Hospitals and health systems nationwide are struggling these days to create a healthcare system of improved care quality and patient safety, efficiency, cost-effectiveness, accountability, and transparency. Yet a small number of pioneering organizations are already charting a bold, clear course—among them, North Memorial HealthCare, a two-community-hospital health system based in Robbinsdale, a suburb of Minneapolis-St. Paul, which encompasses the 300-bed North Memorial Medical Center in Robbinsdale and the 100-bed Maple Grove Hospital.
Leaders there have launched themselves on a path that will position their organization beautifully to adopt the principles of the new healthcare, and it is one that is already reaping rewards. The core of what the leaders at North Memorial are doing is to leverage healthcare IT to facilitate enterprise-wide continuous quality improvement, not only for its own sake, but to achieve clinical transformation across diverse patient care service lines in the organization.
As a result, the leaders at North Memorial HealthCare were named the co-second-place winning team in the Healthcare Informatics Innovator Awards program. They will be honored at the Healthcare Informatics Innovator Awards reception in Orlando in February, during the annual HIMSS Conference.
All the members of the leadership team provided HCI with extensive interviews. Below are excerpts from HCI Editor-in-Chief Mark Hagland’s interview with Linda Engdahl, R.N., M.S.N., director of Women’s and Children’s Services at Maple Grove Hospital, one of the two hospital facilities within North Memorial HealthCare. Engdahl and Jon Nielsen, M.D., a practicing gynecologist and the medical director of that service, have been leading an initiative to reduce pre-39-week elective labor inductions, the first project taken on by the North Memorial leadership in the context of the organization’s overall quality effort. The core achievement of that project: reducing elective pre-39-week labor induction from 1.2 percent to 0.3 percent of deliveries, over the period of about one year.
Linda Engdahl, R.N., M.S.N
Previously, Hagland’s interviews with Dr. Nielsen; J. Kevin Croston, M.D., the organization’s chief medical officer; and Jeffrey Vespa, M.D., medical director for clinical quality for the health system; have been published. Below are excerpts from the interview with Linda Engdahl.
What is your perspective on the labor induction reduction project, and the broader context of North Memorial’s overall quality initiative?
A big part of this has been the cultural piece; you have to start with shared values. And fundamentally, most people are in this business because they want to do the right thing. And sometimes, they’re struggling to stay independent. But if you start with both a shared value and shared understanding about why it’s good not to electively induce too early, and that understanding is separated from the emotion of a particular patient or case, then you also begin by pulling the data. And you see increased c-section rates because failed progression of labor, and increased rates of NICU [neonatal intensive care unit] admission, and doctors and nurses at the table a fair level of agreement right away. And it was very important to have not only executive nurses, but also frontline nurses, involved. If you tap into that inner core of the provider that says, I want the best experience for my patient, and you align your processes with that core value, you start to get a groundswell of support. And what the frontline staff said was, what will help most will be to look at scheduling. Previously, a doctor would just call up and say, I want to induce Mrs. Smith, she’s getting uncomfortable or whatever. And the nurses see what the real practice is. And there wasn’t the rigor to be able to challenge things. So the nurses said, how about if we had a checklist for criteria around scheduling?
And part of that was getting rigor into the determination of gestational age?
Correct. And also, defining what medical necessity is, to determine whether induction is necessary. And a nurse caring for a patient can pretty quickly discern when the patient comes in where they’re at, and they’ll tell us when their due date is. And that’s when the nurse would call Dr. Nielsen, the medical director for obstetrics, or the chair of obstetrics at the individual facility. So the nurses took the form and worked it through several physician groups. And that took a while, because we went through several iterations to more clearly define things, often through the department meetings.
What was that process like?
It was very engaging and very positive; it was always about that the patient was at the center, and what are the right things to do? And people can differ, and that’s where the group itself can tolerate certain variables. The thing to me that was really positive about the process is that while it meant moving towards standardization, it still respected autonomy within the parameters of best practice.
Moving towards more evidence-based, consensus-based, multidisciplinary, data-driven care is a good thing, right?
Managed care kind of took on a bad name, because it ended up being a struggle for control. But the way I try to frame it for people as being about the best care, the right care, optimal care, for patients. And that helps all of us, and helps us streamline our resources and align together. And that makes practice better for doctors and nurses; and the only way you can do that is to have every voice at the table. Otherwise, everyone sits in their own rightness. And it doesn’t mean everybody’s wrong. We just have to come together to align what we’re doing. And the best measure…
And doesn’t it also improve relations between doctors and nurses?
Oh, absolutely! And I will tell you that we have very positive relations between doctors and nurses here. And now we’ve been working on how you manage the labor itself, and what kinds of algorithms do we use to determine when someone’s ready for a c-section, and when labor has really quit. And it’s very nuanced, and we’re working with certain algorithms or models that become points for discussion. And when the discussion happens, most times, you have your best outcome.
And it engenders greater collaboration, right?
Absolutely. There’s respect for the expertise each brings.
How is the use of data changing clinical practice at North Memorial?
It gives us the tool with which we can make those definitions. It provides both the ability to define and measure, but it also gives us the benchmark against which we can evaluate our practice. And technically, that’s been around for a long, long time. But because of the advances in technology and the availability of data, real-time data is now available. And that means that I don’t have to wait three months to hope that my interventions have made a difference. And that helps, because you can course-correct in midstream, or you can pause. And you put those successes out in front of the providers, and you can say, good job, and we can make changes in real-time. I think relevance is a big piece of it.
And both nurses and physicians have to get used to regularly using HIT, right?
Yes, absolutely. But in Minneapolis, we’re pretty far down the road of using EHRs regularly; now we’re more advanced; it’s not just another way of documenting, but it becomes a way of using warehouses to help us define and measure our care.
And really, data is only data; the richness comes with the interpretation, the conversation. And when you bring a group together in a room, someone will come up with something out of left field that will set you down a new direction that no one had thought of. And it really makes it fun. It’s about trying to really understand what’s contributing to a situation, and solving a problem or set of problems. And that’s a beginning point for innovation.