Hospital system managers know it's hard to pull the disparate cultures of a newly merged healthcare enterprise together.
BJC Health System in St. Louis is using outcomes measurement techniques as a tool to enhance systemwide patient-care quality. Along the way, it hopes doctors and nurses will come to think collaboratively and endorse clinical integration among BJC's nine hospitals.
BJC has scheduled 12 clinical initiatives to improve care systemwide, the first of which focuses on better care for women and infants. Phase one of the first initiative, which is under way, aims to reduce Caesarean-section rates. The next phase will target vaginal births after C-sections and induced labor. Upcoming initiatives will take on pneumonia and strokes.
Clay Dunagan, M.D., system vice president for quality, says that in 1995, when BJC was thinking about reorganizing itself by "service lines" instead of traditional hospitals, representatives of its new women and infants program came to him and asked, "*`Can you figure out methods of quality assessment?' We said, `Gee, that's only the first step. You can use the performance measures to enhance care.'*"
Caesarean sections are a logical place to start because so much variance in medical practice occurs, and it's widely acknowledged that too many C-sections are done. The procedure knocks new mothers out of commission for a while, often leads to complications and consumes a lot of resources.
Public Health 2000, the federal government's health policy goals for the year 2000, envisions a national C-section rate of 15% for all women giving birth. The BJC rate was 23% last September, just before its project started. The system is aiming for 17% by the end of this year.
Jennie D. Dulac, director of clinical improvement at BJC, measured the C-section rates at the system's nine hospitals and found that "as you superimpose the data points, what you see is incredible variation in practice," she says. There was plenty of room both to reduce the number of C-sections and to standardize practices.
Dulac and the clinical quality team researched the scientific literature to find the best practices in labor management. They did not want to rely on "expert opinion (because) all individual practitioners have their expert opinion based on their own experience," Dulac says. "What we have learned over time is, that's not the best way to achieve best practice."
Starting in spring of 1996, a seven-person interdisciplinary committee at the system level developed an algorithm, or flow diagram, that marked the critical decision points for helping women through labor and specific criteria to be applied. By October the committee was ready to roll out the first systemwide practice guideline.
"We brought together all nine hospitals," Dulac says. "We walked them though the algorithm, we actually got their opinion, and we asked them who would like to participate. One hundred percent of the physicians and teams present at that meeting said they wanted to use it."
It was crucial to gain support from physicians and nurses. BJC handles 11,500 births per year in its hospitals, and three-quarters of all the OB/GYNs working in the St. Louis metropolitan area have privileges at BJC hospitals.
The quality improvement team started with women who hadn't given birth before, and at one hospital, Missouri Baptist Medical Center in Town and Country, which has a huge labor and delivery volume.
The hospital's labor triage room is where most decisions in the guidelines are made. The algorithm can be placed on the patient chart for doctors to see, and it's also available on a computer work station.
Attending patients eight to 12 hours at a stretch, nurses have a high-profile role in making the guidelines work. "The biggest driver," Dulac says, "is the nurse saying, `This patient is eligible for the guidelines. Do you want to put her on it?' That prompt is very helpful."
In the fall the C-section rate for women who hadn't given birth before was going up and down week by week but averaging 26.9% (See graphic). In late December the labor and delivery guidelines were introduced at Missouri Baptist. Physicians and teams started getting weekly reports showing how many C-sections had been done.
The effect was immediate. The rate dropped to 12.3%. In February and March the rate edged up a bit, to 18.2%, with the exception of one spike.
But around early April data points started jumping around again.
"What happened is, the data abstracter at Baptist was hospitalized for almost two months," Dulac says. "The team and clinicians had no data to see how they were doing. We broke the feedback loop.
"It's a lesson learned. Look what happens when we don't have all the tools."
Clinicians, she says, "don't have the ability to look at data in aggregate in their minds." That's why they need regular weekly updates.
The data are purely clinical. There is no cost analysis. Once a year, the system will look at how the reduction in C-sections is affecting costs, but cost is not the main driver; quality is.
Still, physician support has been uneven, Dunagan says. "Not every single clinician has embraced it. Some people are very enthusiastic; others are more guarded. No one has argued about the value of collecting performance data. We still have mixed opinions on how it should be used."