What happens when you bring together several key ingredients—an organization-wide push for clinical performance improvement; a multidisciplinary approach to such improvement, with buy-in from clinician, administrative and IT stakeholder groups; and the discipline to apply analytics to complex care delivery processes, in pioneering ways? Well, if you are the leaders at Texas Children’s Hospital, and you have the strategic vision, the intelligence, and the perseverance to see things through, you get industry-leading change.
The story of Texas Children’s Hospital’s breakthrough in a key clinical area began when leaders at the Houston hospital embarked in early 2012 on an assessment of their clinical programs to determine which areas needed quality and cost improvement, appendectomy quickly became identified as a key area. Nationwide, appendicitis is the most common acute surgical condition of the abdomen, accounting for more than 1 million hospital days per year and consuming 1.8 percent of hospital discharges for gastrointestinal diseases. Appendectomy is also one of the most common surgeries performed on children in the U.S. Nationally, best practices around appendectomy do exist that could help to streamline processes from the preoperative phase all the way through the postoperative phase; but leaders at individual hospitals like easy access to critical data in this area, and physicians and other clinicians lack access to important data at the point of care and analysis.
At Texas Children’s Hospital, a diverse team of leaders has been working hard to optimize processes around pediatric appendectomy, seeking to standardize clinical practice and improve patient outcomes in this crucial area. Leaders of the team include Charles Macias, M.D., the hospital’s chief clinical systems integration officer and the director of the Center for Clinical Effectiveness and Evidence Based Outcomes at the Baylor College of Medicine and Texas Children’s Hospital; Monica E. Lopez, M.D., assistant professor of surgery in the Division of Pediatric Surgery and a Texas Children’s pediatric surgeon; and Kathleen Carberry, R.N., M.P.H., director of the Texas Children’s Hospital Outcomes and Impact Service.
Macias, Lopez, and Carberry, all of whom had already spent years in clinical process improvement work, headed up the Texas Children’s team on appendectomy processes, began in early 2011 to organize a permanent multidisciplinary care-improvement workgroup for appendicitis, leveraging their organization’s enterprise data warehouse, along with associated analytics applications from the Salt Lake-City based Health Catalyst, to gather and analyze data from the hospital’s electronic health record (EHR) and numerous other sources, to analyze around appendectomy processes. The workgroup itself has drawn from a very broad spectrum of stakeholder groups within the hospital, including pediatric intensivists, surgeons, hospitalists, nursing, finance, quality improvement, and perioperative operations.
In the process of doing this work, the team has analyzed appendectomy procedure workflow, from diagnosis to after-care, and has come up with a variety of process improvements, including, for example, an evidence-based recommended practice incorporated into the workflow involving the optimal use of the antibiotic piperacillin-tazobactam to reduce surgical site infections.
Using the variety of strategies around process improvement in this area, and leveraging IS to analyze the data they had been gathering, clinicians at Texas Children’s have, within the past two years, been able to reduce postoperative appendectomy length of stay by 38 percent; reduce the average variable direct costs of appendectomy by 19 percent; increase EHR order set adoption rates by 36 percent; increase the percentage of patients receiving the recommended antibiotic as their first antibiotic by 53 percent; and decrease the length of time from diagnosis to surgery by 19 percent.
The impetus to examine appendectomy processes is far from new at Texas Children’s; what is new, say leaders there, has been the turbo-charging of processes in the past few years, thanks to a concerted multidisciplinary effort, and the strategic leveraging of IT to analyze and use data. “In the Department of Surgery,” says Lopez, “there had been very strong efforts going back to 2003, related to clinical research, really, that was definitely hypothesis testing, but on a very small scale, in terms of a core team of people who systematically looked at appendectomies and other types of pediatric surgeries. So we already had a team formed that was interested in this. But more recently, since we joined hands with Dr. Macias’s group and the outcomes and impact service, we’ve made great progress uniting the clinical research and real-time outcomes reporting, and using all those data to really guide any decision-making.”
Monica E. Lopez, M.D.
On the technical side of this initiative, Macias reports, “Access to the EDW involved an evidence specialist representing research practice; a data specialist who is a master’s-level nurse, who understands data management; a business intelligence developer translating the data into graphs and visualizations; an outcomes analyst with a statistical background; and our EMR interface person who’s a senior information systems analyst, who can build forms into Epic and make modifications; a complement of EMR experts; and a data architect. The key common element needed,” he adds, “ is the ability to build into the EMR. And a data architect. So once the data is extractable from the EMR, you have to have someone who can extract it.”