The chart below is a summary of how Christiana Care answered six key questions for reducing unwarranted care variation.
How Christiana Care reduced unwarranted variation in stroke care
CVR helped Christiana Care increase compliance with stroke care guidelines, improve quality performance, and reduce waste through the reduction of duplicative imaging.
January 13, 2021
20 Minute Read
In 2015, Christiana Care transitioned their clinical governance from a hospital department model to a system wide service line model to prepare for value based care. In 2016, they launched a care pathways initiative to optimize patient outcomes, enhance financial viability, and improve patient, provider, and staff experience. Stroke was one of the conditions with opportunity to reduce unwarranted care variation.
Christiana Care is a two hospital system based in Wilmington, Delaware, with a large integrated network of 1,500 providers, including 500 employed providers. The main hospital has over 900 beds and was ranked 22nd in the nation for inpatient volume in 2017.
By addressing six strategic questions about care standardization, Christina Care was able to update their stroke care guidelines to meet the standards set by the Joint Commission for comprehensive stroke centers, while also eliminating duplicative imaging, ensuring appropriate specialist follow up, and improving efficiency of patient rounding.
Through their CVR efforts, Christiana care was able to increase adherence for best practice guidelines for stroke treatment and reduce the rate of duplicate imaging from 13% to 5%.
As a designated comprehensive stroke center, Christiana Care’s neurosciences service line was primed for CVR. They had a robust data and reporting infrastructure and a team already committed to continuous improvement. In addition, the service line employed 1.5 FTE experienced advanced practice registered nurse (APRN) stroke coordinators to help with CVR.
Beyond the service line, Christiana Care offers a service called Carelink CareNow, which provides cross continuum care management services, including post discharge follow up.
Care settings tackled in stroke CVR initiative
Ultimately, Christiana Care scoped their stroke initiative broadly to include the inpatient acute episode, including treatment in the ED and continuity of care across all hospital departments. The established Carelink CareNow service allowed the stroke CVR team to exclude post acute care.
Christiana Care selected components that wouldn’t generate controversy. The team started with widely accepted stroke care guidelines: AHA/ASA guidelines for the early management of patients with acute ischemic stroke and Joint Commission comprehensive stroke center measures.
Then they added a few additional components that were easy for clinicians to support: eliminate unnecessary duplicate imaging, ensure appropriate specialist follow up, and improve efficiency of patient rounding. All three focus on optimal use of limited resources.
Christiana Care then determined what resources were needed to help providers translate new stroke care clinical specifications into practice. The table at right summarizes the enablers Christiana Care put in place to support their new care standards. “Enablers” are people, processes, and technologies that make it easier for frontline clinicians to comply with standards.
Christiana Care utilized people and process enablers when prudent, but leaned most heavily on technology.
PowerPlan facilitates compliance with stroke guidelines
Christiana Care’s first enabler to ensure compliance with guidelines is a stroke PowerPlan. They made the stroke PowerPlan easy for physicians to find by embedding it as a subplan in the hospitalists’ admissions order set.
Coordinator ensures all stroke patients are on PowerPlan
The second enabler to ensure compliance is the APRN stroke coordinator. The coordinator monitors stroke patients to ensure that care standards are followed. A “stroke patient” indicator in the chart helps coordinators filter and follow all stroke patients, even when housed outside of the designated stroke unit.
Stroke coordinators also identify potential stroke patients who are not yet on the PowerPlan. Christiana Care designed a surveillance trigger to flag charts with symptoms such as weakness, aphasia, and facial droop. Stroke coordinators then meet with physicians to decide whether the stroke PowerPlan is appropriate.
Pop-up alert warns against duplicate imaging orders
The enabler that Christiana Care built to reduce duplicate imaging was simple an alert that pops up if a similar imaging order has been placed within the last 30 days. After introducing the alert, duplicative orders dropped precipitously, lowering costs and creating imaging machine capacity for other patients. This is because the typical root cause of duplicate imaging orders is simply providers’ lack of awareness that the requested image is already available.
Discharge form ensures appropriate follow-up
Christiana Care’s enabler to support appropriate specialist follow up is an electronic stroke discharge form. The tech team embedded a point and click form in neurologists’ discharge workflow. The form requires the neurologist to indicate whether a post discharge neurology or physiatry consult is warranted. If so, a system generated follow up request email is sent to outpatient scheduling and then their staff schedules the required follow up with an appropriate specialist. Absent this indication, patients are scheduled to see a primary care physician (PCP).
Prior to implementing the point and click form, scheduling instructions were less specific and manually entered. The schedulers defaulted to making appointments with specialists even if a PCP could provide appropriate follow up for many patients.
Rounding tool makes relevant data more accessible
The enabler that Christiana Care built to support interdisciplinary rounding was a custom designed patient centered rounding tool. The rounding tool automatically pulls information from various source systems into one easy to interpret screen. Now rounding runs smoothly, and clinicians can access all the information they need right at their fingertips. This tool was highlighted as best practice by the Joint Commission and recommended for other stroke centers.
Keep rounds on track with a script
The stroke team developed an additional enabler to enhance the efficacy of interdisciplinary rounds. The stroke patient rounding script clarifies roles, responsibilities, and sequence to prevent confusion, inconsistency, and unnecessary delays.
The script also improves patient centered care by prompting conversation about patient and family concerns, and clarifies the anticipated discharge date and destination. More predictable rounds also improve timely discharge. Rounds are now consistently held mid morning to facilitate same-day discharge.
Christiana Care chose to capitalize on their small size and leverage peer to peer relationships as the primary communication approach. Liaisons from each discipline engaged in the stroke CVR work educated their peers on new standards. This approach was particularly effective given the breadth of specialties represented on the stroke CVR team, including neurologists, therapists, hospitalists, ED physicians, and nurses.
Christiana Care uses technology and peer pressure to ensure everyone is on board with the new standard and reinforce adherence.
A core measure compliance audit tool pulls data from the EHR in near real time, with only a five hour data lag. The audit tool’s color coded grid design allows coordinators to quickly identify gaps in care. Green indicates that the requirement has been met. Red indicates failure to meet a measure or missing documentation. Pink reflects an unsatisfied measure that still has time on the clock. This safety net confirms that all patients receive “perfect stroke care” while still in house.
If a stroke patient is discharged without following the stroke PowerPlan, the stroke coordinator emails the noncompliant provider. The email explains the rationale behind the stroke care standards and encourages the provider to use the PowerPlan for future stroke patients.
Christiana Care uses multiple measurement tools to understand the clinical and financial impacts of their new standards. Three are listed below.
Most of these tools are required for Joint Commission comprehensive stroke center accreditation and existed before Christiana Care’s CVR initiative. Christiana Care was already monitoring the metrics they hope to inflect through CVR. Moving forward, Christiana Care plans to enhance reporting capabilities to more accurately measure the stroke pathway’s impact on variable costs of care.
Stroke was among Christiana Care’s first CVR projects. The organization’sexperience helped executives identify where they wanted to better support service line leaders through centralized resources.
Initially, each service line relied largely on their own resources. After auditing early CVR projects, system leaders found that many service lines lacked core CVR skills like project management and data analysis.
To remedy this, the system created an in house consulting group called the Pathway Integration Team (PIT). The PIT offers CVR consulting and cross department liaison services. Their consulting support includes project management or project management training, data analysis, and current and future state workflow mapping. On the liaison side of things, the PIT connects pathway teams with IT to build EHR tools, learning and development to create education content, and the health disparities department for culturally appropriate communication guidance.
The PIT also created a central repository of tools for service line CVR teams to use. These include learning modules, videos, templates, and tools to help teams at each stage of the CVR process.
Christiana Care’s stroke outcomes after CVR initiative
Christiana Care used CVR to tackle both care quality and cost. Their focus on cost containment and cutting waste is reflected in their reduction of duplicate imaging. Additionally, they’ve shown strong quality performance driven by adherence to best practice guidelines for stroke treatment. Of more than 2,000 stroke patients treated annually, 98% meet the high bar for quality set by the Joint Commission for comprehensive stroke centers.
Reduction in duplicate imaging order rates (13% to 5%)
Of stroke patients received care consistent with all
Joint Commission core measures
Stroke PowerPlan adherence across the health system