As American healthcare reimbursement moves from paying healthcare providers for individual interactions toward issuing a single bundled payment for all care provided for a particular clinical condition across care settings (e.g., knee replacement), healthcare providers will need to share information beyond their own offices or hospitals to achieve the expected clinical quality and financial targets. Health systems may be tempted to focus exclusively on physician behavior across care settings. Alternatively, physicians, nurses and other members of the care team could work together in a shared governance model to synchronize efforts across disciplines to improve care delivery across the continuum.
Tim Porter O’Grady defines shared governance as a professional practice model, founded on the cornerstone principles of partnership, equity, accountability, & ownership that form a culturally sensitive & empowering framework, enabling sustainable & accountability-based decisions to support an interdisciplinary design for excellent patient care. The Vanderbilt University Medical Center Shared Governance group identified at least six elements of a successful shared governance model:
- A charter that includes the boundaries of decision-making;
- Collaboration between staff co-chairs and the area manager;
- Regular meetings with a formal means of communication to all staff;
- Mutually planned agendas (co-chairs and manager) distributed before the meetings;
- Ground rules of how to work together (in-person or online);
- Strive for consensus decisions, meaning that everyone agrees to support them after having discussed the options.
From handwritten orders to system-wide order sets and care plans
Electronic medical record order entry can represent increasing levels of care standardization. Before computerized systems, healthcare team members wrote their instructions for their colleagues to execute (e.g., give two liters of normal saline over eight hours). At their most basic level, electronic medical records address illegibility problems by requiring users to type their orders. At the next level, electronic medical records can require users to complete specific order details before the order can be accepted (e.g., administer 0.9% normal saline intravenously at 150 cc/hour for two liters). Orders can then be grouped to fire at a particular time (e.g., admission orders for a planned Cesarean section) that are unique to a particular user. At this point, nurses and other care team members must be aware of what “Dr. Jones” likes or “Dr. Smith” prefers and develops care plans accordingly.
To achieve higher levels of care quality, a hospital leadership team might engage with physicians to develop “one best way” to treat a particular condition. Diabetic ketoacidosis requires significant monitoring and nursing support to manage a patient’s electrolytes and fluids. If each ordering provider uses different order sets to manage these patients, nurses and other care team members are less likely to implement each provider’s instructions with complete fidelity. Encouraging physicians to use one set of orders to manage patients with diabetic ketoacidosis can help improve care team adherence to the expected treatment plan.
The next iteration of this standardization might be standardizing care across care settings. Patients with diabetes and a history of diabetic ketoacidosis may require interactions with an endocrinologist, a primary care provider, a dietician and a home health team. If the care team can agree upon what steps are necessary to help reduce the risk of a recurrence and better manage diabetes, the steps can be presented to patients and family members to help improve patient engagement with their condition and increase adherence to the treatment plan. Similar to managing an acute condition in the hospital using the same protocol, standardizing a care pathway could help coordinate care and reduce unnecessary care.
In March 2013, Aligning Forces for Quality published “Care Across Settings: Challenges, Successes, and Opportunities.” The report outlined five specific recommendations to help deploy care across settings:
- Solicit stakeholder buy-in
- Secure solid financial commitments from stakeholders
- Measure, measure, measure
- Start small
- Dream big
Shared governance could help address the consensus-building elements of building care pathways. Medical informatics can help provide options for how best to deploy these care pathways across electronic medical records and measure pathway adherence.
How might a health system execute a shared governance model for inpatient care pathways?
In my experience at a few medical centers, clinician groups may rely on information technology to convene relevant stakeholders when developing an order set or inpatient care pathway. The risk of delegating this work is that decisions that determine how pathway instructions are presented will be made by non-clinicians that lack the appropriate clinical context or are optimized for electronic medical record maintenance rather than serving the clinician end-users’ needs.
In my organization’s journey toward system-wide inpatient care pathways across a dozen hospitals with three different electronic medical record systems, we have moved away from information technology managing order set standardization. System-wide councils provide suggestions for inpatient care pathways that will help the organization achieve its goals. The inpatient care pathway team includes nursing, pharmacy and physician leaders to determine what site resources might be required to obtain the necessary buy-in to adopt the proposed orders for the specific clinical condition given each site’s specific resource constraints. Nurses determine if the proposed content requires harmonizing site-specific nursing policy or creating a new system-wide policy. Pharmacists provide input into what medications provide the highest value for the organization and are easiest to manage from a formulary perspective. Physicians negotiate what orders should be included, what orders should be pre-selected, and what orders might be modified based on user-preference.
Once the clinical leadership finalizes the content, the information technology team works on translating the content into a format that can be viewed within the electronic medical record. The clinical stakeholders then review the content from a usability perspective. If everyone agrees to move forward, the care pathway is presented to the system’s Pharmacy & Therapeutics Committee for final sign-off. Each site’s local governance group has representation on the system Pharmacy & Therapeutic Committee.
Clinical informatics helps the clinical leadership team
- Determine the best go-live date depending on the pathway’s training requirements, and
- Develop the relevant training materials to help users understand the proposed change
- Develop downtime forms to help clinicians deliver the same level of care when the electronic medical record is not available
Electronic medical record reporting teams can provide data to determine care plan utilization and progress toward relevant clinical outcomes within a hospital and across hospitals to determine system-wide performance.
Extending the Shared Governance Model beyond the inpatient setting
Within the same organization (e.g., an integrated delivery network), outpatient clinics, extended care facilities, rehabilitation centers and home health entities could serve as stakeholders in a larger care pathway framework. For unrelated clinical entities, the Silver Cross leadership team described their experience with clinical partnerships to improve care quality including working with academic medical centers, businesses and physician groups (disclaimer: Silver Cross has a relationship with Advocate Health Care, my employer).
For patients moving to a clinical facility with no affiliation or agreement with the prior clinical facility, the patient and caregiver may be the only connection between the two entities. If patients and caregivers have access to the discharge summary, that would provide some direction about what might be needed next in the patient’s care. Facilities that provide patients and caregivers a copy of their “internal” care plan (i.e., the one developed with cross-setting clinical partners) may help the receiving facility better understand the implications of what might be achieved across care settings.
Standardizing care through order sets and care pathways will reduce variation. In 2002, Brent James suggested three common causes of clinical variation: complexity of clinical practice, lack of valid information identifying best care across a range of choices, and physicians’ continued reliance upon subjective recall in making clinical judgments. Variation is needed to discover what might work for specific patient populations or address conditions in a novel way (e.g.,enhanced recovery after surgery). Groups practicing a shared governance for care pathway development should consider processes to allow for experimentation to improve their care delivery within their standardization efforts.
Electronic medical record systems can present order sets to reduce variation in care delivery in physician ordering. Motivated health systems may use the order set standardization process to include other members of the care team for multi-setting care pathway development. Tracking utilization and outcomes can help determine what changes might be needed further improve care.