Published in the February 2006 issue of Today’s Hospitalist
Residents at Fletcher Allen Health Care in Burlington, Vt., are not only learning valuable lessons about quality improvement, but they are helping reshape patient care at the health system.
Fletcher Allen, a large health care system and academic medical center, is offering a four-week curriculum to introduce residents and nurse practitioners to the world of systems and practice improvement. It is one of 14 organizations to receive a grant from Partners for Quality Education, a national initiative of the Robert Wood Johnson Foundation.
The month-long program, known as Achieving Competence Today, combines Web-based instruction and traditional lectures to teach quality improvement principles, health care financing and team skills. The goal is to introduce students to a systems approach to improving health care.
“We’re giving our residents and graduate nursing students the tools to change and improve processes in our health care organization,” says Anna Noonan, RN, Fletcher Allen’s vice president for quality.
Redefining stat orders
The organizations that received the grant are all using the same curriculum, but Ms. Noonan says there is flexibility in how each organization implements the curriculum. While Fletcher Allen chose to use the curriculum to focus on patient safety, other organizations have taken a slightly different focus.
The health system tries to free residents of their clinical duties during the four-week period. Ms. Noonan says the goal is to give nursing students and residents, who come from multiple specialties, time to fully immerse themselves in the project. And to make sure that everyone has a chance to participate in all aspects of the program, Fletcher Allen also tries to limit the groups to no more than 10 people in one session.
The course starts by giving participants a systems issue that they can work through using the curriculum and faculty guidance. The team searches for solutions and reports on its progress twice a week to the program faculty.
The group that went through the program last fall was charged with examining ways to streamline the use of stat orders for medications.
“Because of the complexity of systems like ours,” Ms. Noonan says, “you don’t always get the medication right away. Most of the time, that’s not a problem, but our goal is to keep it from becoming a problem.”
After studying and flowcharting the hospital’s systems for ordering drugs, the team discovered that the term “stat” varies. “In one service,” Ms. Noonan says, “a physician would write stat to indicate that the patient needs the medicine within 10 minutes, but another physician might mean before the next routinely scheduled medication time.”
In one case, the group found an order written as “super stat,” in an attempt to ensure that the patient received the medication quickly. “Just in the interpretation of the definition alone,” Ms. Noonan says, “there was a lot of variability.”
One of the group’s solutions was to create a clearer definition of the term stat. Physicians are now supposed to place a stat order only if a drug needs to be given within 20 minutes. The group also created a new term, “first dose now,” to avoid delays in the medication administration.
“It was a simple systems improvement that cost nothing at all,” Ms. Noonan says.
A simple systems failure
The group found some other basic problems with stat drug orders. Because Fletcher Allen doesn’t have an electronic medical records system, nurses place orders into clear plastic sleeves, electronically scan them and then send the orders to the pharmacy department.
When a physician orders a drug stat, the order is placed into a sleeve that has stat written on the side. Those orders are put at the front of the processing cue when they reach the pharmacy.
“The team followed stat medications on different units,” Ms. Noonan says. “Each of them took different stat medication orders and tracked them through the organization.”
The group’s detective work identified a simple problem in the process for handling stat drugs: Hole punches or marks on the sides of the order forms were sometimes being misinterpreted by the pharmacy’s scanners as a stat label. The drug order, even if it was for something as simple as milk of magnesia, would then be bumped to the top of the cue in pharmacy.
“The scanner couldn’t discriminate between these markings,” Ms. Noonan explains. “It was a simple system failure. In some cases, unfortunately, the real stat medications were being pushed back in the cue.”
The solution was fairly simple: The team suggested that the stat label be moved to the top or the bottom of the sleeve, not the side. That way, when the machines scanned the orders, they wouldn’t misread holes on the side of the page as stat marks.
The role of teamwork
Residents in the group learned how they learned drugs are processed in the hospital, but Ms. Noonan says that they learned an even bigger lesson about the role that teamwork plays in quality improvement initiatives.
“The most important aspect of the curriculum is the power of the multidisciplinary team,” she explains. “It’s medicine, psychiatry, surgery residents and graduate nursing students working together as a team, and they come from very different perspectives.”
“What’s fascinating is that in their residency training,” Ms. Noonan adds, “they don’t often interface with other disciplines this way. They do consults and talk to each other in grand rounds, but perhaps not enough. It’s been great watching them come together as a health care team.”
The group also has a chance to work with the hospital’s leadership during the course. Throughout the project, the group presents its ideas and solutions to several teams in the organization, such as the medical staff quality committee and the senior leadership team. Some form of the project is then implemented.
“It’s an opportunity to expose the residents to the real world in terms of the administration and the staff working on quality improvement,” Ms. Noonan says.
And an important part of the group’s real-world experience is handling criticism. One group studying patient flow issues, for example, suggested that the hospital create a holding area in the ED for patients whose admission to the wards would be delayed significantly.
“We explained that we need to focus on how patients flow through the system as a whole and fix those downstream systems issues,” Ms. Noonan recalls. “Another holding area may not be the best solution.”
“The group was disappointed that its solution wasn’t implemented,” she says, “but that too is a learning experience. Not every quality improvement project gets fully developed and implemented.”
Reaching more residents
In the year and a half since the program started “three groups have gone through the process “word about it has spread.
“When I bump into the residents in the hallway, they tell me they’re still looking for system failures,” Ms. Noonan says. “They have a new set of lenses with which to view their world because they have been exposed to new tools and experiences.”
To help more residents and graduate nurses take advantage of the program, Fletcher Allen is developing a simplified Web-only curriculum that will be pilot-tested in March. Residents who like the program can then participate in the four-week curriculum, which Ms. Noonan says is more intensive than the Web-only program.
The ultimate goal, though, is to get as many residents as possible to start thinking about performance improvement.
“In the quality world, if you want a different outcome, you need a different design,” Ms. Noonan says. “We really need to think about how we train and educate our physicians, our nurses and other health care providers. If we want them to practice medicine in a different way, they need to be trained and educated differently.”
Edward Doyle is Editor of Today’s Hospitalist