Last year, Tampa General Hospital (TGH), a 1,011-bed teaching hospital in Florida, initiated a clinical process improvement (CPI) program aimed at enhancing standardization and efficacy of treatment for conditions identified as high priority. At the time, officials at the patient care organization noted that the core goal was to develop scalable and repeatable models to tackle difficult clinical initiatives and improve patient outcomes—an objective that Peter Chang, M.D., CMIO at Tampa General Hospital, confirmed in a recent interview.
“As a doctor, naturally your inclination is to want to make the lives’ of your patients better and make them live longer with less comorbidities. So this initiative was born out of [simply] providing better care for our patients. And when we looked across the organization, we lacked a lot of standardized methodologies for how we care for them,” Chang says. He gives an example of a patient coming in for a disease process, but one group of physicians might manage that differently—not incorrectly, but differently—than another group. “So with variability comes variability in outcomes,” says Chang. “We have known this problem exists in the U.S., but also in our organization, so we set out on a path to try to attain standardization for how we care for our patients.”
Early on in the CPI initiative, a top priority was the early diagnosis and treatment of sepsis in the emergency department (ED), where 80 percent of TGH’s sepsis cases originate. TGH tested several known methodologies, yet they lacked scalability and self-service access to the information that stakeholders needed to make quick improvements, according to officials. These methods did not provide insight into the actual process or delivery of care (rather only focusing on outcomes data), which is required for sustainable and scalable process improvement, TGH officials noted.
So clinical leaders at TGH opted for another approach, which involved electronic health record (EHR)-generated alerts and treatment advice, and a clinical process improvement platform from Minneapolis-based LogicStream, which enabled clinical leaders to review clinician response times and treatment decisions in real time.
Chang notes that with the advent of EHRs, other avenues have opened up. Before, when everything was on paper, he says, there would be a paper order set that would have to be located for different things to be enacted. But now, with clinical alerts living inside the EHR, they can kick off different processes to ask the provider, “Do you think this is what’s going on, and if so, please follow the accompanying treatment track.” And Chang adds that much of this is driven by TGH’s quality reporting for CMS (Centers for Medicare & Medicaid Services) star ratings, value-based purchasing, and U.S. News and World Report hospital scores, all of which take some account of quality and outcomes into their calculations. “So there is a secondary gain for wanting the hospital to perform at a higher level. We want to show folks that we treat our patients well here. So that led us onto our path for process improvement and bettering clinical outcomes,” he says.
Regarding sepsis, Chang says that by looking at the Sequential Organ Failure Assessment (SOFA) score (used to track a person's status during the stay in an ICU to determine the extent of his or her organ function or rate of failure) or examining the “Surviving Sepsis” guidelines, one would get differing opinions on what doctors believe is the correct way to manage sepsis. But nevertheless, CMS has adopted a 3-and 6- hour rule for a core quality measure—the Sepsis CMS Core (SEP-1) Measure.
For TGH clinical leaders, being able to leverage its Epic EHR to allow these processes to get kicked off became a key priority. “We created a sepsis alert order that goes into the EHR and is an overhead page to everyone in the ED to say that there’s a sepsis alert in X room [for example],” Chang explains. “So when that happens, it initiates a chain reaction of events from nurses to physicians to pharmacists to make sure that the correct protocols are being followed. And the use of LogicStream in that sense allows us to analyze the compliance and usage of the elements that we have built into the EHR,” he says.
Chang says that Epic has two major tracks in its system to help treat patients: best practice advisories and order sets. The best practice advisory, he continues, looks at information that lives within the chart, be it labs, documentations, vitals, or discrete data inside the EHR, and will kick off an alert to a nurse or physician, leading that person to an order set. The nurse or physician can then see that even though the patient meets the criteria for labs and vitals, maybe he or she just has the flu and is not septic.
“It gives you a way to ‘opt out;’ the computer just knows the patient from what’s inside the EHR. So we use best practice advisories to alert nursing in triage and physicians to say that their patient could potentially have sepsis based on multiple criteria, do you want to go ahead and initiate that sepsis order alert, and do you want to continue down the path of using the order set we have outlined to achieve the 3- and 6- hour timeframe from the SEP-1 measure?” says Chang.
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