positioned to root out cost savings at the provider level, Weaver said. "Differences in costs are often something the provider is unaware of. They may be using a supply that costs $500 more than everybody else."
He says the clinical councils, which meet quarterly or every other month, have generated several "wins" over the past year:
Pharmacy: Clinical council initiatives have saved more than $7 million in inpatient pharmacy costs year-over-year. The percentage of patients discharged from emergency departments across the system with a narcotic decreased from 14.5% to 8.3%.
Supply chain: Preferred-vendor contracting saved $3.5 million annually. Contracting changes lowered the cost for total hip and knee replacement procedures.
Information services: Order sets guidelines have been reduced by 651 from a total of about 3,500 to decrease care variation. The percentage of EMR transactions that take more than 5 seconds has been reduced by more than 50%, easing user burden on clinicians.
IU Health has taken five primary steps to form its clinical councils and put them to work.
1. Borrow from other health systems
Before launching its clinical councils, IU Health found two other health systems that were pursuing similar concepts: Phoenix-based Banner Health and Vanderbilt University Medical Center in Tennessee.
"Banner Health has care collaboratives, where they bring providers in their regions together. They really focus on information services like care pathways and order sets. We took their idea and broadened the scope to areas like pharmacy and quality work," Weaver says. "Vanderbilt has a similar idea that we have tweaked and made it a much broader approach."
2. Roll out strategically
IU Health started its clinical council initiative with the health system's top service lines.
"We wanted to start with those councils to make sure that they had support and direction at the system level. So we started with cardiovascular surgery, cardiology, orthopedics, neurosurgery, neurology, and oncology. Then, when we had big initiatives that we knew we wanted to drive across the system, we would organize a council," Weaver says.
There are three strategies to form a clinical council and guide a new council, he says.
First, when clinical councils are organized, members are asked to identify opportunities where they see practice varying or where they see variation in quality or cost from place to place or provider to provider.
Second, the health system uses Vizient data to benchmark externally and identify opportunities in either quality or cost for supplies and drugs. If significant opportunities are found, it prompts formation of a new council.
Third, physician leaders have sometimes prompted IU Health to form a clinical council. When providers push initiatives to improve quality or reduce costs, a clinical council can start with "buy-in that we need," Weaver says.
3. Select council members purposefully
The clinical councils exemplify how IU Health has embraced and elevated physician leadership, Weaver says.
"Our leadership at the highest level is saying, 'Instead of us sitting in offices making decisions for physician practices or the whole system, we believe in the experts providing care to patients making these decisions,' " Weaver says. "The one caveat is they have to make decisions; otherwise, someone will come along and make decisions for them."
4. Prepare to tackle tough issues
Clinical councils must be ready to confront resistance to change, Weaver says.
Making changes in supply chain such as reducing 10 vendors to two for implants can be controversial. "Some providers can be adamant about practicing under those guidelines, but the clinical council can get involved along with the regional leadership to have a conversation about why there are quality benefits," he says.
5. Capitalize on physician engagement
IU Health's clinical councils have successfully heightened physician engagement despite challenging circumstances, Weaver says.
"It's not an easy environment for providers these days, with all of the changes in healthcare. So, engagement and satisfaction are more and more of a struggle," he says.
The clinical councils are a genuine attempt to enlist physicians in significant decision-making, and they appreciate the effort, Weaver says.
"As decisions are being made, we are putting them in providers' hands, so they don't feel like changes are happening to them," he says.
A recent survey of healthcare providers on the clinical councils found a 90% attendance rate and 85% of members indicating the highest level of satisfaction, Weaver adds.
"They felt the health system was listening to them."
Selection of a surrogate for end-of-life decisions is just the starting point for effective advance care planning.
Patients' end-of-life surrogates are overly confident in their readiness to make crucial decisions for their loved ones, recent research shows.
Ill-prepared surrogates at the end of life are a vexing challenge for health systems and hospitals, with care teams often facing a heart-wrenching struggle to determine appropriate care plans in the absence of clear direction. Several studies have shown that surrogates are not well-acquainted with patient preferences, but patients believe that their loved ones already know their wishes.
The lack of surrogate knowledge takes a heavy toll on loved ones when life-or-death decisions arise, researchers wrote recently in JAMA Internal Medicine. "Substantial proportions of surrogate decision makers who have made end-of-life decisions experience burden, expressing stress, guilt, and doubts about having made the right decision."
The researchers focused on decisions related to three health states that could result from treatment of serious conditions: physical disability, cognitive disability, and severe pain. The health states were rated as acceptable or unacceptable by 349 patients and their surrogates.
Although 75% of surrogates said they were extremely confident of their loved ones' wishes, only 21% of surrogates knew the patients' ratings for all three health states.
"Surrogates' confidence in their ability to make treatment decisions based on knowledge of patients' ratings of the acceptability of health states resulting from treatment of serious illness far exceeded and was not associated with their actual knowledge of these ratings," the researchers wrote.
The determination is consistent with the results of an earlier study, which found 79% of surrogates rated themselves as confident or very confident, but only 35% knew their loved ones' wishes.
Preparing surrogates
The lead author of the research told HealthLeaders that health systems and hospitals can help prepare surrogates for end-of-life decisions.
"The first essential step is for these organizations to recognize the need to include surrogates in the process of advance care planning. Without this recognition, if any planning happens at all, it is done only with the patient. Unfortunately, healthcare organizations can think their work is done when the patient formally names a surrogate," said Terri Fried, MD, of the VA Connecticut Healthcare System in West Haven, Connecticut.
Once surrogates have been included in advance care planning, programs and tools can facilitate conversations about end-of-life care, she said.
"Respecting Choices is an intensive program utilizing a specially trained facilitator to conduct conversations with patients and their surrogates. Because it requires the commitment of resources, it is probably best suited for patients with advanced illness and a high likelihood of needing a surrogate decision maker in the near future," Fried said.
To promote use of safer drugs and to lower risk of patient harm, pharmacists can guide patients and physicians in deprescribing potentially dangerous medications.
A pharmacist-led educational intervention can effectively discontinue inappropriate medication prescriptions, recent research shows.
Medications are listed as inappropriate under guidelines such as the American Geriatrics Society Beers Criteriabecause of the availability of safer therapies and risks of patient harm, including adverse drug events, falls, cognitive impairment and emergency hospitalizations. In 2015, an estimated 29% of Medicare beneficiaries filled at least one prescription for an inappropriate medication.
Pharmacists can play a key role in helping physicians discontinue inappropriate medications among older adults, researchers wrote recently in the Journal of the American Medical Association.
"Deprescribing is the act of reducing or stopping medication that is no longer necessary or that may cause harm. Primary care physicians express a lack of time, poor awareness of the harms of medications, and fear of withdrawal symptoms or patient criticism as barriers to deprescribing. Pharmacists can assist physicians in optimizing medication management," the researchers wrote.
In a study featuring 489 older adults, the researchers examined the impact of a pharmacist-led education intervention to deprescribe inappropriate medications. They found 43% of patients receiving the intervention achieved discontinuation of inappropriate medications after six months compared to 12% receiving usual care.
Patients receiving usual care had normal care delivered in everyday practice with no educational materials from pharmacists.
"Pharmacists in the intervention group were encouraged to send patients an educational deprescribing brochure in parallel to sending their physicians an evidence-based pharmaceutical opinion to recommend deprescribing. The pharmacists in the control group provided usual care," the researchers wrote.
Pharmacist-led intervention to deprescribe inappropriate medications
For patients, educational material featured a drug-specific brochure. Pharmacists distributed the brochures in person or via mail. The brochures explained how the medication could be inappropriate and alternative therapy options. For sedative-hypnotics, patients were given a visual taperingprotocol.
"The patient brochure was eight pages and had true and false questions about the risks of medications, an explanation why the medication may no longer be safe, alternative and safer treatments, a peer champion story, and a tapering protocol where appropriate," Cara Tannenbaum, MD, MSc, a co-author of the JAMA research, told HealthLeaders last week.
For physicians, educational material featured an evidence-based pharmaceutical opinion that pharmacists could use or adapt for each study participant's clinician.
The pharmaceutical opinion included an explanation of why deprescribing was being recommended, potential medication harms, sources of recommendations, options for safer therapies, and study participant data.
Sleep deprivation and fatigue have plagued emergency room physicians for decades but apparent widespread use of sleeping aid medications entails risks.
Use of sleeping aid medication among emergency department physicians is likely far more common than previously reported, recent research shows.
Fatigue has been linked to cognitive impairment among ER physicians but sleeping aid medication is a problematic solution. Sleeping aid medication fails to induce normal sleep stages and their progression to natural sleep, and health concerns have implications for physician wellbeing such as rebound insomnia after discontinuance of medications.
A study involving 144 ER physicians in Alberta, Canada, found higher than expected rates of sleeping aid medication use. The study found 67% of the physicians had used a sleeping aid medication at some point in their career, and 56% were actively using a sleeping aid medication. The most commonly used medication was a nonbenzodiazepine hypnotic such as Ambien.
Use of nonbenzodiazepine hypnotics among emergency physicians was estimated at 3 to 4 times higher than the usage rate in the general population.
"Pharmacologic sleep aid use among Canadian emergency physicians may be more common than previously assumed. This could have implications for physician wellbeing and performance," the researchers wrote in Annals of Emergency Medicine.
In an accompanying editorial, Scott Votey, MD, of the David Geffen School of Medicine at UCLA, wrote that the Canadian research is a wakeup call for all emergency departments.
"The adverse cognitive effects of pharmacologic sleep aids linger for hours beyond awakening, resulting in the grogginess and 'hangover' well known to users and prescribers alike. This is particularly concerning, given that 47% of individuals using pharmacologic sleep aids reported taking these medications to sleep before a night shift," wrote Votey, a professor of clinical emergency medicine in the Department of Emergency Medicine at the Geffen School.
This week, Votey told HealthLeaders there are three approaches to reducing sleeping aid medication usage among ER physicians.
1. Educating ER physicians
There are a pair of educational strategies to address the problem, Votey said.
"One is that these medications are not good for ER physicians, and there is enough information on fatigue to make a good case for that," he said.
The professional association for ER physicians could be the best vehicle to carry this message, Votey said. "The American College of Emergency Physicians could provide education and reach the majority of emergency physicians in the country."
He said the second educational strategy is to encourage ER physicians to find behavioral alternatives to sleeping aid medications such as the National Institutes of Health's list of sleeping tips.
"People are using these drugs because they perceive a need. That's true of pretty much everybody who takes an Ambien and certainly true of emergency room physicians. They feel their sleep is disrupted and they are desperate enough to give this a try. You have to address how you can improve sleep without medication," Votey said.
2. Changing ER schedules
Changing ER physician schedules can ease fatigue and stress such as limiting the number of night shifts a physician works and shortening night shifts, he said.
Votey works in a large emergency department with several faculty-level physicians, so the ER schedule can be crafted to avoid multiple overnight shifts in any given month.
Shortening overnight shifts can establish regular schedules for ER physicians, which eases the Circadian burden on clinicians, Votey said.
"To get people to stay on these shifts, hospitals will pay the same amount for a six-hour shift that they pay for an eight-hour shift. You can get someone to take these shifts on a regular basis and adapt to that Circadian rhythm. They are incentivized to do it and get less fatigued."
3. Adopting new policies
ER physicians need the same kind of duty-hour restrictions that were established for medicine residents by the accrediting agency for graduate education, Votey said.
"They created policies for how long a doctor in training could work, how much rest they needed between their shifts, and other rules that were enforced by the institutions in the training programs as part of their accreditation," he said.
Hospital also have a role to play and should adopt more enlightened staffing policies, Votey said.
"You want to have enough doctors and you want them to be working few enough hours to avoid fatigue. The business rationale for that is pretty reasonable—tired doctors are less effective. They have worse communication skills and they have poorer patient satisfaction. There are several studies that have shown that if you tire them out, they aren't good at their job. If you want doctors to be good at their job in your hospital, you should create rules that make sure they don't work too much."
Care coordination covers a multitude of activities and requires a coherent collaborative effort among policy makers, payers, community agencies, healthcare providers, and families.
Care coordination features an essential set of services, particularly for patients with conditions that are complex and long-term, a recent article in JAMA Pediatrics says.
To deliver effective care coordination, healthcare providers and community partners should have key shared assumptions such as comprehensive assessments of patient needs, a written care plan, and coordination between clinicians and community service professionals.
"Despite the centrality of care coordination to healthcare reform, practice redesign, and chronic care management, there remain multiple definitions, expectations, and approaches to its provision. This variability reflects the different purposes for which care coordination is intended, such as improved quality, reduced healthcare use and costs, more comprehensive care, meaningful response to social determinants of health, and planning care over the life course," the JAMA article's author wrote.
This week, the author told HealthLeaders that establishing shared assumptions about care coordination is crucial to extending the concept to include the personal and social circumstances of patients and their families.
"In the past, care coordination focused on coordinating among medical care providers and, sometimes, other healthcare providers. Today, the need to address the patient's social needs such as housing, nutrition, social support, and education to achieve good health outcomes is appreciated and some health plans and payers, including Medicare and Medicaid, are beginning to pay for such services as legitimate health expenses," said Edward Schor, MD, of the Lucile Packard Foundation for Children's Health in Palo Alto, California.
Schor's article highlights 10 pivotal shared assumptions for care coordination.
1. Teamwork emphasized
Care coordination should be family-centered and team-based with clearly established goals, frameworks, and obligations.
2. Assessment conducted
Services should be crafted and deployed based on a comprehensive assessment that gauges the health and psychosocial needs of the patient.
3. Plan promulgated
Care coordination services should be documented in a written care plan designed by the patient, family, and healthcare providers. "It is generally not possible to have coordination in the absence of a plan. Otherwise, service providers are merely reacting," Schor said.
4. Care plan monitored
The plan for care coordination services should be supervised on a regular basis and revised as needed.
5. Communication expanded
Electronic communication should supplement face-to-face communication between the patient, family, and healthcare providers to strengthen the working relationships between clinicians and others involved in the patient's care.
6. Information shared
The patient and the family should be given information and supports that can help them manage the patient's care.
7. Community professionals included
Healthcare providers should coordinate their efforts with community-based professionals who offer services and support to the patient and family.
8. Care coordinator assigned
Patients should have an assigned care coordinator who has regular contact with the family and primary clinician.
9. Information shared electronically
An electronic medical record should be used to share the patient's health information with family members and all healthcare providers.
10. Transitions of care managed
Any patient transitions between settings should be managed to ensure continuous access to care. "Care coordination for transition, whether between settings or from pediatrics to adult care, is hazardous, especially for patients with chronic or complex health conditions. I consider transition services to be a subcomponent of care coordination," Schor said.
Healthcare organizations are being urged to help patients address cardiovascular disease risk factors such as hypertension and smoking.
A national effort to reduce cardiovascular disease (CVD) events such as heart attack and stroke has made progress but is at risk of stalling, a recent article in the Journal of the American Medical Association says.
The Million Hearts initiative, which is a joint endeavor of the Centers for Disease Control and Prevention along with the Centers for Medicare & Medicaid Services, is designed to prevent CVD events including heart attack, stroke, heart failure, and related conditions.
CVD events are costly, deadly, and often preventable. In 2016, CVD events accounted for about 2.2 million hospitalizations and 415,480 deaths, according to the JAMA article. If the 2016 trends continue through 2021, there will be an estimated 2.2 million preventable deaths and 11.8 million hospitalizations with costs of about $170 billion.
Million Hearts was launched in 2012 with a goal of preventing 1 million CVD events over five years by focusing on the ABCS risk factors: aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation. "Projections using 2012-2014 data suggest that an estimated 500,000 events may have been prevented by 2016, although improvement in risk factors was slow," the JAMA article's authors wrote.
A recent CDC report detailed the limited success in addressing the ABCS risk factors.
"Appropriate aspirin use decreased between 2011-2012 and 2013-2014. From 2011-2012 to 2015-2016, small but statistically significant reductions were observed in combustible tobacco use and physical inactivity. No significant improvements were observed for hypertension control or statin use among eligible persons; sodium consumption remained high," the JAMA article's authors wrote.
Healthcare leaders have a key role to play in reducing CVD events, the lead author of the JAMA article told HealthLeaders this week. "Leaders are critical to achieving high performance by setting an expectation of excellence; establishing an aim, target, and timeline; and resourcing their teams to make and report progress," said Janet Wright, MD, executive director of Million Hearts.
Leaders can have a significant impact in addressing CVD risk factors, she said. "Healthcare leaders can make a difference in the population's health—for their employees, patients and families, and community—by creating the conditions for excellence in the ABCS."
Wright and her coauthors identified four efforts that healthcare organizations can embrace to prevent CVD events.
1. Run a quality improvement cycle
"We recommend starting by prioritizing a cardiovascular condition such as hypertension, abnormal cholesterol, or smoking; pulling together a small team led by a passionate champion; analyzing current performance and setting a target and timeline for improvement; and implementing one or more strategies that move the needle," Wright said.
This approach can be applied by a variety of organizations, she said. "We have seen systems large and small use this highly replicable quality improvement cycle to achieve excellence—and to build on success in one area like blood pressure control then tackle a challenge like in-clinic smoking cessation."
2. Capitalize on MIPS measures
Addressing the ABCS risk factors can be done in conjunction with the cardiology, general and family medicine, and obstetrics and gynecology specialty measure sets of the CMS Merit-based Incentive Payment System (MIPS). For example, high blood pressure control is a high priority MIPS measure.
3. Gain from real-time insights
Tools are available to help healthcare providers track risk-factor performance, Wright and her coauthors wrote.
"Population health management tools are widely available, permitting real-time insights into performance on the ABCS. Million Hearts partners and others have developed tools to identify patients with undiagnosed hypertension who are 'hiding in plain sight.' This approach can be adapted for other risk factors."
4. Adopt and adapt proven strategies
To prevent CVD events, there is no need to start from scratch, the JAMA article's authors wrote.
"A common strategy is a clinician-led, team-executed treatment protocol that incorporates the practice's preferred counseling language and medications, facilitates identification of patients who need customized attention, and enables more patients to be optimally treated."
In less than 5 minutes, the Shock Index assessment can gauge the severity of a patient's condition.
Stroke is a deadly and expensive-to-treat condition that kills about 140,000 Americans each year, with annual costs for healthcare services and medications estimated at $34 billion, according to the Centers for Disease Control and Prevention.
But what can clinical leaders do to mitigate deaths and healthcare costs due to stroke?
For stroke patients prior to hospital admission, a simple and inexpensive assessment can guide treatment decisions and predict a range of outcomes, recent research shows.
A Shock Index (SI) calculated as heart rate divided by systolic blood pressure can quickly and inexpensively assess stroke patients, researchers wrote recently in Journal of the American Heart Association.
"Our study shows that SI is a significant predictor of important patient-related acute stroke outcomes including mortality, acute hospital length of stay, discharge destination, ambulatory status at the time of discharge, and poststroke disability," they wrote.
The researchers collected data from more than 425,000 patients. Most of the patients (89.7%) had experienced ischemic stroke.
Here are three reasons to use the Shock Index assessment on your stroke patients.
1. It's a good predictor of outcomes
The lead author of the research says the SI is a powerful predictive tool.
"SI appears to be a very good predictor of several stroke outcomes immediately after stroke—not just mortality but also for dependency and discharge destination other than home," Phyo Kyaw Myint, MD, of the Institute of Applied Health Sciences at University of Aberdeen's School of Medicine in the United Kingdom, told HealthLeaders.
2. It does not require expensive equipment
The SI is particularly valuable for healthcare facilities that struggle to fund expensive assessment technology or to train staff on the National Institutes of Health Stroke Scale (NIHSS), he said.
"SI is calculated based on the heart rate and blood pressure, and these measurements are usually done by trained clinical staff. It doesn't require any special equipment or computer system to calculate SI. It is easy to perform and takes less than 5 minutes. Therefore, SI as an alternative tool to assess the prognosis of stroke patients at the time of assessment is extremely useful in low-resource settings such as rural hospitals and low-income settings," Myint said.
3. It can be used in clinical settings now
Although Myint and his research coauthors are calling for more research on the SI, he says the assessment tool is appropriate for use in clinical settings now.
"As this is a physiological index, it can be applied in clinical practice immediately. We stated more research is needed in the sense that, to make change in practice, large numbers of studies are required before we can start to see changes. Therefore, our findings should be replicated in different populations as well as in different healthcare settings to demonstrate the external validity of the findings to convince clinicians of the robustness of the SI as a useful prognostic assessment," Myint says.
As more studies are conducted, patients can benefit from clinicians using the SI, he says.
"In the interim, we would recommend that stroke patients with high SI should be carefully monitored and clinicians should be made aware of their likely poor diagnosis to ensure appropriate management strategies can be implemented and realistic expectations of the outcome can be communicated with the patient's relatives," Myint said.
SI by the numbers
Myint and his coauthors divided the patients in their study into three SI cohorts: patients with SI values greater than 0.7, patients with SI values between 0.5 and 0.7, and patients with SI values less than 0.5.
Patients with SI values greater than 0.7 were at higher risk for poor outcomes and comorbidities, the researchers found.
For example, compared to patients with lower SI values, patients with high SI values were prone to have peripheral vascular disease and heart failure. "They had significantly higher heart rate and lower systolic BP on admission and were associated with significantly higher rates of poor outcomes for all outcomes examined," the researchers wrote.
The researchers found SI greater than 0.7 was associated with several poor outcomes.
There was high mortality relative to other stroke patients. In-hospital mortality was 11.0% for patients with SI greater than 0.7 compared to 5.9% for other stroke patients.
For patients with high SI values, 55.7% were not able to ambulate independently, compared to 48.0% of other stroke patients.
Other poor outcomes for patients with high SI values included longer hospital length of stay and higher likelihood of disability.
The SI provides clinicians with a powerful stroke assessment tool at low cost, the researchers wrote.
"This information may be useful in clinical practice for managing stroke patients, to identify those with high risk of poor outcomes from the point of contact, particularly if NIHSS is not available, and to better inform patients and their significant others about the prognosis of these important outcomes," they wrote.
The Clinical Frailty Scale assessment can be performed in less than a minute and indicates likelihood of post-surgical mortality and loss of independence.
Prior to vascular surgery, an easy nine-point frailty test can predict non-home discharge as well as long- and short-term mortality risk, recent research shows.
Vascular surgery, such as abdominal aortic aneurysm repair, often involves high-risk procedures, particularly for frail patients. Tools that can predict surgical outcomes can help vascular surgery practices enhance transitions of care, inform patient decision-making, and set patient expectations.
The researchers used the Clinical Frailty Scale (CFS), which can assess frailty in less than a minute, to predict loss of independence after major vascular procedures.
"The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict likelihood of requiring discharge to a nursing facility or death after surgery. The identification of frail patients before major surgery can help manage postoperative expectations and optimize transitions of care," the research wrote this month in the Journal of Vascular Surgery.
The CFS rates frailty on a scale of 1 to 9. In the study, patients with CFS scores greater than or equal to 5 were considered frail.
The study featured 134 independent patients who were assessed with the CFS before undergoing seven vascular surgery procedures, including open abdominal aortic aneurysm repair, endovascular aneurysm repair, and carotid endarterectomy.
Frail patients were found to be at higher risk for several negative outcomes.
62% of frail patients needed mobility assistance after surgery compared to 22% of non-frail patients
22% of frail patients were discharged to a non-home location compared to 6% of non-frail patients
8% of frail patients died within 30 days after surgery compared to 0% of non-frail patients
Frail patients faced more than a 12-fold higher risk of 30-day mortality or loss of independence.
Frail patients experienced a significantly longer hospital length of stay (6.4 days) compared to non-frail patients (4.2 days)
Multiple benefits
The ability of CFS to predict post-surgical outcomes has high value for vascular surgery practices and their patients, the researchers wrote.
"The decision to subject a frail patient to surgical stress associated with a major vascular procedure may result in a physiologic decompensation and lead to morbidity, loss of functional independence … or death, a conceptual framework that has been called the disablement process," they wrote. "Moreover, providing information on the risk for loss of independence or mortality before surgery is important as it may influence a patient's decision to undergo an elective vascular procedure."
Utilizing CFS scores can help vascular surgery practices enhance transitions of care, the corresponding author for the research told HealthLeaders.
"For patients electing to undergo surgery, sharing this information up front allows them and their families to prepare for the fact that they will not be going home immediately after surgery. As such, the CFS provides important data that helps patients prepare and optimize their transitions of care before and after surgery," said Benjamin Brooke, MD, PhD, chief of the Division of Vascular Surgery, Department of Surgery, University of Utah Health.
The CFS assessment tool is valuable for vascular surgery practices, Brooke said. "The CFS provides a fast, easy, and validated method to identify frailty and risk stratify every patient you encounter in clinic, emergency departments, or on the hospital wards," he said.
For vascular surgery practices, the CFS is a superior option to other frailty assessment tools, Brooke and his coauthors wrote.
"Although it is well recognized that risk assessment is an essential component of the preoperative surgical workup, most risk calculators are either too cumbersome or time-intensive to be employed on a routine basis in outpatient clinical settings. In comparison, the CFS score is a simple eyeball test that can be easily measured on all patients in conjunction with other vital signs collected during clinic visits," they wrote.
