November 20, 1998

Mort

"While we have had broad participation and terrific design coming out of the OI effort, we are hoping for even more participation going forward. We are still facing important challenges in our hospital's length of stay and cannot rest on the successes to date."

– Elizabeth Mort, MD

Erickson

Nicholson

Richter

Mongan

This issue of Hotline is dedicated to the Operations Improvement (OI) Program at the MGH. The stories in this issue illustrate the accomplishments of MGH employees and staff who are developing and implementing OI projects to streamline processes, reduce costs and, most importantly, improve the quality of patient care at the MGH.

Taking a look back
The MGH has a long history of performance improvement, characterized by a hospitalwide commitment to high-quality patient care. The 1990s have seen ongoing enhancements to the MGH's quality improvement initiatives. Physicians, nurses and administrators formed the Clinical Practice Council, which developed new patient care programs. The MGH also initiated hospitalwide quality improvement training for more than 300 administrators. Starting in 1994, patients' views of their hospital experience were routinely measured using survey tools in order to provide more patient-focused care.

OI was formed in 1995 to address issues involving both clinical quality and operational efficiency. The program has been able to build on enthusiasm, expertise and ideas from around the hospital and develop an organized approach to simultaneously improve efficiency and clinical quality.

Accomplishments through OI
The fundamental goals of OI have remained consistent since its formation: to improve the quality and effectiveness of care delivered across the MGH system, to achieve tangible cost savings from the redesign and restructuring of operations and to produce measurable improvements in patient satisfaction.

"In many areas we have seen important, tangible improvements at the MGH," says Elizabeth Mort, MD, director of OI. "The success of OI lies with the dedication of hundreds of administrators, physicians, nurses, therapists and front-line employees who carry out the work of more than 20 performance improvement teams."

According to Mort, OI has fostered measurable improvements in both clinical and operational areas. And even though there have been many successes through OI, more work is to be done. This issue of Hotline celebrates some of the key OI innovators. Future issues will feature additional OI success stories.

"While we have had broad participation and terrific ideas coming out of the OI effort, we are hoping for even more participation going forward," says Mort. "We are still facing important challenges in our hospital's length of stay and cannot rest on the successes to date."

Hospital costs also have been significantly reduced over the last few years. Through FY '98, OI has achieved $35 million in savings on an annual basis. Approximately $83 million has been saved cumulatively through a variety of management initiatives, such as changes in pricing and contracting and consolidation of programs and services across the MGH and throughout Partners.

Progress report
In the area of patient care, more than 60 clinical pathways have been developed by 16 clinical teams. Pathways are clinical guidelines to help physicians, nurses, therapists and other caregivers provide the most appropriate care to patients in a coordinated manner.

These pathways also ensure quality while streamlining patient care. They create a partnership between the patient and provider by setting goals for the hospital stay and helping patients move effectively through the various stages of their care. Discharge planning and transfer to rehabilitation facilities can be arranged in advance before a patient is even admitted to the hospital. Most pathways are oriented to patients admitted with particular clinical conditions, such as congestive heart failure, respiratory failure or asthma (see "Helping patients with failing hearts," "Helping patients breathe easier – the non-invasive way," and "Helping children and families manage asthma" in this issue).

"Using pathways for the right patients can help ensure they are getting appropriate care in the best setting," says Britain Nicholson, MD, chief medical officer for the MGH and co-chair of the OI Steering Committee. "Pathways also are a way to introduce innovations into the mainstream of health care delivery."

A major factor in the success of the pathway program is the enhanced collaboration between case managers and clinical nurse specialists. Both groups work with the health care teams to ensure that care is delivered as designed by the pathway. One of their key roles is to provide education to patients and their families about their illnesses. Dottie Noyes, RN, is one example of how clinical nurse specialists can improve patient care through education, careful monitoring and guidance through the pathway program (see "Helping patients with failing hearts.").

"One of the cornerstones of the OI process has been collaboration across disciplines," says Jeanette Ives Erickson, RN, MS, senior vice president of Patient Care Services and chief nurse. "I am very proud of the way in which our nurses, social workers and therapists have played leadership roles in the OI effort and continue to develop innovative ways to enhance our patients' experience."

In the operations area, OI has had several successful initiatives that have improved patient care and streamlined efficiency. One example is the automated dictation system in Radiology (see "New systems streamline Radiology operations," in this issue), which has decreased reliance on transcriptionists and improved patient care efficiency by directing voice-activated, printed reports into the hospitalwide Patient Care Information System (PCIS).

The OI teams continue to monitor operational restructuring and examine ways to increase efficiency in areas such as lab testing, radiology and blood bank operations. Operationally, efforts are targeted to further reducing length of stay by identifying unnecessary delays in delivering patient care. Mort predicts another $6.5 million may be saved annually by further streamlining services and restructuring operations for more efficiency.

Success of OI structure
Because the OI teams include representatives from many different departments, the team structure successfully promotes enhanced interdepartmental communication among all teams. The initiative as a whole has been supported by James J. Mongan, MD, MGH president, and W. Gerald Austen, MD, president and CEO of the MGPO, who meet with team leaders quarterly.

As the director of OI, Mort works to ensure teams have necessary resources and can move forward to succeed. "I have a terrific team in the Decision Support Unit, which has supported the efforts of the OI teams, hospitalwide," says Mort.

To help support the efforts of the hospital-based and MGPO-based teams as they work collaboratively on OI projects, two steering committee chairs were appointed early in 1998 – Nicholson and James Richter, MD, medical director of the MGPO.

In addition to closely collaborating with the hospital staff on OI activities, the MGPO created the Specialty Care Management Program, which is in the process of establishing 16 multidisciplinary teams of specialists to determine a process for managing patients' care under new managed care contracts.

Led by Richter and Jeff Weilburg, MD, the Specialty Care Management teams are designed to educate staff physicians about the use of new medical management techniques such as pathways. The teams also review patient cases to identify opportunities for reducing waits and delays and improving clinical quality. "To improve the care of all patients requires a deep and broad commitment across all clinical staff," says Richter. "With Specialty Care Management teams established this year, we will enjoy even more success. We will help spread innovation across the institution and ultimately shorten length of stay and enhance patient care quality."

The Specialty Care Management teams work closely with the OI teams to ensure coordinated care of patients and overall efficiency in the management of care. "In this competitive medical environment, we must view the hospital as a valuable resource and continue to manage our patients' time in the hospital effectively," says Richter. "Clinicians should continue to plan for their patients' discharge in the beginning of the treatment process, with involvement of case management, to set realistic discharge expectations for patients."

OI moving forward
When OI was conceived in 1995, it was viewed as a three-year program. OI will continue, however, to have an important role in the hospital's future. Fortunately, the MGH is in a financially stable enough position to work carefully, thoughtfully and methodically to continue improving efficiency. With new Medicare legislation reducing reimbursement levels, continuous pressures from other payors to reduce costs and greater competition with other teaching and community hospitals, the MGH must continue streamlining to maintain a competitive edge.

"The OI strategy has worked – and continues to work – and we are looking to this effort as a way to enhance the work we do daily and help us become more productive, control costs and improve patient care," says James J. Mongan, MD, MGH president.

According to Mort, the future of OI depends on MGH staff and employees incorporating the principles of OI into their daily work. "Our future goal is to become an institution that continually works to improve patient care through collaboration and teamwork and, most of all, dedication to excellence in clinical care, service and efficiency," she says.