| Section
5 Chapter 1 |
Quality Patient Care |
Regardless
of the specific improvement plan implemented, the ultimate goal is for the organization
to never become stagnant but to always be moving forward in its systems, processes,
thinking, and philosophy. Another goal is to identify defective areas and opportunities
for improvement and to implement an action plan for improvement, applying the
CQI methodology.
USING STRUCTURE/PROCESS/
OUTCOMES TO MEASURE QUALITY
One of the biggest obstacles affecting the performance
improvement strategies of any healthcare organization is the difficulty in linking
structure, process(es), and outcome(s). Case
management has been defined as a structure and process model because
it links both of these elements to the outcomes of care.
The Structure of Care
The structure of the organization has to do with
the characteristics of the systems of the organization and its environment (Box
1-3). The structure is also concerned with the characteristics of the providers
of care and the patients themselves. Structure characteristics relate to the
setting/level of care, the nature of the care delivery system/model (e.g., interdisciplinary
approach), the credentials, competencies, and educational levels of the providers,
and the health status and condition of the patients.
The system characteristics of any organization are complex and diverse. Those
listed in Box 1-3 are just a small sample
of the types, elements, or characteristics that make up the healthcare system.
Each of these, either individually or in a group, has an effect on how care
delivery is structured and how it ultimately affects patient and organizational
outcomes.
The provider characteristics demonstrate the diversity of the care providers
in any organization. It is clear from this list that each provider brings unique
characteristics (i.e., skills, knowledge, and competencies) to the care delivery
model, and based on the differences, each may approach a particular patient
or clinical problem in a different way. The provider's years of experience will
also affect how the group of providers may address a particular problem or patient
situation. The varied experiences of the providers will ultimately impact how
the group may problem solve a complex or challenging situation (see Section
4, Chapter 1 for more on this topic).
Finally, the patients and their families/caregivers bring a unique view of themselves,
of the care providers, and of what they may believe is quality care. Their participation
in their own care may be dependent on the providers' ability to engage the patients
in ways that are relevant to them and that are consistent with their values,
beliefs, and needs. Ultimately these characteristics shape the patients' responses
to care activities, their participation in the care processes, and finally the
outcomes of the care interventions.
The Processes of Care
Healthcare is delivered using specific and predetermined
processes. These processes are the procedures providers use, the methods they
deploy, and the various styles and techniques they may render in the delivery
of healthcare services. The processes of care (Box
1-4) are concerned with the functions and responsibilities of the healthcare
providers and how they fulfill them. The processes can be divided into two groups,
the technical and interpersonal styles employed as healthcare providers care
for patients and their families. These, when combined with the structural characteristics
described previously, will ultimately affect the organization's ability to assist
patients in their transition toward expected outcomes of care.
The processes of care are applied within the structural elements listed in Box
1-3 and discussed previously. The structure can be thought of as the skeleton,
and the processes as the muscles. The processes are what get one from point
A to point B. They move patients from one destination to the next. To provide
quality care, therefore, it is necessary to have both the structure and the
processes. The list in Box 1-4 is only
a sample of the possible processes in any healthcare organization. Case managers
will find themselves interfacing with virtually any and all kinds of processes
in the course of their work. The providers' and case managers' technical styles
may be affected by the organization they work in and their personal (i.e., structural)
characteristics as described previously. Have you ever walked onto a patient
care unit and been able to feel something? You may have had an immediate sense
that the environment was positive, negative, or apathetic. You may not have
known why you felt that way but there was something present in the environment
that gave you that specific impression. What you were sensing was the interpersonal
style and dynamics of the setting you were in.
Case Management Links Structure and Process
Case management transcends all of these structural
and process variables as it attempts to move patients toward their expected
outcomes of care. The case
manager must consider all of the elements in the structure and in
the processes while creating care plans; planning for discharge; and interacting
with patients, physicians, and other healthcare providers. Case managers must
consider and assess all of the variables to make cogent and appropriate plans
of care. Finally, the case managers must, in conjunction with members of the
interdisciplinary team, identify expected outcomes that are consistent with
the characteristics within the structure of care and compatible with the processes
of care.
Outcomes of Care
Outcomes of care can be thought of as the goals or
objectives of the care rendered and the services provided. Like structure and
process, outcomes too can be categorized and thought of in various subsets or
classifications. They are the end results and consequences of care delivery
and processes and the effects of the structural variables/characteristics of
the healthcare delivery system (Box 1-5).
A quality case management
plan usually includes the structure and processes, as well as the
expected outcomes of care. Each process should include an expected outcome as
illustrated in Section
4, Chapter 2 and Section
4, Chapter 3. Each intervention should also include an expected
outcome that is prospectively identified.
Typically, case managers will use the clinical endpoints as indicators for when
a patient has completed a particular stage in the care process and can be moved
on to the next. The outcomes can be linked to those found in the InterQual criteria
(InterQual, Inc, 1998) and Milliman
& Robertson Healthcare Management Guidelines (Schibanoff,
1999). For example, a drain might be removed postoperatively after the drainage
has decreased to a predetermined and acceptable amount/ volume per hour.
Outcomes can also be used very effectively when linked with discharge/transitional
planning. By moving the patient toward a predetermined set of outcomes, the
time for discharge, or transition to the next level of care, is driven by the
patient's achievement of those expected outcomes and is not based on arbitrary
timeframes. In this way the case manager can defend the time at which a patient
should be discharged if the patient, family, and/or physician are resistant.
The case manager can also defend the need to extend the hospital stay in the
event that a premature discharge is identified based on a review of the patient's
progress in achieving the expected outcomes. The case manager can also use the
achievement, or lack of achievement, of the expected outcomes for clinical insurance
reviews to ensure that reimbursement occurs and, when necessary, that additional
hospital days are approved by a third-party
payer. In these ways outcomes can be a powerful and dynamic tool
that provides the case manager with objective indicators for use for a variety
of purposes.
The classification of outcomes has shifted over time based on the individuals
or groups defining them and also has been influenced by the changing sociopolitical
characteristics of the healthcare environment. Traditionally, outcomes have
been defined by the providers of healthcare services, particularly physicians.
Physicians have always examined outcomes as measures of patient mortality, morbidity,
complications
to treatment, errors, and adverse events or side effects. These types of outcomes
were driven by physician practices and reflected the interest of physicians
in their own services. Not until the mid-to-late 1980s, but more so during the
last decade, did consumers of healthcare become more influential in changing
the outlook of outcomes. They were successful in pressuring providers to examine
the quality of care using outcome indicators that are consumer-focused rather
than provider-focused. This movement resulted in defining a new set of indicators
that is considered more contemporary. Examples of these indicators are clinical
outcomes such as resolution of disease symptoms; patient's quality of life and
well-being; functional ability; satisfaction with care; and financial outcomes
such as cost per case/encounter, reimbursement denials,
and many others. These indicators are most fit today for evaluating the impact
of case management models/systems of healthcare.
Using Structure/Process/Outcomes to Measure
Quality
Because case management links the three elements
of structure, process, and outcome (Case
Manager's Tip 1-2), case managers can serve an important function in assisting
their organizations in the measurement of quality of care. As case managers
review the patient's achievement of the expected outcomes of care, they can
also review the processes used to achieve those outcomes. The processes, as
identified on the diagnosis-specific case management plan, become the standard
of care for patients with that diagnosis. The patient's ability to reach the
expected outcomes is dependent on the selection of the most appropriate processes
for achieving those outcomes. It is also dependent on the organization's processes
supporting the care interventions needed. For example, perhaps the case management
plan calls for a particular test such as magnetic resonance imaging (MRI) to
be done on day 1 of the hospital stay. What are the consequences if day 1 happens
to fall on a Sunday when MRIs are not routinely done? The patient's stay will
be prolonged, quality care will not be provided as per the case management plan,
the patient's satisfaction with care will suffer, and reimbursement may be put
at risk. The case manager, by collecting these delays as variances, can provide
the organization with meaningful information that may assist in making organizational
improvements, which in turn will result in the provision of better quality of
care.
Another example is the switch of a patient from an intravenous (IV) antibiotic
to its oral form. The case management plan may call for the switch to take place
after several prerequisite clinical outcomes have been met. In the case of community-acquired
pneumonia, the switch from an IV antibiotic may depend on the patient's achievement
of a reduced white blood cell count, a reduction in fever, and the ability to
take oral medications. What might happen if the patient achieved these outcomes
but the attending physician does not write an order for the switch to take place?
This may result in compromising the quality of care, prolonging the hospital
length of stay unnecessarily, and increasing the cost of care or sustaining
a denial in reimbursement by a commercial insurer.
QUALITY CATEGORIES OF ORGANIZATIONAL
VALUES
Commonly, organizational values can be divided into
five categories of quality:
(1) patient/customer
focus,
(2) total involvement of taking responsibility for quality,
(3) measurement or monitoring of quality,
(4) systems support, and
(5) CQI (Organizational Dynamics, Inc,
1991).
To differentiate
the categories, it is necessary to define each more fully and to give examples
of a strong versus a weak organizational commitment to quality.
Patient/Customer Focus
The patient/customer focus of quality is related
to service, products available, and sharing of information to both internal
and external customers of an institution (Case
Manager's Tip 1-3). Customer service has become a common buzzword. Determining
whether one's external customers received the quality they valued is a powerful
tool for an organization to use. In the past, most facilities believed that
if they tracked the number of problems or occurrences and they remained within
an acceptable level, then the organization was providing quality customer service.
More recently, the technique of asking the consumers about their expectations
of quality care was found to be much more telling and accurate rather than a
hospital making random assumptions as to what the customer needed or considered
as quality care. Patient care surveys are now widely used in all types of settings
as successful tools for quality care assessment and improvement.
As case management programs become more visible, patient satisfaction surveys
may need to be altered so that they capture not only environmental amenities
such as food and room comfort but also include the professional care received.
Case management should be added to patient care surveys.
It is appropriate to consider an example of an organization's commitment to
quality customer service: Patients are called after discharge to hear if their
expectations were met. Their suggestions and complaints are taken seriously,
addressed, and responded to. The organization that does not incorporate customer
service into its quality program, does not respond to patient complaints, and
ignores suggestions made by its customers jeopardizes its reputation, competitiveness,
market share, and financial status.
Total Involvement
The total involvement of taking responsibility for
quality relates to the fact that management personnel or QA personnel cannot
be the sole personnel involved in QA and QI efforts. It is everyone's responsibility
to be involved in the achievement, enhancement, and maintenance of quality.
Quality is the direct result of positive and desirable employee behavior (Williams,
1994). Positive employee behavior is usually the result of staff job satisfaction.
Employees tend to feel ownership of their organization's values when they have
been involved in the selection of those values. Productive behavior is evident
when an organization's goals are clear and understood by its employees, their
role in the organization is defined, and the policies and procedures governing
their role are well communicated. For example, the hospital that supports a
strong case management team and empowers its members with the permission to
solve problems independently and autonomously is an organization with a commitment
to quality. The hospital that shows weakness in this area of quality commitment
will not address the need for a case management program and will wait for some
divine intervention to solve its problems.
Measurement or Monitoring of Quality
Measurement or monitoring of quality must be done
to meet the goals. Improvement is impossible without measurement (Organizational
Dynamics, Inc, 1991). The case manager's role is to ensure that the patient
is moving along in the acute, subacute, or home care level of care in a timely
fashion. If any outcomes are not achieved or are delayed, it is the case manager
in these settings who is responsible for determining why and for facilitating
a corrective action plan. These untoward occurrences are called variances
(see Section
5, Chapter 2). By reviewing a patient's progress regularly and
anticipating the plan, patient variances will be kept to a minimum and length
of stay issues will be avoided. Healthcare provider variances are
related to omissions or errors made by practitioners. Regulations and policies
govern this area. If a healthcare provider omits a medication, this is a variance
that could affect the treatment plan and outcomes. Operational variances are
those that happen within the healthcare setting. Examples include a patient
waiting for a rehabilitation bed, delays in discharge, equipment failures, and
scheduling delays. Retrospective analysis and trending of variances result in
identification of frequently occurring variances. This analysis will help monitor
quality and identify areas for improvement. Outcomes are paramount criteria
of good quality either by themselves or as related to costs if efficiency and
optimality are to be determined (Donabedian,
1991).
Systems Support
Systems support includes planning, budgeting, scheduling,
and performance management needed to support the quality effort. If systems
are well coordinated, the time it takes to accomplish the work will be reduced.
Everyone should be invested in providing quality work. A team effort should
be fostered to accomplish unified goals. A good example of this is a healthcare
delivery system called patient-focused care that
is being adopted in many acute care settings. This system is based on the philosophy
that the patient is the center core of focus and that all disciplines involved
with the patient must be able to access that patient easily. Patients should
not have to seek out the area needed for their treatment; it should come to
them. The patient requiring physical therapy should not have to be transported
to the physical rehabilitation department; the department's physical therapist
should be available in the unit in which the patient resides. This decreases
the nonproductive time of transport and can ultimately have the effect of shortening
the hospitalization.
Continuous Quality Improvement
Through CQI, organizations foster creativity
to do things better tomorrow than they did yesterday. CQI is a way of correcting
flaws and making improvements. Well over a decade ago, the industrial leaders
of the world realized that to remain competitive and survive in our economy
today, CQI techniques were needed. There are three individuals who stand out
as pioneers in the development of QI techniques: Philip B. Crosby, W. Edwards
Demming, and Joseph M. Juran. Crosby
(1979) designed a 14-step approach for his quality improvement process (QIP)
(Box 1-6).
Demming's and Juran's work dates back to the 1920s and 1950s, respectively,
and was responsible for enormous improvements in Japanese manufacturing. In
1986 Demming's approach to QI came to America. He is best known for involving
the employee in the QI effort, applying a never-ending cycle of continuous improvement
and eliminating rework and non-value adding processes to reduce cost. This approach
involved groups of employees coming together to discuss problem identification
and problem solving. When this process is applied to healthcare, it involves
strategies not only to improve quality but also to reduce costs.
In the United States the concept of quality has matured first
from the early quality control or inspection and testing effort to the middle
ground of QA, in which selected specialists monitored quality, identified errors
or incidents, and kept report cards on each individual blamed for the problem.
The QA specialists tend to lack the authority or clout necessary to change the
way work is performed. Moreover, QA and its inspection techniques never catch
the real issues affecting patient care. The fully mature quality effort is known
as continuous quality improvement or total quality management.
The organizations that embrace this concept are those advanced in the ability
to empower their employees to be responsible for quality. For the past decade
the JCAHO (JCAHO, 1996, 2001)
has set forth the charge to integrate QI endeavors that focus on actual performance
and outcomes.
The JCAHO has designed the quality cube (Figure
1-1) to depict a model for assessing quality. It illustrates the relationship
of performance and important functions to a range of patient populations and
services provided. The cube is a tool that stimulates thought related to improvement
priorities.
Health professionals have successfully shifted their efforts from QA to QI and
most recently advancing to such terms as continuous quality
improvement (CQI), total quality management (TQM), and JCAHO's latest
term: process improvement (PI). QA, as stated earlier,
tends to focus on reduction of errors, meeting standards set up by regulatory
agencies, and measuring defined outcomes. This model functions in response to
problems and has a retrospective view of tracking occurrences after they have
happened. QI, on the other hand, focuses on improving a process to effect improvements
in the outcomes, meeting customer needs, and measuring customer-identified outcomes.
It is a continuous proactive process that avoids focusing on employee and punitive
approaches and involves all employees at all levels. The QI approach is one
in which the advantage is clear, and it assumes that most people want to do
the right thing and do it well. According to the Health
Outcomes Institute (1994), quality in healthcare is achieved by "doing the
right thing right," where "the right thing" is outcome management and one does
it "right" by controlling the process.
We have moved from the paradigm of QA, where provider-defined
outcomes (such as morbidity, mortality, and clinical endpoints) rule, to QI,
which relies on customer-defined outcomes (such as cost of care, health-related
quality, and patient satisfaction). QI focuses on the continued improvement
of all processes rather than just those identified as a problem. This type of
approach can improve quality of care of the majority of patients and also decrease
statistical outliers. Outlier
thresholds are set by the Centers for Medicare
and Medicaid
Services (CMS), formerly known as the Health Care Financing Administration (HCFA).
This is the range of days a patient may stay hospitalized at the maximum reimbursement
rate. Outliers are those who exceed the set range of days. In contrast, QA governs
itself by the 80/20 rule (or "Pareto Principle"), which states that 80% of costs
are generated by 20% of the patients. Therefore those who abide by this principle
will only address a small percentage of issues. Table
1-1 provides a snapshot summary of QA versus QI activities.
CASE MANAGEMENT AND CQI
How does the QI approach to healthcare fit in with
a case management model? Case managers' skills and role characteristics, as
discussed in previous chapters, exemplify many of the descriptive elements of
QI: problem solving, negotiation, mentoring, quality monitoring, customer relations,
and outcome analysis. Usually the first function for a case manager is to select
those patients who would benefit from case management. The next function is
to facilitate patient treatment goals and discharge plans. In a successful case
management program all patients should be monitored for quality, use of resources,
and length of stay. Once a patient is identified as one who would benefit from
case management, a case management plan of care is designed. The plan is developed
to optimize the treatment plan and outcomes, streamline the care to avoid delays
or roadblocks, and avoid any compromise in quality. By following these guidelines,
quality issues are easily tracked. Two tools that are commonly used to track
issues of quality are indicator reports and variance reports. Indicator reports
are usually geared more to physician practice patterns and untoward occurrences
as sequelae to their practice (e.g., an unplanned return to the operating room
during the same hospitalization, postoperative complications, or abnormal laboratory
results not addressed)—simply put, identifying anything that does not
happen when it should. Variance reporting is discussed in much more detail in
Section
4, Chapter 2.
In general, the case manager is the driving force behind
the success of quality patient care through case management. The case manager
who checks on quality indicators (outcomes) and variances not only identifies
problems but also must find remedies for the patient's care to continue to successfully
and efficiently move through the hospital system.
A case management program has a major importance to any quality
effort. Case managers have the potential to reduce readmissions and the ability
to evaluate the possibility of meeting a patient's healthcare needs in an alternative
and probably less-costly setting. The case manager must ensure that a patient
receives adequate and appropriate care while acute and must provide adequate
quality follow-up and postdischarge care. By doing this efficiently case managers
reduce premature discharges at healthcare facilities and help to guarantee that
patients' discharge plans are adequate, safe, and meet their needs, with the
ultimate goal of quality care, patient satisfaction, and avoiding unnecessary
readmissions.
You can quickly conclude after reviewing Case
Study 1-1 that had all the healthcare disciplines involved in the discharge
plan of Mrs. Lopez been consulted, the undesired outcome could have been avoided.
By simply reviewing with the home care agency the equipment that the patient
was using in the hospital versus the equipment being used at home, the undue
anxiety of the patient's family would not have occurred. Had the home health
nurse and case manager assessed the ventilator and related supplies that would
be used in the home, the patient's well-being could have been maintained by
altering the education of the caregivers in the home.
CONSUMER/PATIENT SATISFACTION
An important outcome of any case management program
is customer satisfaction. Patient and family satisfaction are essential outcomes
to measure; physician, team members, and other involved agencies, as in the
previous example, are also important customers. Case managers must work closely
with all members of the healthcare team to assess, monitor, and analyze the
delivery of care, the case management plan, and the patient/family response
to the care to continuously improve the organization's quality of performance
(Flarey and Smith-Blanchett, 1996).
A case management plan
is designed typically through a multidisciplinary process; when executed correctly,
the team's collaboration designs the single best treatment plan for a specific
patient type. The plan also provides for a collection and ongoing evaluation
of potential quality issues. These issues are usually identified through variances
or complications. The entire process enables a focus on quality by continually
assessing and identifying opportunities for improvement (Flarey
and Smith-Blanchett, 1996).
Case management's efforts for improvement must be accomplished case by case.
Case management plays a crucial role in evaluating and monitoring a patient's
case management plan and outcomes such as discharge goals. Case managers are
the professionals most aware of the patient's functional, physical, and cognitive
abilities and know best how these abilities will affect and determine a patient's
level of functioning after discharge/transition from an acute care setting or
an episode of illness. Offering the best possible discharge/transitional plan
is vitally important because of the potential for reducing readmissions and
providing alternative care methods for less cost—and thus the ultimate
outcome of heightened patient, family, physician, and payer satisfaction.
Being able to exceed customers' expectations for quality service must be the
driving force; this central concern is a primary reason a registered nurse or
social worker becomes a case manager. Quality service should be a way of life
for any case manager on a day-to-day basis, and it is one of the standards necessary
today for healthcare to prosper and survive (Case
Manager's Tip 1-4).
COST/QUALITY/CASE MANAGEMENT
As healthcare costs increasingly become a public
issue and managed care organizations spend more and more time examining documentation
of healthcare expenses and charges, it is more apparent that quality monitoring
must also include elements of not only practice patterns and patient satisfaction
but also cost-containment strategies.
In healthcare organizations problems that go undetected can
have devastating effects that involve wasted time and money. When a problem
is not fixed at the time it occurs, it will only become more costly to fix later
(Organizational Dynamics, Inc, 1991)
(Figure 1-2).
Costs usually involve the necessary expenditures and those
that are avoidable. A necessary cost is one that
is needed to sustain a certain standard. Avoidable costs
are those that occur whenever things are done wrong or when unnecessary steps
are applied in the process. Necessary and avoidable costs can be further defined
by prevention, inspection, and failure costs. Prevention
costs are those intended to ensure that things will not go wrong. Inspection
costs are the costs of finding an error or variance and fixing it. Failure
costs are those incurred when outcomes and patient or customer satisfaction
are negatively affected. Any institution pays a big price for a marred reputation,
rework, waste, legal penalties, extra charges, or loss of business.
Poor quality is very costly. To help reduce the potential
costs poor quality incurs, it becomes imperative that case managers facilitate
QI by making sure that they get involved and have the confidence and skills
required to do their job well. This does not mean that case managers are solely
responsible for the cost of quality. They must work in concert with all of the
members of the interdisciplinary team. For example, a physician writes an order
for a medication that the patient has an allergy to. If the nurse notices this
error as the order is picked up, it would involve a simple solution of ordering
another medication that is more appropriate for the patient. However, if the
order goes to the pharmacy and the allergy is not noted, the pharmacist fills
the order, and the nurse administers the drug; it could end in terrible tragedy.
The cost of the incorrect drug is only the tip of the iceberg for this error.
The dollars alone cannot fully measure the impact of such an avoidable error
on the patient and the hospital. The real cost of this undetected problem shows
the heightened damage as illustrated in the 1-10–100 rule. Not only has
a medication occurrence added increased cost, but patient satisfaction is at
stake as well.
The obvious key to reducing costs and maintaining quality is prevention. The
case manager, in the daily review of patient care, works toward preventing errors,
delays, problems, and bottlenecks to care. The next best strategy after prevention
is early detection and treatment of the problem. Again consider the scenario
of the drug error. If the immediate physician order error goes undetected, then
the first level of prevention fails unnecessarily. However, if the nurse detects
the problem before administration of the drug, then early detection prevents
the potential full impact of the error. On the other hand, if the nurse administers
the incorrect drug, then early detection is not employed. To compound this error,
perhaps the patient is aware that a mistake has been made, and this is ethically
necessary. Now the confidence in the physician and hospital staff has been marred.
The case manager is now involved in identifying this quality issue and must
now get the physician and perhaps a hospital representative in to speak with
the patient and attempt to make amends. It now becomes clearer that the cost
of quality in this example could have the worst effect of all no matter how
simple the issue may be-a dissatisfied patient who will never return to that
healthcare facility.
A second area in which cost and quality intertwine is the
cost associated with misuse of personnel or equipment resources. For example,
a case manager specializing in cardiac care began to notice a strange occurrence
on the unit. Many of the cardiac patients were being monitored simultaneously
on both the telemetry units and physician-ordered Holter monitors. The case
manager began to ask the obvious question, "Why?" The Holter monitors were an
added expense for the hospital not only because the equipment was costly but
also because of the misuse of personnel required to read the Holter monitor
data and generate and file a report. The same data were available on the telemetry
monitors. The case manager decided to investigate the problem by analyzing the
cost of the Holter monitoring. In addition, the case manager met with various
physicians and the medical director to troubleshoot the rationale behind ordering
the Holter monitoring for telemetry patients. What was discovered by the case
manager was that new telemetry technicians had been hired by the hospital and
the physicians did not have the confidence that their patients' monitors were
being read with the same caliber as they were with the previous telemetry team.
The case manager then set out to reassure the physicians of the qualifications,
training, and orientation of the new telemetry technicians and personally reviewed
a number of cases in which the Holter and telemetry were used, comparing the
diagnostics of both to show the physicians that the quality of their patients'
care had not been compromised. Because of the perseverance of this case manager,
the additional use of Holter monitors with telemetry units was diminished. By
analyzing this problem the case manager identified an opportunity for QI through
the most cost-effective method available to the patients.
The last area is the cost of delays. There is much at stake when quality is
affected by a delayed service. All of the issues mentioned thus far come into
play here. The cost associated with delays, the impact on patient satisfaction,
and the misappropriation of resources and personnel will significantly affect
the cost of outcomes. Delays are very costly to hospitals and can negatively
influence how they are judged by managed care companies, other physicians, customers,
and patients.
The example of the ventilator-dependent patient is useful here as well. Suppose
that the patient appears to have the potential to be weaned from the ventilator.
Weaning can be an arduous task, but the ultimate payoff is so exciting and cost-effective
that if done successfully it can save the hospital many costly dollars. The
challenge of weaning a patient from a ventilator lies with an experienced team
who follows the patient very closely. This involves the efforts of case management,
as well as social work, dietary, respiratory therapy, speech therapy, the physician,
nursing staff, the patient, and the family. The multidisciplinary approach to
this complex patient's care management plan is essential to its success.
First the case manager and social worker must work with the
family to help them adjust to the idea that weaning their loved one may take
some time and may or may not be successful. This alone is difficult and at times
frustrating and disappointing for a family. Once the case manager has established
that the patient and family are emotionally prepared, the next step is for the
other disciplines to educate the family on the care required at home. The timing
and availability of the other departments can make or break the length of time
it takes to wean a patient. It becomes crucial for the case manager to stay
on top of the whole process from start to finish so that everything is in place
at the right time. The social worker must work on applications for personal
care attendants or any financial arrangements that need to be finalized before
discharge. The dietitian must be closely involved with the patient, watching
all food intake. The right balance of protein, fat, and carbohydrates must be
monitored because weaning cannot take place without the proper caloric intake.
A negative nitrogen balance from inappropriate intake can significantly delay
the weaning process.
The speech therapist has the vital role of training the patient in different
speech and swallowing techniques. If this is attempted with a dedicated positive
approach toward the patient's progress, the odds of success are greater. Not
all patients are able to meet the criteria for successful speech therapy. It
is the case manager who will discuss the potential with the speech therapist
and physician to see if the patient is a good candidate. Successful speech and
swallow training can make the difference between a patient who will require
tube feedings and the patient who can go home on oral food intake. Imagine the
delays that can occur in this area alone if no one takes an aggressive risk
in attempting to train the patient. Should this area not be explored or attempted
with strong expertise, the patient will require tube feedings, which will surely
cause a delay because of the added teaching required. The family will need to
learn the tube feeding procedures, and the patient will have an additional psychological
hurdle to get over.
This is an area in which the case manager can again be involved. A patient-teaching
checklist can assist all disciplines in tracking the progress of the family
and their ability to learn various tasks such as tube feeding. Without the use
of such a tool an additional delay can occur because there will be no record
of the progress or lack of progress a family is making in learning the necessary
skills required. Another discipline that must coordinate its intervention when
weaning a patient is respiratory therapy. The therapists must monitor all of
the oxygen saturation data and be willing to try the patient on and off the
ventilator for periods, knowing that this is a tedious task that requires patience
and perseverance. Any missed opportunities to try the patient off the ventilator
could delay the ultimate weaning process and may even cause a failed weaning
of the patient. Obviously if the attempts are failed the medical costs of this
patient's care increase dramatically.
All interdisciplinary efforts should be to work toward keeping
the cost of this patient's care as low as possible. It is very important for
the physician to have a trusting relationship with all of the involved disciplines
in the patient's discharge plan. If the physician becomes discouraged with the
progress being made, the chances are that he or she will make the decision that
the patient is not weanable. The physician must be kept well informed by the
nursing staff whenever progress is being made (Case
Manager's Tip 1-5).
The case manager again has the important role of assisting the physician in
making educated decisions regarding whether the patient is making significant
enough progress to be weaned off the ventilator. The case manager must also
have the expertise to know when to call the skilled nursing agency to begin
the preparations for discharge from the hospital setting. If the timing is off
on this phase of the discharge plan, a major delay will be incurred. As in the
scenario discussed earlier in this chapter (see Case
Study 1-1), if the skilled nursing piece is not included in the discharge
plan the risk of an unnecessary readmission is significant. Similarly, if the
outpatient home respiratory therapy company is not brought into the loop at
the right time, the home may not be properly prepared for a ventilator if this
patient cannot be weaned. It behooves the company to check the home electricity
for the ability to accommodate the ventilator. Thus if the patient does not
come off the ventilator, the potential delay of wiring the home for appropriate
electricity can be avoided.
There are other tools that can assist the case manager's efforts toward a successful
weaning and cost effective quality discharge plan. The use of a clinical
pathway or multidisciplinary
action plan (MAP) that is specific to weaning a patient off the ventilator
will serve as an excellent guideline for all disciplines involved in the case
to help track areas of strengths and weaknesses. It will help to standardize
the process and yet individualize it to specific patient needs. Patient teaching
pathways or patient education tools can help to include the patient and family
in the plan. The teaching guidelines can assist as a resource for the patient
and family at times when the information being taught becomes overwhelming.
Anything that can help to reinforce teaching will ultimately be a benefit to
the patient/ family and ultimately lead to a timely discharge not hindered or
delayed by lack of understanding on the patient's or family's part (Case
Manager's Tip 1-6).
CASE MANAGEMENT AND
OUTCOMES MANAGEMENT
Outcomes management
is a process that focuses on cost and quality of healthcare.
It is defined as a method for the implementation of ideal and desirable patient
care services that ultimately enhance patient and organizational outcomes. Case
management provides the mechanism by which effective and efficient outcomes
are provided, ensured, enhanced, and facilitated. Both outcomes management and
case management processes are interested in quality patient care. This makes
their marriage desirable and feasible. Almost all of the case management programs
today include an outcomes management component whose purpose is to measure the
effectiveness of the program. Other benefits of having an outcomes management
program are as follows: