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J Am Coll Cardiol, 2005; 46:1-29, doi:10.1016/j.jacc.2005.09.018 © 2005 by the American College of Cardiology Foundation |
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* St Joseph’s Mercy Hospital, Ann Arbor, Michigan
University of Michigan Cardiovascular Center, Ann Arbor, Michigan
* Reprint requests and correspondence: Dr. Kim A. Eagle, University of Michigan Cardiovascular Center, 300 North Ingalls, 8B02, Ann Arbor, Michigan 48109 (Email: keagle{at}umich.edu).
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1.0 Introduction |
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 Top 1.0 Introduction 2.0 ACC AMI-GAP QI...3.0 Planning phase4.0 Implementation phase5.0 Monitoring tool use...6.0 Remeasurement phase7.0 Results phase8.0 Sustaining the gain9.0 Summary11.0 Appendix A: Project...12.0 Appendix B: AMI-GAP...13.0 Appendix C: ACC...Heart attack discharge formReferences |
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2.0 ACC AMI-GAP QI model |
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Top1.0 Introduction2.0 ACC AMI-GAP QI...3.0 Planning phase4.0 Implementation phase5.0 Monitoring tool use...6.0 Remeasurement phase7.0 Results phase8.0 Sustaining the gain9.0 Summary11.0 Appendix A: Project...12.0 Appendix B: AMI-GAP...13.0 Appendix C: ACC...Heart attack discharge formReferences |
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Incorporating successes and lessons learned from the GAP pilot project (8,9) and the Flint-Saginaw Expansion GAP project (10), the third project, entitled the Southeast Michigan Expansion GAP project, was launched in the Fall of 2002. Like the first two GAP projects, this project aimed to improve the care of patients with AMI through implementation of the ACC AMI tool kit and a concentrated QI intervention led by local cardiology physician champions and hospital project leaders. The level of support provided to hospital teams was intensified through implementation of the ACC AMI-GAP collaborative model, which was based on the lessons learned from the previous GAP projects (10). The GAP collaborative model was modeled after that of the Institute for Healthcare Improvement (IHI) breakthrough series model (BTS) (12) with several important distinctions. In both models, teams from multiple organizations come together to work on a common problem. In the IHI model, the teams work at their own pace, sharing successes and lessons learned at learning sessions held periodically throughout the time span of the collaborative. The ACC AMI-GAP collaborative model is a research model imbedded in a QI model, in that all hospital teams are working within the same time frame for baseline measurement, intervention implementation, and remeasurement. Furthermore, the ACC AMI-GAP collaborative model is a collaborative rapid-cycle model that focuses on successful project implementation through five distinct QI phases: planning, tool implementation, monitoring tool use, remeasurement, and results (Fig. 1).
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(13). Physician champions and project leaders subsequently coordinated multidisciplinary teams to plan their respective hospital’s activities. The multidisciplinary teams developed a systematic process for implementation of their project, including an introductory kickoff of grand rounds at each hospital. Five project leader learning sessions that corresponded with the phases of project implementation were conducted to:
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3.0 Planning phase |
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Top1.0 Introduction2.0 ACC AMI-GAP QI...3.0 Planning phase4.0 Implementation phase5.0 Monitoring tool use...6.0 Remeasurement phase7.0 Results phase8.0 Sustaining the gain9.0 Summary11.0 Appendix A: Project...12.0 Appendix B: AMI-GAP...13.0 Appendix C: ACC...Heart attack discharge formReferences |
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Suggested readings:
3.1 Identify a Focus. Which comes first, the team or the problem? Does a team identify a problem to solve or does a problem exist and a team forms to address it? Local situations will determine the order of events, but for the purposes of this manual, it is assumed that the readers have decided or are in the process of deciding to implement an AMI-GAP project. This decision may be sparked by regulatory agencies, identification of a high cost or high volume patient population, a known opportunity for improvement in quality of care indicators, and/or interest by local cardiologists or other clinicians from reading the articles that have reported the successes of the ACC AMI-GAP projects. The care of patients with AMI is very broad. As such, the ACC AMI-GAP projects and this manual have narrowed the focus to a QI initiative that supports health care providers in caring for patients hospitalized with AMI, through the use of standardized care tools that guide clinicians through decisions that are consistent with the ACC/American Heart Association (AHA) guidelines.
3.2 Project Support and Approval. Before proceeding with the AMI-GAP project, it is suggested that hospital administration and leadership from cardiology, nursing, emergency care, and QI declare the project a priority and provide support and resources. In all three previous GAP projects, teams that had this approval and support appeared to be more successful because personnel resources and support for all phases of the project were made available. This supportive group is labeled differently by various sources as the "guidance team" or "team sponsor" (14), "system leaders" (15), "leadership team," or simply "leaders" (16,17). They are commonly defined as those who are in a leadership or management position, who have a stake in the process or problem (stakeholder), and have decision-making authority, clout, and, most importantly, financial and manpower resources to support the QI activity.
The list may be expanded beyond the list provided in the previous text; it is important that each team identify from whom they need support and be able to articulate the involvement that is needed. The support and involvement was obvious and visible in the teams that were most successful in the three GAP projects. For example, the kickoff grand round events were high-profile events with participation by executive leadership and presentations by physician champions from cardiology as well as the emergency department. At some sites, the chief executive officer sent letters to physicians announcing the project and the expectation that the standing orders would be used! Successful projects had resources for monitoring tool use rates, and team members were able to attend all of the learning sessions. The support and involvement of leaders was obvious in successful teams and less so in those teams that seemed to struggle at various phases of their project implementation.
3.3 Creating a Team. Most often a team comes together for the life span of the project and to report the results to an oversight leadership team. Team size, structure, and membership may vary, according to the organizational culture, but it is critical to success that the team is comprised of members that meet the needs of the project. Those teams most successful in the ACC AMI-GAP projects were led by very active and dedicated physician champions and project leaders. The culture of the facility will determine how the project leaders are selected; they may volunteer, it may be assumed that a cardiology nurse specialist and chief of cardiology assume the role, or it may be a QI specialist and cardiologist who are interested in QI. Successful teams also had team members that were representative of the entire process of caring for patients with AMI, such as representatives from the emergency department, critical care, cardiac catheterization laboratory, and post-critical care nursing units. Additionally, members representing the work that needed to be done to implement and measure the QI effort should be included on the team, such as QI specialist, data collectors, medical records, and clerical staff. A sample team member list is provided in Appendix B.
The ACC AMI-GAP collaborative model provides a roadmap for the team leadership to follow as they guide the team and caregivers through a successful project implementation, but it is important that all team members accept responsibility and accountability for the work necessary for a successful journey.
3.3a. Physician Champion Role
There is often confusion regarding the physician champion role with some interpreting the role as comparable to the role of an opinion leader. An opinion leader is one who is often the first to know about and adopt innovations, one whom their peers look to for guidance or opinion, and one who can informally influence others’ attitudes or behavior (18).
The physician champion may very well be an opinion leader, but rather than simply exerting an informal influence, they need to be an operational leader in designing, implementing, and measuring improvement. The physician champion role was critical to the success of the GAP projects. Having the GAP standardized tools available was not enough to create change. Sites that had effective clinical leadership provided by physicians and nurse leaders are generally more successful in achieving behavioral change or tool use (19). The physician champion ideally is someone who is respected for leadership skills, clinical role-modeling, and practice outcomes, and is enthusiastic about achieving high-quality performance indicators and process improvement. In the three GAP projects, they were most often a cardiologist, but if the majority of patients with AMI are treated by a different specialist group, such as family practice or internal medicine for example, then the physician champion may be from that physician group. Another model is to have the project led by both a cardiologist and a non-specialist, complementing each other. In the third GAP project, the group of hospitals that was the highest achievers of tool use and QI rates was led by physician champions from both the cardiology and the emergency department.
Overall responsibilities for the physician champions are noted in the following list. The level of involvement (oversight or day-to-day management) and the time spent on these responsibilities depend both on needs of the project and of course availability. In general, the physician champion(s) should either lead efforts to or:
Develop, customize, adapt, and implement the tools Develop action plans for implementing systematic processes of care Help troubleshoot barriers to implementation, by first identifying barriers and then facilitating strategies to overcome barriers Monitor tool use and barriers to use in order to optimize care Monitor progress of project Report project progress The physician champion(s) is crucial to the success of the project. It was evident in all three GAP projects that when the physician champion was not actively leading the project, grand rounds were poorly attended, there was little, if any, feedback to physicians who did not use the forms, project leaders were frustrated with the lack of a partnership implementation, and tool use rates were less than the aggregate mean. Those sites with high rates of tool use had very active and enthusiastic physician leadership, which was committed to implementation and active, iterative change required to overcome barriers.
3.3b. Project Leader Role
A variety of skills are required to be an effective project leader. The project leader is the day-to-day project manager who ensures that the project is planned, actions are completed, reports are generated and reviewed, and modifications to the plan are made. The project leader should be someone who has a good understanding of QI principles and techniques and a basic knowledge of the process of caring for patients with AMI. The project leaders in the three GAP projects were nurses, with the exception of two teams that were led very successfully by physician QI directors. The main responsibilities for the project leader are to ensure that a complete and detailed plan is developed, written, and successfully implemented, that project progress is monitored, and that barriers to success are identified and strategies developed to overcome them. An effective project leader is organized, detail-oriented, able to lead meetings, and willing to delegate while providing expectations and guidance. The project leader generally is the individual who communicates to the rest of the organization, such as reporting to administration or presenting at department or staff meetings. It is imperative that the project leader develop a close working relationship with the physician champion and also have access to the physician champion when the need arises.
The project leader role is summarized as follows:
Prepare and provide agendas that include topics of discussion, a time limit, and lead person for each topic Maintain a written record of each meeting Ensure meeting roles of leader, facilitator, timekeeper, note keeper, and team member are maintained Provide team members with project explanation, expectations, and guidance for successful team meetings and project implementation Utilize collaborative quality improvement (CQI) tools when their use will facilitate effective discussion and decision making Develop and implement action plans Monitor project implementation and use of tools Identify barriers to successful project implementation and develop strategies to overcome them Report project progress There can be no project without the project leader! The list looks short, but each item can be very complicated. Effective project leaders have a unique combination of basic clinical and QI knowledge. The project leader does not have to do everything in isolation, but needs to ensure that everything has been done. In fact, in our three GAP projects, those leaders with detailed and comprehensive written action plans and team members that were able to share the work load were more successful with project implementation. The project leader responsibilities may require 8 to 20 h per week depending on the team structure, sharing of responsibilities, and other positions already in place at the hospital, such as QI specialist, marketers, and data collectors.
3.3c. Team Members and Structure
It may be obvious but needs to be acknowledged that those who have made the decision to implement an AMI GAP project cannot conduct the project in isolation or without the knowledge and support of others who represent care for AMI patients! It is important to create a team structure that supports project implementation and team membership representing all units and staff that care for patients with AMI. It is challenging to spontaneously generate a list of stakeholders, so creating a "high-level" process flow chart of AMI care will be useful. A "high-level" flow chart is generally 6 to 12 steps that show the major components of a process and, therefore, may be helpful in understanding the process flow, identifying stakeholders, collecting data, and identifying resources (20). When flow charting the care of the AMI patient, it is important to start pre-hospital, through the emergency department, catheterization laboratory, and through critical care, general nursing units, and through to discharge. The flow chart should list all of the departments that care for the patient or influence the care of the patient or project, laboratory services, radiology, pharmacy, pastoral care, clerical staff, admitting staff, discharge planners, clinical nurse specialist (CNS) or advanced nurse practitioner (ANP), information technology, medical records, QI department, cardiology services, executive or administration, internist, family practice, resource pools, and hospitalists. Creation of a stakeholders’ list following the flow chart is helpful. The stakeholders’ list is not the same as the team members’ list. But the team members’ list can be generated from the stakeholders’ list. Creating the team members’ list is described in the following text.
Some of the stakeholders may serve in an ad-hoc capacity, or information-sharing capacity, but it is important to start with a full and complete list so that one can use all of the resources and influences necessary for a successful project implementation.
Some teams may choose to conduct all of the business in a large group. Others may have smaller working group meetings, with one member of the working group meeting reporting to the larger group. It really is a matter of preference and culture.
Being creative with team membership is easier when one develops a flow chart incorporating aspects of the project and measurement. Creative team structures observed in previous GAP projects have included subgroups to work on tool development and approval processing, data collection and reporting, educational planning and implementation, emergency department implementation, processes and timeliness of reperfusion, and oversight leadership groups. For example, several teams recruited a marketer to help develop an educational and publicity plan. The marketer was an ad-hoc member attending smaller planning meetings, and reporting to the larger group. Others enlisted a representative from medical records to help plan sampling for monitoring tool use and remeasurement. This was a key person to have input from when developing strategies to overcome incomplete records at time of remeasurement. Many teams recruited clinical care unit champions who had separate meetings to report the successes and barriers of their respective units. Some may not realize the importance of having an emergency medical services representative as an ad-hoc member. But the measurement of the early administration of aspirin quality indicator can be greatly influenced by the documentation on the "run sheet," which documents care provided at home or during transport, which is often the time the aspirin is administered.
Different teams will need to meet at different intervals and at different times in the project depending on local circumstances. If the group decides to use the subteam concept, then each subteam should report to the larger oversight or leadership team. Team members need to be responsible for guaranteeing their attendance at meetings, contributing in planning, and participation in the activities of project implementation.
3.4 Project Goals. After collecting baseline data and information, it is important to develop a clear and concise statement of the intended improvement for both the AMI quality indicators and for care tool use. Further discussion about clinical tool use and indicator measurement is provided in sections 3.8 and 3.9 in the following text. Comparing the baseline with the targeted rates helps illustrate the rationale and importance of the project.
Developing a specific aim statement for an AMI-GAP project should include specific targets for each of the quality indicators. It is useful to keep in mind that quality indicators are NOT the guidelines; rather they help determine how successfully we are applying the guidelines. The quality indicators that have been measured in the AMI-GAP projects are consistent with those that are measured by Centers for Medicare and Medicaid Services (CMS) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) core measures. These include:
Aspirin 24 h before or within arrival Beta-blocker within 24 h of arrival Timely reperfusion; 
30 min for thrombolytics or 90 min for percutaneous coronary intervention (PCI) Aspirin prescribed at discharge Beta-blocker prescribed at discharge Angiotensin-converting enzyme inhibitors prescribed for those with ejection fraction <40 Smoking counseling Measuring low-density lipoprotein cholesterol Prescription of low-density lipoprotein cholesterol-lowering medication for those with elevated low-density lipoprotein cholesterol Dietary counseling A hospital team may want to add additional indicators such as referral to cardiac rehabilitation, use of emergency department protocol, or documented education regarding when and how to use nitroglycerin, or when to prescribe additional pharmacologic agents such as clopidogrel It is equally important for teams to identify an aim statement and target rate for tool use for all of the tools that will impact the quality indicator rates and that will be part of the permanent record such as standing orders, discharge document, and clinical pathway. Each of the three previous AMI-GAP projects showed that when the standardized guideline-based care tools are used, the indicator rates are higher and the documentation is more complete. The rate at which the tools are used is a good marker of how successfully the new process of care (using standardized forms) is implemented.
If hospitals have already been using standing orders, it is useful to identify the baseline tool use rates and look for trends of use. Identifying patterns of use allows the team to write an aim statement specific to the current status. For example, one team in the third GAP project found that the standing orders were not being used by the hospitalists. This led to development of a special focus in their plan with a specific aim statement related to use by hospitalists. Another group of hospitals assumed that their standing orders were being used and did not develop plans to increase their use. The early treatment indicators did not improve because the standing order tool use had not changed.
Aim statements should be specific, measurable, and should include a target goal and a time frame. Teams may develop an overall aim statement for all of the quality indicators or a separate aim statement for each of the quality indicators. If they have high rates on some of the quality indicators, and an individual aim statement may not be needed for all indicators. Tool use aim statements may incorporate all of the care tools, or the team may select to have a separate aim statement for each care tool use. There is an advantage to having separate aim statements for all of the indicators and care tools. Different groups of caregivers may impact the rates or tool use, such as physicians impacting standard tool use rates and early indicators documentation and nurses impacting the discharge tool use. Measuring these separately provides more information and data for feedback than if they were lumped together.
A word of caution is needed regarding aim statements. Some teams have a tendency to be very cautious and will write aim statements reflecting only small incremental improvement. For example, a team wrote that the tool use will increase by 10% every month. It would take nine months to get to 90% if you are starting out at 0%! It would be better to expect larger increments such as an increase of 25% each month or shorten the time frame to 10% every week or two weeks. Expecting a more substantial gain can facilitate a departure from a practice-as-usual mindset to a systems-based concept.
Examples of clear, concise aim statements for an AMI-GAP project may be:
3.5 Project Action Plan. The purpose of the action plan is to document a detailed plan for implementing the AMI-GAP project. It is a written, detailed plan including assessment of the current status or resources related to AMI care, actions or strategies that will be implemented, persons responsible for activities, time frames, and measure of successful completion of the various phases of project implementation.
The action plan is best developed through a team effort. A sample action plan form is included in Appendix B, and it provides a basic listing of issues to be planned for. Project plans need to be individualized. The project leader and physician champion may want to provide a draft template for the first project team meeting. This will help give guidance to the team and provide structure for their discussions.
Topics to be planned for include:
Project status Progress and results 3.6 ACC AMI-GAP Tool Kit. The decision to implement the GAP project implies that the ACC AMI-GAP tool kit will be used and that during project planning, hospital-specific tools will need to be created or existing tools modified to be consistent with the ACC AMI-GAP tool kit (21). At the very least, in order to achieve the high rates reported for the quality indicators in previous GAP projects, a standing order set and AMI-specific discharge document is needed. The ACC AMI-GAP template documents are included in Appendix C.
The hypothesis of the ACC AMI-GAP projects is that the quality of AMI care can be enhanced through a performance improvement initiative that includes providing institutions, caregivers, and patients with tools and strategies, that targets treatment goals, focuses on improving key processes of care, and optimizes adherence to guidelines. During the first GAP pilot project, core team members consisting of local cardiologists and nurses created templates for the standardized forms that were to be used by each hospital team. The templates were based upon the national ACC/AHA guidelines for AMI and tools that had already been utilized successfully at several southeast Michigan hospitals (8). The templates were reviewed by the ACC’s task force on practice guidelines and GAP steering committee to confirm that they conformed to the national AMI guidelines and after approval became the ACC AMI-GAP tool kit. The GAP tool kit consists of seven critical pieces:
The pocket guide/pocket card was created by the ACC/AHA Task Force for Practice Guidelines from the AMI guidelines. Chart stickers were created by ACC project staff to serve as a reminder to caregivers to provide appropriate and timely AMI-specific care to the patients.
The physician and nurse leaders and the multidisciplinary team at each hospital were expected to customize and implement the ACC AMI tool kit. Each of the three GAP projects provided different experiences with the tool kit. In the pilot project, all sites utilized a standardized order set and discharge document, modifying their own to be consistent with the template or creating a new order set based on the template. All order sets in the pilot project were "AMI order sets." Most but not all hospitals used a critical pathway and the pocket guide and card. All had patient educational materials. None of the 10 selected to use the chart stickers.
The experience with the five hospitals in the second project (Flint-Saginaw expansion) was different. All five used all pieces of the tool kit, again modifying their own forms or creating new forms based on the templates. Several of the hospitals chose to implement "acute coronary syndrome (ACS) order sets" rather than AMI-specific orders. Some teams felt that an ACS order set was more inclusive, and help to ensure guideline-based care in patients with ACS in which the distinction between instable angina and non–ST-segment elevation myocardial infarction was not clear at admission. Hospital teams in the third GAP project used all of the tools, again with some creating ACS order sets to capture more patients up front. Some sites reported that quality indicator rates were lower than expected because the patients that presented without an obvious AMI were not started on the standing orders for AMI. Creating a standard order set that reaches all ACS patients allowed these institutions to capture those patients who eventually "ruled-in" with AMI.
Several hospitals were very creative with the patient information form, incorporating the material into a professionally designed tri-fold brochure. Others incorporated explanations of commonly administered tests and procedures such as electrocardiograms, telemetry monitoring, echocardiography testing, and stress testing. Some sites determined that if the family was present in the emergency department, the materials should be distributed to them at the time of admission. Again, a given hospital’s culture and pre-existing care and education tools will dictate the final design for each project.
It is important to recall that new care forms may require approval of the "forms committee" thought by some to be the most powerful committee in the hospital system! The review and approval process can sometimes be lengthy. The team should be aware of the process in advance including the committee’s meeting schedule and a likely date when the project’s forms will be reviewed in order to create a realistic time frame for the action plan. Some hospitals may require approval from other pertinent committees such as cardiology and nursing practice in advance of the forms committee. Getting their feedback during the form development will help gain their approval for the finalized forms. Sometimes the physician champion can favorably influence the time required by the forms committee. Teams need also to be sensitive about the time required to typeset and print the new forms. This too can be a lengthy and time-consuming task. It would be detrimental to a project’s success to have to delay an announced start date because the care forms had not been approved and were therefore not available.
3.7 Planning for Implementation Phase. The implementation phase includes the educational plan and marketing plan execution and the implementation of new or modified GAP tools. The team must also plan a method to evaluate the implementation phase and, very importantly, modify or create new plans and activities if necessary to achieve a successful implementation phase.
3.7a. Educational Plan
One of the barriers to tool use identified during the first two GAP projects was that some staff reported "I did not know anything about the GAP project." The cause of this lack of knowledge could have been that the project team didn’t plan educational presentations to reach all of the staff, or that all of the staff did not attend the planned presentations. The important lesson learned from the three GAP projects is that it is important to develop an educational plan detailing the content for staff education and scheduling educational events to reach all of the staff. The measures of success for this aspect of the project are that the presentations are planned to be inclusive of all staff that will be working with the care tools and that an attendance record has been kept and evaluated for completeness. Additional presentations can be planned to ensure that all staff members are reached.
The following list is the recommended content for the GAP presentations:
Consider planning the required number of educational events that will reach close to 100% of the following care providers and staff:
Review the process flow chart to determine that all pertinent staff members that need to be reached with the educational plan are involved
3.7b. Project Kickoff Educational Event
The methodology of all three GAP projects included a project kickoff event held at each hospital. This educational event was a presentation by the project and hospital leadership and included an overview of the GAP project and previous findings and specifics regarding the hospital’s project forms, timeline, and expectations. The main objective was to create an awareness of the project, promote participation by all staff, and reach a target audience of physicians—cardiologists, internists, family practice, and all others who care for patients with AMI. The event typically was a presentation at a normally scheduled or specially convened physician meeting with additional staff invited to the "ACC AMI-GAP Kickoff." In the three GAP projects, we found that using an already existing meeting was the best forum to maximize attendance. Having the nationally visible and local cardiologists as guest speakers, and advertising their presentations, was a drawing card for physician attendance. Many hospital teams created a very enthusiastic event that was well marketed, and with upbeat promotions from the chief executive officers or institutional leaders as well as presentations from emergency medicine and cardiology physician champions and project leaders.
Participation in a multihospital collaborative project such as the ACC AMI-GAP collaborative is not required to have a successful project kickoff. Any hospital project can be kicked off in this manner. Featuring a prominent local expert as a guest speaker can serve as a drawing card for the target audience, and the project leaders can use the event to reach a large number of people with one event.
3.7c. Implementation of New Care Tools
Many QI specialists recommend that changes be tested on a small scale before spreading to a larger scale (17,20). This is an effective strategy for many problems, but may be less than ideal for certain aspects of the GAP initiative. If, for example, the team decided to use the new tools on only select units, there would be inconsistent use of standard orders between units, thus contradicting the term "standard order" and causing confusion about using them. This is especially true if teams were to design a project that overlapped the use of old and newly modified standing orders. It is recommended that teams select a start date on which all staff on all units will start using the new tools. Teams will need to develop plans for removal of old forms, placement of new forms, and follow-up to determine that the new care tools are being used. If the team has unit champions, they often can accept accountability for this part of the project. Then, having unit managers and clerical support staff assume responsibility for ensuring the availability of tools is important.
The process by which the care tools are made available to the physicians and nurses needs to be determined. Do the emergency department physicians start the standing orders? That decision is very dependent on the usual practices at each site. Will the discharge orders be placed with the nurses notes, or will the nurse have to go hunting for the new special AMI form? Will the nurse be required to complete the general discharge form as well as the new AMI discharge form? These last two questions are examples of issues that should be defined before the project begins. Both of these, care forms not on the charts and requiring two separate discharge forms, were considered barriers to tool use in previous GAP projects and should be taken into consideration when planning tool implementation.
An important component of the implementation plan is the start date for use of the new tools. This should be part of the plan and announced during the educational events. Caution should be used to avoid dates that conflict with other important events in the hospital, holidays, high vacation periods, and so on.
3.8 Planning for Monitoring Tool Use Phase. Monitoring clinical care tool use is critical because the tool use rate is a determination of project success. During the planning for this phase, the team will need to create a mechanism to monitor use of the care tools, develop a sampling strategy, determine who will collect the data, and at what intervals. Frequent monitoring, such as every two weeks, should occur in the first few months of a project, until the team is confident that the majority of barriers have been identified. The plan should allow the team to answer the following questions:
This concept was first tested in the second GAP project and became an expectation in the third project. Teams that monitored tool use were best able to increase the clinical care tool use as the project progressed.
The first challenge is to determine how to identify a sample of records to monitor. Some teams had the clinical laboratories generate a daily or weekly list of patients with elevated serum troponin levels and then this list was used to create a sample of charts for review. Other teams used unit champions to track cases and review charts for tool use. Some teams asked the hospital chart coders to check for tool use, and others asked the clerical staff to keep a list at discharge. A few teams with more resources reviewed all records concurrently and provided individual feedback to physicians and nurses regarding the use of standard orders and discharge documents.
The monitoring tool can be as simple as a checklist that includes the following information:
The leadership team also needs to create a forum for receiving feedback from the staff. The most valuable information is to determine why or why not the tools are being used. Feedback can be solicited one-on-one or in groups such as staff meetings. Quality improvement strategies that require active participation are often very useful, including brainstorming, identifying restraining forces to tool use, or open dialogue, to name a few (20). Team members who are comfortable leading discussions with staff and with whom the staff are relaxed and open are good facilitators for this very important task. Thoughtful planning in advance to select a method for soliciting feedback will allow the team member to be well organized and rehearsed before conducting the feedback meetings. Discussion about overcoming barriers in this phase is discussed in section 4.0.
3.9 Planning for Remeasurement Phase. Several aspects of the project need to be measured. The most obvious are measures of processes of care reflected in the rates of performance of the quality indicators such as those listed in section 3.4. Most hospitals implementing the AMI-GAP project have identified this clinical topic as a priority area and may be collecting and submitting the core measures for AMI care to the JCAHO. In the previous GAP projects, there have been occasions when project leaders were not aware of how AMI cases were identified and/or how the data were collected or rates calculated. Including someone from the "core measures process" on the leadership team provides valuable local insight to the measurements of the quality indicators. Those teams who are not collecting data via the core measures tools will need to develop an abstraction tool that defines the patient population, defines exclusion and inclusion criteria for each indicator, and collects the variables that allow for measurement of the criteria, and then determine an analysis plan. Defining the components of the data collection is beyond the scope of this manual. However, a good source of information for such an activity can be found under performance measures on the JCAHO website (22).
Many leadership teams want to measure aspects of the care process that go beyond the quality indicators, such as the care provided to those patients transferred from other emergency departments or acute care centers. This group of patients, by definition, is eliminated from the early treatment indicator measures in the core measures, and would not be measured in the core measures report. The team thus will have to develop an additional strategy to collect information on those transferred to their site. In another example, some teams will want to measure timely reperfusion for all patients, including those coming directly to the emergency department and those transferred from others. This distinction is obviously important because the flow for the patients is different and the actions to increase guideline-based care will also be somewhat different.
There may be other indicators that the team wants to measure, such as referral to cardiac rehabilitation, or the test indicators of measuring and treating cholesterol, or dietary counseling. Leadership teams might be interested in the documentation of contraindications to the recommended treatments with aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, or reperfusion. These may not be captured with the core measures abstraction tool, so the team will have to define how these variables will be abstracted and rates calculated.
As previously mentioned, the initial GAP experiences have shown the importance of monitoring tool use rates both during a baseline period and during the remeasurement phase. In all three GAP projects, there was a significant increase in the quality indicator rates when the clinical care tools were consistently used. Some leadership teams may wish to identify the rate of clinical tool use among various types of physician groups such as cardiologists, family practitioners, and internists. If the measurement plan and abstraction mechanism does not include measurement of care tool use, such observations are not possible. An important exercise that the team must consider is to develop a grid that lists the variables being collected and cross matches these with the quality indicators and other measures used to evaluate the project.
Remeasurement may be predetermined or may occur after the tool use rates are at or near the goal established by the team. If the remeasurement time period is predetermined, it is best to allow a several-month period for the new tools to become part of the systematic process of care. If the quality indicators are being measured as part of the core measures submission to the JCAHO, the remeasurement time period may coincide with one of the routine quarterly measurement periods.
3.10 Planning for the Results Phase. This phase is meant not only to analyze the data that were collected, but also to determine successes and next steps. Oversight teams should collectively review the analysis and draw conclusions about the status of the project relative to the targets that were established in the planning phase. Decisions and recommendations about new processes or changes implemented for the project could include:
Adopt the change; Abandon the change; or Alter and continue cycles of improvement; Continue until target is reached. Or perhaps the desired state has been achieved, in which case the team needs to make plans for sustaining improvement and monitoring the care tool use and indicator rates to ensure the improvements are sustained.
During the results phase it is important to provide feedback to all of the involved staff and departments. This can be done with presentations at departmental meetings or staff meetings, but planning in advance for these activities will help them with budgeting and scheduling. Some previous GAP participants have used newsletters, reports in pay checks, and poster story boards. Certainly this should be a time to celebrate the successes and acknowledge those who have the supported the project! A strategy used by one previous GAP team was to have the marketing department plan a special event for sharing the results.
3.11 Measures of Successful Planning. At the conclusion of this phase of the project, team leaders should create and review a checklist to determine if they have planned for all aspects of the project. An example of a planning checklist is included in Appendix B, but each oversight team should create their own unique and inclusive list to capture all of their planning needs. Measures of successful planning include:
Physician champion identified Project leader identified Team members and team structure finalized Meeting schedule determined Forms modified or created Standing orders Discharge document Critical pathway Patient information form Back from printer QIs selected and QI calculation plan determined Data collection methodology determined Plan and tool for monitoring care tool use designed Baseline data collected and reviewed; aim statement written Tool implementation start date determined Kickoff scheduled Educational plans written and sessions scheduled "Learning sessions" planned Evaluation plan written Reporting plans determined, report format designed Project plan written 3.12 Potential Barriers in Planning Phase. Numerous barriers may surface during the planning phase. The best defense is to be very well organized and detailed in the planning phase, stay alert to barriers, and strategize to overcome the barriers. Being alert to prevent the occurrence of the following barriers that were identified in previous GAP projects will help prevent problems (Table 4).
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4.0 Implementation phase |
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Top1.0 Introduction2.0 ACC AMI-GAP QI...3.0 Planning phase4.0 Implementation phase5.0 Monitoring tool use...6.0 Remeasurement phase7.0 Results phase8.0 Sustaining the gain9.0 Summary11.0 Appendix A: Project...12.0 Appendix B: AMI-GAP...13.0 Appendix C: ACC...Heart attack discharge formReferences |
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After completing the educational plan, the oversight team should review the attendance and evaluations (if part of the plan) and then decide if there is a need for additional educational presentations. This will complete a plan-do-study-act cycle (PDSA) (17) related to the educational plan.
In all three Michigan AMI-GAP projects, a portion of the nursing staff needed additional presentations, such as those on the midnight shifts, as well as clerical staff and resource pool nurses. One hospital actually contacted the resource pool manager and asked that they arrange for the presentations. Another team prepared story boards that could rotate to units and reach the evening and night shifts. One team asked the central orientation department to include the project and the clinical care tools as part of central orientation to reach new staff.
Physician staff that are important to inform about the process but may be difficult to schedule may include residents rotating on the cardiology service, and non-cardiologists who admit patients with AMI. In a large teaching hospital, the chief resident sent out monthly e-mails and held orientation classes for those physicians rotating to the cardiology service. The physician champion recorded attendance at the monthly meetings to identify the non-cardiologists that had not yet been reached. Several teams had one-on-one follow-up by the physician champion to physicians unable to attend the presentations.
Once the team has planned for implementation of the new tools, the start date represents a busy day for team leaders because ideally they visit each unit on each shift, determine if the tools are being used, determine what the barriers are, and make plans to immediately overcome the barriers. Some of the barriers related to the start up were unpredictable, but are offered as lessons learned because if one can predict them then it may be possible to prevent them from happening. For example, one unit did not start using the new clinical care forms because the clerk thought that the priority should be to avoid waste and use all of the old forms before using the new forms. This was further complicated by the fact that the clerk had a "stash" of old care forms hidden in the ceiling tiles so that she always had a ready supply! In a subsequent project, after hearing this story, a team decided that they would go to each unit, remove the old forms, and replace them with the new forms. Another team, unfortunately, forgot to check that the forms were back from the printer on time, and had to delay their project for three weeks.
Several major lessons were learned about the design and process of using some of the care tools. Specific lessons to the standard order set is to determine if they will be used in the emergency department and, if so, then the emergency department medical staff needs to be involved in the planning process. Some sites in GAP already had standing order sets and assumed that the order sets were being used consistently by all physicians and with all patients. In these situations the early treatment quality indicators influenced by the standing orders did not improve. The data analysis indicated that the standing orders were not being used consistently. Thus, rather than assuming a high rate of use of pre-existing order sets, an assessment should be completed that includes current tool use rate and identifying barriers to tool use.
Another barrier experienced by several hospitals was a predetermined notion not to advocate for use of the order set among physicians in training, thinking that standard orders would interfere with their learning, and also by groups of hospitalists who thought that they did not need the "crutch" of standing orders. The care culture at each site will influence the ability to overcome these barriers. By far, the most often sited barrier was physicians’ resistance to do what is perceived as "cookbook medicine." Sometimes physician champions were able to overcome the resistance with one-on-one discussions and data feedback. When introducing the standard order sets, it is important to emphasize that the orders do not dictate the care; decisions regarding patient care still need to be made on an individual patient basis. The standard orders simply make those decisions easier to remember and to document. In the GAP experience, the sites with the highest standard order set use were the hospitals with electronic order entry as well as those sites that had very active physician champions and emergency department involvement.
The standardized discharge documents in all but a few hospitals were designed to be used by the nursing staff. Those sites that required nurses to use two discharge forms, the old general form and the new AMI specific form, had a low use of the discharge tools. There were a few sites that designed a form to be used by the physician alone or by the physician and the nursing staff. These sites had the lowest rates of discharge tool use across all three projects. The sites with the highest discharge document rate were those sites that made standard use by nurses in every AMI patient a clear expectation, monitored the use, and provided feedback.
4.1 Measures of a Successful Implementation Phase. Before moving on to the monitoring phase, the oversight team should pause and determine if they have successfully completed the implementation phase. The following list was common to most GAP participating hospitals, but each oversight team must develop their own checklist. Examples include:
4.2 Potential Barriers in the Implementation Phase. After determining the clinical tool use rate and identifying barriers to tool use, the oversight team can develop strategies to overcome the barriers. Several barriers have already been discussed; those that were most common in Michigan GAP projects are summarized in Table 5 with recommended strategies to overcome them.
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5.0 Monitoring tool use phase |
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Top1.0 Introduction2.0 ACC AMI-GAP QI...3.0 Planning phase4.0 Implementation phase5.0 Monitoring tool use...6.0 Remeasurement phase7.0 Results phase8.0 Sustaining the gain9.0 Summary11.0 Appendix A: Project...12.0 Appendix B: AMI-GAP...13.0 Appendix C: ACC...Heart attack discharge formReferences |
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As mentioned, these cycles are repeated until the tools are being used consistently at a high rate. This seems simple, but this phase can take as long as three to six months, based on the cooperative nature and culture of the hospital staff and the oversight team’s ability to overcome the barriers. Teams that are struggling with meeting their goals will need to be careful to avoid "aim drift" defined as deliberately decreasing or "drifting away" from a challenging aim (20). A team that is struggling with reaching high tool use may want to refocus and perhaps consider continuing with a focus on just one or two of the tools, such as the discharge document and the standing orders.
5.1 Measures of a Successful Monitoring Tool Use Phase. It is appropriate for the oversight team to pause at the end of each PDSA cycle within the monitoring phase, and review a checklist of successful completion of this phase. The checklist may seem obvious, but again needs to be individually developed. Measures of successful monitoring include:
Sample identified Patient records examined 5.2 Potential Barriers in the Monitoring Phase. As in the other phases, there are potential barriers that are unique to the monitoring phases. Some of these are related to tool use and were mentioned in section 3.7, but are repeated here, because they are most commonly found in this phase (Table 6).
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6.0 Remeasurement phase |
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Top1.0 Introduction2.0 ACC AMI-GAP QI...3.0 Planning phase4.0 Implementation phase5.0 Monitoring tool use...6.0 Remeasurement phase7.0 Results phase8.0 Sustaining the gain9.0 Summary11.0 Appendix A: Project...12.0 Appendix B: AMI-GAP...13.0 Appendix C: ACC...Heart attack discharge formReferences |
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Some unique lessons learned during the ACC AMI-GAP projects bear mentioning here. One site had a lower than expected discharge tool use rate. This was confusing because the records had been checked concurrently during the admission, and there was a high rate of discharge tool use. During review of the results, it was discovered that some of the medical records staff were disposing of the discharge form, thinking that they were a pilot form that was not to be a permanent part of the records. Including the medical records department in the planning phase can help overcome this sort of barrier.
Engaging the medical records department in physician feedback helped one site overcome the delayed closure of records. Coders applied special "GAP notes to physicians" to records that needed to be completed in a timely manner for the rapid-cycle project.
During the remeasurement phase, it is important to track AMI patients that received PCI or cardiac surgery. In the GAP projects, it was observed that the patients that went for PCI actually had high rates for the discharge indicators. However, those that received cardiac surgery had lower rates for tool use and for evidence-based therapy for AMI at discharge. Collecting data at this level of detail allows for a much more focused action to improve the rates for a subset of patents.
The remeasurement phase is not a time that the leadership team can "sit back and take it easy." There are still barriers that need to be overcome, and early on to ensure that the sample and data collection are complete and accurate. This is a good example of the potential use of a subgroup to assume responsibility for a certain aspect of the project.
Once again, a PDSA cycle needs to be completed early in the phase:
6.1 Measures of a Successful Remeasurement Phase. It seems that as the completion of the project becomes nearer, the lists grow sho
