Intermountain Press Release

Burley, Idaho—Cassia Regional Medical Center uses a multidisciplinary approach to improve the quality of patient care. The core of Cassia's efforts is the patient care rounds held three times a week to identify patients' needs and assure those needs are addressed. Although other professionals might attend as needed, and as possible, the rounds are spearheaded by the case manager, social services representative, discharge planner, health information specialist, charge nurse, and director of the medical-surgical unit.

The rounds have apparently contributed to great improvements in recent months in quality of care indicators for clinical conditions targeted under Medicare's Health Care Quality Improvement Program. The improvements have been documented by PRO-West, which analyzes Quality Care Checklist data provided regularly by Cassia and many other Idaho Hospitals.

The multidisciplinary approach to improving care was advocated in a recent report from the prestigious Institute of Medicine. William C. Richardson, the chair of the committee that wrote the report noted: "For even the most common clinical conditions, such as breast cancer and diabetes, there are very few programs that use multidisciplinary teams to provide comprehensive services to patients."

At Cassia, which is a member of Intermountain Healthcare, two factors gave extra impetus to quality improvement efforts in the spring of 2000. One was an effort to educate physicians in evidence-based standards of care from Intermountain. The other was PRO-West's work on behalf of Medicare's Health Care Quality Improvement Program. Both efforts focused on common cardiovascular diagnoses and pneumonia.

Patient care rounds by an interdisciplinary team identify patients' needs and assure those needs are addressed.

Interdisciplinary Rounds
Staff at Cassia has a well-established method of quality improvement: interdisciplinary rounds. Key members of the interdisciplinary team are Jeanette Wheeler, RN, Case Manager and Utilization Review Coordinator; Jerry Lankford, BSW, Discharge Planner; and Marilyn King, RN, Director of the Medical-Surgical Unit. Marilyn plays a critical role in making sure the rounds happen, says Jeanette. "At times Marilyn relieves the charge nurse so she may attend or assists in communicating with the physicians regarding concepts discussed during care rounds. She provides cohesiveness to the effort," she says.

The charge nurse is essential
"Although case management leads the team, the charge nurse is the key to the quality improvement effort," says Jeanette. "She brings information to the team based on her knowledge of the patients and her side-by-side work with the physicians. The case management efforts are based on the vital information."

Physical therapists, pharmacists, respiratory therapists, dieticians and others attend the rounds as needed. The core team communicates with other disciplines depending on patient needs.

Key Tools
The team uses two key documentation forms for their work. The patient history form, which is completed by the patient, family, and admission nurse, covers health history, advance directives, medications, and allergies, as well as personal information such as mobility and home situation. The Interdisciplinary Plan of Care is the working document the team uses to identify patient needs and assure they are met.

All patients are screened for immunizations through use of the patient history and care rounds. Care for patients with each targeted clinical condition is assessed as appropriate. For example, if a patient with arterial fibrillation is ready for discharge, the team assures the warfarin is considered by the physician. A patient who has multiple admissions for heart failure may need a repeat echocardiogram or may not have had an angiotensin-converting enzyme (ACE) inhibitor prescribed at the last discharge. Additional triggers for action are utilization review issues, discharge planning needs, readmissions, and length of stay.

The team faces many challenges
One is that the group does not represent every department. Assignments must be made to each team member to assure communication with other professionals about patient needs. Assignments must be clear and accepted with an anticipated time of completion. Availability of charts and, most importantly, time are constant challenges. The hospital administration's strong support for quality improvement efforts and for improved utilization of resources has helped to meet these challenges.

Other Quality Improvement Components
Another component of Cassia's quality improvement effort is the Case Management Committee, which addresses both quality and utilization issues. Aggregated data are presented to physicians to show whether patient care standards are being met. When appropriate, physicians are reminded of these standards individually.

In addition, Sonya Hubbard, the lead DRG coder, recently initiated concurrent coding during rounds. She reads physician documentation during the patient stay and informs the physicians of what DRG the documentation supports.

"We have had two patients so far who were assigned different DRGs based on the concurrent coding," says Jeanette. "The Physicians involved are receptive to the committee suggestions and documentation assistance."

Cassia's efforts to address patient needs efficiently and completely have improved health care quality and compliance. Collaboration among professions coordinated by a multidisciplinary team establishes Cassia as a leader in efforts to redesign health care delivery in Idaho in the 21st century.