Measuring the benefits
Measuring the benefits
and outcomes of CM:
and outcomes of CM:
Clinical Pathways
Clinical Pathways
Trish White BN MN (Trish White BN MN (dist)dist)
Nurse Practitioner: Adult Urology
Nurse Practitioner: Adult Urology
Hawke’s Bay DHB
Outcomes
Outcomes
Defined as the end result of a process, treatment or Defined as the end result of a process, treatment or intervention
intervention
Traditionally mortality and morbidity – measures of Traditionally mortality and morbidity – measures of clinical outcomes and physiology
clinical outcomes and physiology
Modern Parameters:Modern Parameters:
Physiological Physiological
Psychosocial (attitude, mood)Psychosocial (attitude, mood) Behavioural (motivation)Behavioural (motivation)
Functional (ADL’s)Functional (ADL’s)
QOL (symptom control, well being)QOL (symptom control, well being) Knowledge (medications, diet)Knowledge (medications, diet)
Financial (costs of care)Financial (costs of care)
Why do it?
Why do it?
Improves standard of careImproves standard of care
How good is the care we are providing?How good is the care we are providing? Measures the benefit of careMeasures the benefit of care
BenchmarkingBenchmarking
Promotes continuous quality improvementsPromotes continuous quality improvements
Nurses should be critical thinkersNurses should be critical thinkers
Clearly illustrates benefits of the roleClearly illustrates benefits of the role
Justify roleJustify role
Prove impact in a measurable wayProve impact in a measurable way
How I measure outcomes….
How I measure outcomes….
Monthly reportMonthly report
Linked to Nursing Council competencies Linked to Nursing Council competencies
Clinical data: number of pts seen in ward, OPD, homeClinical data: number of pts seen in ward, OPD, home Referral sources: Nurse, Urologist, GP, HospiceReferral sources: Nurse, Urologist, GP, Hospice
Prevented admissionsPrevented admissions Teaching sessionsTeaching sessions
Professional activities: presentations, publication, mentoringProfessional activities: presentations, publication, mentoring
Audits: readmissions, active review, day cases, blood Audits: readmissions, active review, day cases, blood transfusions, returns to OT
transfusions, returns to OT
Clinical Pathways: variance monitoring reports Clinical Pathways: variance monitoring reports ResearchResearch
Clinical Pathways
Clinical Pathways
“
“
Documentation of variance – key to
Documentation of variance – key to
improving patient outcomes”
improving patient outcomes”
Sheehan, Nursing Management, Feb 2002
Clinical Pathways: process
Clinical Pathways: process
IT obtain patient data & enter onto Excel IT obtain patient data & enter onto Excel
spreadsheet spreadsheet
Clinical audit of medical recordsClinical audit of medical records
Manual input of clinical data into spreadsheetManual input of clinical data into spreadsheet Report generatedReport generated
Analysis by meAnalysis by me
Feedback to clinicians (nursing and medical) Feedback to clinicians (nursing and medical)
& discussion & discussion
Hyperemesis Gravidarum
Hyperemesis Gravidarum
Multidisciplinary CP implemented in
Multidisciplinary CP implemented in
1999: input from nursing, dietitian &
1999: input from nursing, dietitian &
medical staff
medical staff
HBDHB Quality Award, NZ Gynaecology HBDHB Quality Award, NZ Gynaecology
Nurses Conference best paper 2002 Nurses Conference best paper 2002
Replaces daily flow chart Replaces daily flow chart Ability to individualise Ability to individualise
HG – Length of Stay
HG – Length of Stay
CP CP Introduced Introduced LOS LOS days days Year YearHG – Cost implications
HG – Cost implications
Pre Clinical Pathway
Pre Clinical Pathway
$85,367 per annum $85,367 per annum
Post Clinical Pathway
Post Clinical Pathway
$35 – 47,000 per annum $35 – 47,000 per annum
Readmissions
Readmissions
25% of patients readmitted
25% of patients readmitted
Aggressive management for readmissions
Aggressive management for readmissions
NG feeding NG feeding
Ethnicity: July 03 – Dec 04
Ethnicity: July 03 – Dec 04
%
HG – Clinical Indicators
HG – Clinical Indicators
Demographics
Demographics
Nausea & Vomiting Day 2
Nausea & Vomiting Day 2
Ketones Day 2
Ketones Day 2
Ptyalism
Ptyalism
NG feeding
NG feeding
CP completion rates: ED & ward
CP completion rates: ED & ward
Potential to be used in PHC
Potential to be used in PHC
TURP Data
TURP Data
Implemented as guideline in 1998
Implemented as guideline in 1998
Variance Monitoring 2001
Variance Monitoring 2001
2002
2002
TURP volumes = 18.2% of surgery
TURP volumes = 18.2% of surgery
105 case weights = 28% of total
105 case weights = 28% of total
contract
TURP - LOS
TURP - LOS
Clinical Indicators
Clinical Indicators
Acute vs Elective
Acute vs Elective
Admission DOS
Admission DOS
CBI/MBI
CBI/MBI
Readmissions
Readmissions
Operating time
Operating time
Fever
Fever
Postop Hb
Postop Hb
TOV
TOV
LOS
LOS
Benchmarking
Benchmarking
Benchmarking – (ACHS) Australian Council Benchmarking – (ACHS) Australian Council Healthcare Standards
Healthcare Standards
Each variance has betweenEach variance has between
60 – 84 Health Care 60 – 84 Health Care
organisations reporting organisations reporting
figuresfigures
Tissue weight, histology, blood Tissue weight, histology, blood
transfusions, operating time,transfusions, operating time,
readmissionsreadmissions
Outcomes – Last report:
Outcomes – Last report:
Reduced TURP LOS by 0.5 day
Reduced TURP LOS by 0.5 day
Plan to reduce readmissions in place
Plan to reduce readmissions in place
Frequency of postop blood tests
Frequency of postop blood tests
reviewed
reviewed
Difference in practice: CBI reviewed
Difference in practice: CBI reviewed
Rate of DOS admissions discussed
Rate of DOS admissions discussed
Hysterectomy
Hysterectomy
Includes: vaginal, abdominal &
Includes: vaginal, abdominal &
laparoscopic
laparoscopic
LOS further broken down by type of
LOS further broken down by type of
surgery & gynaecologist
surgery & gynaecologist
Hysterectomy - LOS
Hysterectomy - LOS
LOS LOS days daysClinical Indicators
Clinical Indicators
DemographicsDemographics
Readmission rateReadmission rate Admit DOSAdmit DOS
Postop blood workPostop blood work Intraoperative injuryIntraoperative injury
IDCIDC
Nausea & vomitingNausea & vomiting FeverFever
Bowel functionBowel function
Outcomes – last report:
Outcomes – last report:
2004-2005 for first time Laparoscopic 2004-2005 for first time Laparoscopic
Hysterectomy has shortest length of stay Hysterectomy has shortest length of stay
IDC removal and patients tolerating diet on IDC removal and patients tolerating diet on
Day 1 improved Day 1 improved
Fever rate >38 increased – no trend notedFever rate >38 increased – no trend noted HBDHB within ACHS benchmarksHBDHB within ACHS benchmarks
Length of stay reducingLength of stay reducing Readmission rate reducedReadmission rate reduced
Conclusions
Conclusions
Clinical indicators selected on potential impact Clinical indicators selected on potential impact
to quality of care and LOS to quality of care and LOS
Little benefit having clinical pathways without Little benefit having clinical pathways without
a robust VM system a robust VM system
Clinical pathway an option even with different Clinical pathway an option even with different
techniques between clinicians techniques between clinicians
Linking clinical outcomes with dataLinking clinical outcomes with data Provides a guideline for staffProvides a guideline for staff
Current method labour intensive Current method labour intensive
