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Health Care System "In Pursuit of Excellence" Case Example
Meridian Health is a not-for-profit health care system that provides a broad range of health care services through its three acute care hospital campuses (Jersey Shore University Medical Center, Ocean Medical Center, and Riverview Medical Center), its K. Hovnanian Children’s Hospital and in-home care. Serving the New Jersey counties of Monmouth and Ocean, Meridian Health provides care for more than 250,000 people annually.
Meridian Health has maintained 100% Magnet nursing status continuously at all three medical centers since 1998 and has received exemplary scores on national evidence-based indicators for cardiac, pneumonia, and surgical care. In 2005, the organization was awarded the John M. Eisenberg Award for Patient Safety and Quality by the Joint Commission and the National Quality Forum, and was recognized for its innovation in embedding evidence-based practice clinical guidelines as part of its computer-based physician order entry system (CPOE).
Meridian Health is committed to and embraces its mission to improve the health of the New Jersey communities it serves by providing quality, patient-centered health care services and advancing medicine through clinical education and research. The organization also seeks to foster a culture of excellence through collaboration. Meridian Health actively searches out innovative solutions, technologies and partnerships to further the achievement of their mission.
The Meridian Health Institute for Evidence-Based Care (IEBC) is an outcome of Meridian Health’s dedicated desire and commitment to advance quality of care to a new level of excellence. Recognizing the challenges physicians, nurses and other staff face in staying abreast of leading medical knowledge and technologies, the Institute was established to help meet that challenge, through both evidence review and original research. Through the IEBC, Meridian Health’s medical professionals are able to access research, apply scientific evidence in a health care setting, evaluate results and findings, and establish a continuous loop of evidence-based care. Highly unique to the IEBC’s efforts to improve quality is its interdisciplinary approach to patient-centered care. This dual interdisciplinary and patient-centered approach is fundamental to Meridian’s mission and is a key component of the foundation upon which the work of the IEBC has been built.
The IEBC’s Philosophical Foundation. The Institute for Evidence-Based Care is based upon three core philosophies:
Patient and family centered care. Consistent with Meridian Health’s established model of care, the IEBC’s first focus is on the patient’s values and needs as a driving factor and consideration in the provision of care and treatment. Patients and their families are acknowledged as partners in care and are given the information they need to make choices about the care received. Patients’ values, cultural preferences, comfort, past experiences, health status and rights are all considered as treatment plans are developed and as care is delivered by Meridian Health professionals.
Science. Meridian Health endeavors to raise the quality of the care provided through scientific evidence and research. Establishing the resources and ability to conduct local research has helped Meridian Health bridge gaps between traditional methods of providing care and evidence-based methods. Scientific evidence is reviewed and evaluated at the Institute for its quality, strength and scientific merit. Balanced with patient preference and resource utilization, scientific evidence becomes the foundation of care.
Integrated Clinical Expertise. An interdisciplinary team approach is at the center of the IEBC’s scientific research, evaluation and application. Teams comprised of medical staff, nursing staff, nutritionists, radiologists, pharmacists and many other disciplines are involved in the research and development of care and treatment programs that are based on patient preference and scientific evidence of treatment efficacy balanced with resource utilization.
The IEBC’s Infrastructure. The IEBC is anchored by its Clinical Excellence Committee. This committee is comprised of respected physicians from throughout the Meridian Health system who have been recognized as leaders in clinical excellence. Multiple disciplines are represented on the committee, ensuring an integrated and collaborative approach to delivering quality care. The committee’s recommendations are presented to the Medical Executive Committee for review and approval.
An Academic and Research Council has also been established within the Institute. Also interdisciplinary, the Academic and Research Council is comprised of physicians, Doctorates of Pharmacy (Pharm. D.’s), library resources and others. This council helps to scan literature, prioritize the IEBC’s initiatives, and provide other supportive work for the Clinical Excellence Committee.
A Value Council is part of the IEBC’s structural model; however, resource focus to date has been on determining appropriate protocols and putting them into practice. The council is responsible for determining how to extract data and measure program effectiveness.
The IEBC is staffed by a nurse (doctoral student) and statistician who support the Clinical Excellence Committee’s work by providing research and data in response to questions and ideas generated by the committee. The addition of a physician to the team is envisioned for the future.
Making Change Happen. Strict adherence to the practices and protocols that the IEBC develops is not mandated but is embedded within the organization’s practices. Several factors are credited for ensuring support and successful implementation of the recommended protocols:
- The members of the Clinical Excellence Committee are proponents of the recommended changes and highly respected clinical leaders. Their opinions are valued, and their recommendations are taken into careful consideration by their peers and others;
- The recommended protocols are well-supported by research and clinical evidence. The science behind the recommendations gives them credence and is valued and appreciated by the medical staff;
- The Chief Risk Officer has provided organizational education regarding the research and science supporting the protocols and the risks inherent with not following them;
- Meridian Health is heavily invested in computerized physician order entry (CPOE). Quality protocols are embedded in their CPOE system, along with specific exceptions to protocols. When recognized protocols are not prescribed, the ordering physician must acknowledge the existence of one of the recognized exceptions or document their rationale for not adhering to protocols; and
- Meridian Health is building strength in a culture of best practices that is embraced by the medical staff and other professionals, and which opens the door to continuous improvement efforts.
Finding Funds for Change. Meridian Health serves an area of the nation with one of the highest concentrations of residents over 55, and one of New Jersey’s most indigent populations. The opportunities to improve quality and efficiency while lowering cost have significant importance not only to these communities but across the nation. Supported in part by funding from Meridian Health, the IEBC has successfully secured grants from other sources to further its work. These sources include grants from HRSA (U.S. Department of Health and Human Services, Human Resources and Services Administration), Cardinal Health and C. R. Bard.
Grant funds have been used to obtain and expand programming of human simulators for the evidence-based protocols. Grants have also been used to fund the hiring of a full-time nurse educator to provide training to physicians, nurses and ancillary providers on the principles of evidence-based care.
Meridian Health has also initiated a Quality Scholar Program. In the program, bedside nurses attend an intensive three-day, off-site session during which they advance their skills in creative problem-solving, learning to review and evaluate evidence-based literature, and focus their time on performance improvement and teamwork. Participants identify and conduct quality improvement projects that are generating evidence-based, beside care protocols.
In less than a year from the initiation of their attention to evidence-based medicine, Meridian Health completed studies of multiple disease categories, implemented recommended protocols across the organization, and embedded them in their CPOE system. Those categories included:
- Colon surgery (gum chewing, cancer surgery practice);
- Infectious disease (MRSA decolonization chlorhexidine bath to prevent central line infection);
- Gastroenterology (nasogastric tube – NGT);
- Obstetrics (crew resource management);
- Palliative care (quality measures);
- Cardiology (CHF disease management practices, cardiac catheter complications); and
- General medical/surgical care (ambulation).
The organization saw their above average scores on quality measures rise to the top deciles.
In its initial 14 months, the IEBC engaged in several evidence reviews that included identifying study priorities the specific questions to be researched; gathering research teams; evaluating evidence; establishing protocols; obtaining approvals; and implementing practice changes.
Examples of IEBC Research
Specific examples of IEBC research in the last year include:
- Compliance with Joint Commission requirements for medication reconciliation is a challenge for hospitals. Patients are frequently prescribed different medications from more than one physician or specialist and may have those prescriptions filled at various pharmacies. Without an accessible, automated repository of information on patient medications, hospitals are reliant upon the patients themselves to convey the medications and dosages they are taking. Physicians with the IEBC hypothesized that Pharm. D. interactions with patients may result in decreased complications from poly-pharmacy related issues, reduced length of stay, lower costs and improved patient safety. A research demonstration project funded by the Cardinal Health Foundation on medication history taking and reconciliation was initiated in early 2009; data collection results are still pending. Approximately 20 data points are being measured to determine if care may be improved by the interaction of a Pharm. D. directly with the patient. Initial anecdotal reports from participating pharmacists indicate a significant need for improved communication between hospitals and nursing homes. The lack of streamlined information about patient medication history often results in the receiving nurse spending a substantial amount of time untangling disjointed information.
- Based on evidence that gum chewing during immediate recovery from colon surgery resulted in a more rapid recovery of bowel function, this protocol has been impl
- Protocols for MRSA decolonization were identified and implemented across all sites.
- Examples of other protocols that have been researched and established include:
- Colon cancer surgery protocols
- Nasogastric intubation testing
- Soap type used for patients with essential catheterization
- Protocols to reduce vascular complications for cardiac catheterization
Shared Learning. Meridian Health and representatives of the IEBC are committed to working collaboratively and sharing best practices with others. Meridian Health is a member of The Leadership Institute, a membership organization dedicated to “facilitating the exchange and exploration of different perspectives, information, and experiences related to common issues and problems of care delivery systems.” Within that organization, Meridian Health and others have created an affinity group of hospitals and health systems whose purpose is to explore and share best practices, protocols, challenges and issues related to medical research.
To further their commitments to collaboration and shared learning, Meridian Health IEBC created and sponsored “Knowledge in Motion: Interdisciplinary Evidence-Based Care,” a national conference in 2009. The conference featured national speakers and was designed to increase knowledge and application of interdisciplinary, evidence-based approaches to care.
The IEBC also created a series of Webinars for the benefit of their interdisciplinary staff.
While specific value measures have yet to be developed, the IEBC can cite a number of potential benefits and outcomes from their focus on interdisciplinary, patient-centered, evidence-based care:
- Scores for quality of care measures that are in the top deciles
- Improved patient outcomes
- Improved efficiencies
- Reduced costs
- Challenging clinical initiatives that engage and interest physicians, nurses and other staff
- Pride in a culture of best practices
In tangible recognition of the value of its innovative approaches to evidence-based care, Meridian Health was awarded the John M. Eisenberg Award for Patient Safety and Quality in 2005.
Advice for Ensuring Program Success. IEBC representatives recommend the following for ensuring the success of similar programs:
- Respect the physicians;
- Allow physicians to lead efforts to identify and develop research and study initiatives;
- Support physician efforts by surrounding them with competent clinical people, necessary resources and outside consultation;
- Ensure professional recognition of the work and accomplishments;
- Embrace an interdisciplinary approach to evidence-based medicine; and
- Consider offering a stipend, in recognition of the significant amount of time and effort physicians and others contribute on a volunteer basis.
While this initiative benefits from the size of the Meridian Health organization, IEBC representatives believe that the success of an endeavor like this is more dependent on the vision, innovative thinking, commitment and focus of a hospital or organization than it is on the size.
Creating an interdisciplinary, evidence-based approach to quality is not a project. Its success lies in creating a new culture, a journey with an approach to thinking that includes the freedom and encouragement to question “why are we doing this?” and “what is the patient outcome of doing this?”
Contact Name: Richard Hader, R.N., Ph.D., FAAN
Title: Senior Vice President and Chief Nursing Officer
Tel: (732) 776-4632
Fax: (732) 776-4571