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.”
Charles Macias, M.D.
That group of several IT and data experts came together with a clinical team drawn from a number of areas, but with strong guidance from Macias, Carberry, and Lopez. The resourcing of such an initiative is necessarily worked out of complexity, says Carberry. “With regard to the technical work, we’ve been connecting with an organization-wide business intelligence team,” she notes. Performing this kind of work, she says, “forces you to really think as an organization as a whole, and to figure out how to prioritize care delivery. Because of the resource intensity, you’re talking about millions of dollars in resource support” for all the initiatives going on at the hospital, she notes, “so you need alignment. Those teams are heavily matrixed. In our service, we have some dedicated folks and Dr. Macias has an order set person. So we do have some core decentralized folks, but we also are heavily matrixed.”
Kathleen Carberry, R.N.
Breaking Down the Complexity for Understanding
On a very basic level, doing this kind of work—analyzing processes and outcomes, and moving forward to try to standardize clinical and care delivery processes—is difficult because of a fundamental lack of standardization of concept and process with regard to appendectomy care delivery, say the Texas Children’s leaders. Lopez notes that surgeons nationwide—and there are 15 at Texas Children’s who perform appendectomies—all judge the types and levels of severity of cases differently, and make very different kinds of decisions regarding what kinds of antibiotics to administer, how long to administer them, and so on—even as the core of the invasive procedure itself is relatively straightforward. Even what surgeons tell the parents of children being operated on has been different. With regard to categorization, Lopez notes that “There is no variation in methods of diagnosis among the surgeons, but rather, they all describe their findings at the time of surgery differently. Each surgeon will describe differently how the appendix looks, and how that surgeon categorizes appendix appearance will vary, and that variation will influence the care management of each case.” So one of the advances in this initiative was to provide the surgeons with an analytics-based visualization application that has helped surgeons use standardized vocabulary to categorize cases by appearance, leading to improved standardization of case management.
More broadly, Macias, Carberry, Lopez, and all the others involved in the initiative took time to break down all the variables in surgeon assessment of patient cases, perioperative care delivery, medication administration, and so on, and then, once they had isolated and identified all the variables, says Carberry, “Once the physicians saw the data, they knew what the problems were; and the presentation of the data to them validated what they already knew intuitively. But it was important to be able to track and measure the improvements,” as clinicians worked to improve and standardize care delivery processes.
As a result, Lopez says, “From the evidence-based outcomes center that Dr. Macias leads, we with their help created practice guidelines that were evidence-based, and based on a rigorous review of the literature of existing guidelines at other hospitals and also incorporating guidelines from other hospitals, we created a single overarching guideline for appendicitis care that encompasses emergency room practice, and that standardizes the operative and post-operative approach” to appendicitis care at Texas Children’s—with the results, as outlined above, that have been achieved.
Work remains with regard to integrating a number of aspects of clinical decision support into the hospital’s EHR, the Texas Children’s leaders concede; indeed, that is one of the areas they will be attacking next. But what the Texas Children’s leaders have proven is that, guided by performance improvement-focused leadership and facilitated by strong data analytics work, even the most complex and non-standardized care delivery processes can be mapped, analyzed, and optimized. And that is an accomplishment with tremendous implications for patient care organizations nationwide, at this time of intense demands for system performance improvement across U.S. healthcare.