The leaders at Aria Health, a three-hospital, 500-bed health system based in Philadelphia, have put technology in place that is improving patient safety, care quality, and efficiency in their organization. Literally seconds from when a nurse sees a patient, key data on that patient’s condition is entered into customized dashboards that provide front-line clinicians with important data for real-time use. The results have provided Aria’s clinicians with a new level of visibility into performance across their organization, as well as better insights into the performance of key drivers of high-level outcomes, such as infection rates.
At a basic level, the technology that has been implemented is saving considerable time on clinical data input and report creation, and ensuring greater timeliness in interventions to change care delivery patterns.
Recently, Bea Leyden, R.N., Aria’s director of nursing performance improvement; Jessica Satinski, R.N., nursing performance improvement coordinator; and George Casper, the health system’s director of technical services, spoke with HCI Editor-in-Chief Mark Hagland regarding their innovations. Below are excerpts from that interview, with Ms. Leyden’s responses to Mark Hagland’s questions.
How did you come to this particular innovation?
We were part of a larger hospital group investing products. This was with a hospital alliance. And we decided to expand. We were doing just some very high-level metrics initially, and decided we wanted to do a deeper dive. The nursing department had already had a dashboard system in place—a high-level organizational dashboard that was created about two years ago. And then a year-and-a-half ago, we started working on a nursing metrics dashboard. We can drill down from the system level to the campus level to the individual unit level. In the nursing department, we’re looking at the incidence of unit-acquired pressure ulcers; that’s a metric that we monitor. And it’s a nursing-sensitive metric, and is one of the Medicare ‘never events,’ as are patient falls with injury. We’re also looking at central line-acquired infections and at urinary catheter-associated infections. And we’re looking at ventilator-associated pneumonia. Those are some examples. We’re now starting to do data collection; we’re also looking at utilization of patient restraints.
We’re also looking at things like patient satisfaction at the unit level. There are actually specific questions related to nursing here, so we’re putting those items on the dashboard level, from the unit to the system level. As to which metrics to look at, our idea was that the selection should flow from one’s organization’s strategic plan, which metrics to look at. In terms of some of the overarching metrics, some are determined through analysis; with regard to our infection numbers, for example, our team looks at cases. The same thing is true with falls: an event generates a report, that kind of thing.
But there are two components; there’s the dashboard piece, and then there’s iRounds. We have iPads, and iRounds is a web-based application on the iPad. Some of those things on the dashboards are outcomes measures. But you might audit what things might prevent an infection. And looking at central line-associated infections, we have a checklist of best practices, and we have a team once a month that goes forward and does some auditing. There’s a team making sure people do the right things. So it’s not necessarily worked into the daily workflow.
Bea Leyden, R.N.
So it’s a kind of walk-around audit process?
Yes. And when you collect information, you can make it a metric on your dashboard. So if you’re a nurse manager and you say, my VAP rate—ventilator-acquired pneumonia rate—is up. A good example is that we collect data monthly on pressure ulcers. And did patients get the right nutritional plan? Did they get the right pressure-sensitive bed equipment? Did they get moisture management? There are several best practices around preventing pressure ulcers. So it can be at the nurse manager level; the campus level, such as with regard to nutritionists; or at the organization-wide level.
So it’s not about the daily workflow of the nurse?
That’s correct. We have some nurses who do data collection as part of their work. And then some of these topics have specific teams around them; for example, we have a wound care team that does audits.
When did the iRounds piece of this go live?
That’s the newer element; it’s been around nearly nine months now. We have outcome metrics, but we’re just working with the company now on getting some of these intervention metrics into the system. Benchmarking against best practices. So if my rates aren’t good, we can ask why they aren’t, how are we doing compared with best practices?
Where are you in terms of extracting metrics?
We’ve seen some real time-savings in terms of the analytics process. For example, we were doing pressure ulcer prevalence measurement once a month, and the wound care nurses are deployed and they physically do an assessment of every patient and will check to see whether the best practices are in place, and they’ll fill out every form on paper. And we will do a manual tabulation, and then hand-input that into a dashboard. And we participate in a national database for nursing, so we would hand-populate that into that national database, so that’s really labor-intensive. Now, we’ve automated that process, and that eliminated the paper right away.
So now our unit-acquired pressure ulcers already map to our dashboard automatically. And we’re working on getting the best-practice metrics into the dashboard. We could hand-query and do that, but they have a product that will cross-over in that area automatically.
And we participate in the NDNQI, the National Database of Nursing Quality Indicators, and we’ve been participating in that for six or seven years, now, an XML upload is currently uploading all that information. That went live about three or four months ago, and rolling it out gradually across our campuses now. That eliminates hand entry of data; we’re probably saving about 16 hours a quarter in that area. We can now also give them monthly data.
What have your biggest lessons been learned so far?
A lot of it is in the planning, making sure you understand what metrics you want. And even down to the level of the audits: Jessica builds the audits, and you can be very creative with them, you can build a lot of logic into them. So someone can build an audit, but you need someone who understands the process, so you’re not just plugging in the audit verbatim. And you can’t boil the ocean. You do have to kind of do this in stages. We’re dealing with nursing; there’s radiology, there’s pharmacy—there are a lot of other departments that could do this as well. So tactically, you have to organize it; and strategically, you have to decide what’s important to the organization, too, because you could have thousands and thousands of metrics going into the system.
What should our audience of CIOs and clinical informaticists consider around all this?
It depends on the organization, and where people are at in terms of level of sophistication. But for us, this was a way to really tie everything together. It’s the same idea of aligning with your strategic plan for your organization. It’s about providing people with the right information they need. And I think you have to start at that level and align it with your plan. And some elements are the mechanical elements of this—where are the iPads going to live, and who will have them? That sort of thing. But most of all, it’s about aligning with what your organization wants to know.