Leaders in healthcare IT innovation are often large academic medical centers with access to great resources. In these changing times, however, small community hospitals are finding ways to harness the power of IT to not only improve patient care, but also to help protect and bolster their bottom lines. For these hospitals, it's more than prestige is at stake. With heavy competition for admissions, it is a case of outright survival. One such hospital is 220-bed Chester County Hospital in West Chester, Pa. Located near Philadelphia, which is also home to many large academic medical centers, Chester faced the need to stand out.
“We needed to distinguish our hospital from other hospitals both locally and regionally so we created our own “Hospital of Distinction” campaign,” says COO Michael Barber. “Our goal was to distinguish ourselves from a quality and safety perspective.” And for Chester, an innovative approach to automating the infection control process that would improve patient outcomes was the jumping off point to earning that distinction. Using an existing module of Malvern, Pa-based Siemens Soarian enterprise EMR that it already had, Chester utilized business process management (BPM) to automate its clinical processes for infection control notification in order to improve patient care outcomes for Methycillin-resistant Staphylococcus aureus (MRSA) as well as compliance for Centers for Medicare and Medicaid Services (CMS, Baltimore) core measures. This was done with no investment other than the time of its dedicated staff.
The foundation of BPM, widely used in industries other than healthcare, is similar to other quality performance methodologies though technology is its key enabler. But BPM goes a step further by stating that this approach can be supported, or enabled, through technology. In Chester's case, a BPM engine that is part of its Soarian system automates and manages the workflow changes. “It came with the product but people didn't know what to do with it; they were using it as a glorified rules engine,” says Vice President of Information Technology, Ray Hess, referring to Soarian. “One of the things I find frustrating with my peers is that we look at what we can't do rather than what we can do,” he says. “In this case, there was functionality that we said we can leverage in a different way.”
BPM automation evaluates workflow processes, targets with the goal of decreased variation in the execution of each process step, decreases in missed or delayed steps, fewer errors, more timely completion of the process, decreased workload for the staff and ultimately improved outcomes. But hospitals have traditionally lagged behind other industries in its use because of the unique nature of healthcare. “BPM is a niche in the IT industry that allows you to put processes in the system and allows the system to manage and direct the process,” says Hess. “It's very popular in many other industries, but you don't see a whole lot in acute healthcare environments because of the complexities of the processes we are trying to automate.”
At Chester, the processes they wanted to automate were in the department of infection control. “Infection control has been a major hot button for years,” says Hess. “We had a group working on it and were having a hard time getting our arms around because of all the handoffs.”
Although Chester's Infection Control team met regularly, Hess says that no matter how much they honed the process, they didn't get the desired results. “We had a good flowchart of the process, but it was dependent on multiple people doing the right thing,” says Hess. “For example, all it took to throw a wrench into the workflow was one unit secretary who didn't order an isolation cart.”
The hospital found it had anywhere from eight to 12 manual processes every time it tried to put a patient into isolation (see sidebar.) “If any of those didn't happen you would be at risk,” notes Hess. Automating the management of those manual processes came from using Chester's existing Siemens BPM engine to improve two Soarian-driven workflows - Bed Management and Infection Control. The goal was to automate the manual steps within the process of identification, notification and tracking of patients with infectious diseases. The Chester team built the automated process themselves and then showed it to Siemens.
Chester's Steps for Automating its Infection Control Process
Evaluate patients for a history or MRSA at all points of entry
Pre-Admission Testing; Ambulatory Care Unit; Cath Lab; Emergency Department and Inpatient Admission
Notify nursing staff in each area of positive history
Notify nursing bed manager on all admissions for appropriate placement
Change the isolation flag in the system
Write a clinical note into the medical record
Check for recent positive MRSA tests
Order isolation kit from central
Notify nursing staff to (collect) a MRSA screen if no recent positive results
Evaluate microbiology results for new MRSA positives and alert if unknown
Maintain /update the MRSA history database
Listen for negative screens, calculate if the patient may be able to come out of isolation and notify the staff and bed manager
Notify infection control
Notify housekeeping that the room is “isolation clean” on patient transfer/discharge
If no history, assess patient for “high risk” MRSA status
The hospital's Infection Control workflow now automatically triggers processes to identify and manage patients with a positive history of contagious infections at admission to keep it from spreading. The system sends automated alerts through the EMR, e-mails, printed information, text pages and text-to-speech telephone messages to different areas of the hospital.
By leveraging its existing EMR product, Chester was able to manage the infection control process from beginning to end with more consistency and better accuracy. By performing key tasks and interacting with the clinician to decrease the manual requirements of a process, the automation also resulted in reducing their workloads for clinicians as well as improved patient outcomes. As a result, Chester has seen a 60 percent drop in hospital-acquired MRSA cases over the last four years.
With BPM being such an effective method of automating processes and so many BPM products already on the market, it begs the question as to why it isn't more prevalent in healthcare. The challenge, according to Hess, is to integrate a commercial BPM system with the hospital's enterprise information system. Soarian has a BPM engine that uses service-oriented architecture and is already integrated into its core workflow functionality. Hess saw an opportunity to automate the infection control process management. He had an additional reason to expect success: “I chose this over a dozen projects because I had a Director of Infection Control who was a champion of driving the process of improvement,” he says. “I thought I had a good chance of winning this one.”
That enthusiastic champion, Director of Infection Control Charlee Faucette, says the project began much like many others at Chester - in a meeting. “I mentioned to Ray that for MRSA admissions we had a very laborious process that was totally manual,” says. Faucette says at the time, she was working with ADT (Admission, Discharge, Transfer) staff on a way to recognize and flag patients with prior MRSA infections before admission. The process got more complicated from there. “The lab was calling the floor; we were letting the doctor know there was a MRSA patient, making sure the patient was in isolation, letting the bed manager know. It was all dependent on manual phone calls and multiple entities,” she says. “And there was always some lag time.”
According to Faucette, Hess began brainstorming with her about developing a workflow that would electronically capture this information and bring it to one place. “He said, ‘Let me work on that.’ And from there it grew,” she says. “All of those manual processes and communications that were dependent on my phone calls were eliminated.”
Though Chester used a traditional project management approach to improve the notifications for infection control, what set this project apart was the integration of BPM into the process. This allowed project managers to review each step of the process to be automated. Once the workflow was automated, Chester IT validated it and looked at it in the background for six months before pushing it out to the end users. The first release was just to infection control managers and let them know there was a MRSA patient present. “Then we moved it out to the bed managers, and nurses, and kept adding pieces,” says Hess. “Automating reduced the workload - and that's how you get buy in.”
In addition to fast and accurate notification of everyone involved with a MRSA patient - from dietary to bed assignment - BPM has also been a patient satisfier. The automated notification system now eliminates the need to move patients with a history of MRSA since they're placed in an isolation bed at admission.
None of this would have been possible without a strong culture of collaboration.
“Our IT people sit on every process improvement task force to see what role they can play and are always willing to work with us to make the process more timely and less individual-dependent,” says Faucette. “They ask,' Is there something we can do from the electronic standpoint to make this process more efficient?'”
Success stories often include input from end users, and Chester is no exception. “I could talk directly to Ray,” says Bernie Mascherino, R.N., an inpatient triage nurse who sat on the patient flow committee with Hess. “He's approachable.” In reality, Hess was more than approachable: To fully understand the process from Mascherino's point of view, he spent a day on the floor. “He made notes, and after that we sat down and had a meeting.”
Barber is also part of the support process; he personally reviews all of the items on the “barriers list” that Chester utilizes to identify items that might impede adoption. Barber still had to approve the BPM infection control project: Although it had no added budgetary dollars, the project incurred staff costs by virtue of their time. “You're taking resources away from other opportunities,” he says.
But Barber points out that Chester's size is advantageous in that the approval process may be less complex than in larger hospital systems. “We have a value analysis committee that I chair that meets monthly and employees bring ideas on changing anything,” he says. “Because we are an independent single community hospital there is not a lot of red tape that our employees have to jump through.”
Since the success of using BPM to automate the infection control process, Chester has gone on to automate dozens more, in particular to meet CMS and Oakbrook Terrace, Ill.-based Joint Commission measures for chronic diseases. Chester currently has six disease-specific certifications from the Joint Commission.
“I've become a zealot for BPM in healthcare,” says Hess. “There are a lot of tools out there that allow for communication and coordination that have opportunities to be leveraged in the clinical environment. It was easier for us to do this with an integrated solution, but there are plenty of opportunities for people to do this.”
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Healthcare Informatics 2010 March;27(3):38-40