With 86 hospitals and numerous other care sites, it can a daunting task for Livonia, Mich.-based CHE Trinity Health to fulfill its goal of delivering the highest quality care to every patient, every time at every clinical location.
The system's clinical arm, the Unified Clinical Organization, is tasked with making this happen. According to Senior Vice President and CMO, Donald Bignotti, MD, the system develops and then implements evidence-based guidelines at all of its care sites through the UCO.
"We've had a number of areas where I think we have led the country," in terms of implementing guidelines and improving quality, Dr. Bignotti says, noting that the UCO's efforts have achieved significant results. One prime example is Trinity's Perinatal Patient Safety Initiative, which started about four years ago.
The system had been working to address complications during vaginal births after Cesarean sections. "The care there did not lead to our most proud moment," Dr. Bignotti says. "We were just not where we wanted to be as an organization" when it came to complication rates for mothers and children, Dr. Bignotti says. So, the system used the challenge as an opportunity to educate its obstetrics providers on best practices and to standardize the care not only when it came to vaginal births after C-sections, but to all prenatal practices. There were three main goals of the PPSI: to standardize treatment for vaginal births post-Cesarean section, standardize use of Pitocin in stage two of labor and to limit elective deliveries before week 39.
To implement guidelines — for the PPSI project and countless others undertaken by the UCO — CHE Trinity follows four steps, outlined below.
Step 1: Establish the burning platform. "Start by making the case," Dr. Bignotti says.
Hospital and health system officials or department leaders have to communicate to physicians why they may need to change the way they provide care. He suggests laying out the data and explaining where the system wants to be in terms of benchmarks.
Step 2: Weigh the evidence. In this step, organizations should pull evidence from various sources together and sort out any conflicting evidence that may arise.
Step 3: Develop the guidelines. After examining and sorting out the evidence, it is time to develop the guideline based on that evidence. Many times, CHE Trinity Health uses its own clinical experts to help develop these guidelines, but "if others have led the way and done the research, we do not hesitate to ask those people to assist us," Dr. Bignotti says. It is also important to allow providers in the field to weigh in during the creation process.
Step 4: Implement and give feedback. The final stage involves educating and training clinicians on the new protocols. Then, it is important to provide continual feedback to providers on how they are following the protocols, according to Dr. Bignotti. That way, the clinician knows how he or she is performing against the guidelines
By following these four steps, Trinity achieved widespread positive results. For example, prior to the implementation, 15 to 20 percent of pre-39 week deliveries in the organization's Trinity Health group were elective. Now, that number is down to 0.4 percent. Additionally, the system has not had any babies injured as a result of inability to handle a vaginal birth after a c-section.
At the end of the implementation process and when positive results start rolling in, hospitals and health systems should celebrate the success of the process with everyone involved, Dr. Bignotti says. For example, for the PPSI, leaders went back and recognized the physicians who went through the training for the guidelines. Some of the system's hospitals even took out ads in local newspapers to thank them for their work.
To further celebrate successes, members of a successful team are invited to come to other forums to share their experiences. "We take the learnings in any one area and transfer them to multiple initiatives," Dr. Bignotti explains. "This knowledge transfer can make other improvements more efficient and timely."
A note on sustainability
Though the guidelines are up-to-date when they are implemented, medicine is constantly evolving, and often the evidence-based guidelines will change as well. Taking this into account, CHE Trinity Health's UCO leverages its electronic health record capabilities in many ways. Clinical leadership regularly extracts reports from the EHR that allows them to make data-driven decisions. They also infuse the EHR with rules, processes and protocols that standardize the way care is delivered.
For example, as clinicians and researchers become aware of treatments that result in better outcomes for certain diseases or conditions, they can update the systems with the recommended protocols. By using the system to create or implement order sets, all physicians in the network can be prompted electronically and immediately on the latest evidence-based guidelines. "We use technology to provide evidence at the point of care," Dr. Bignotti says.
If large changes need to be made to the evidence-based guidelines, the UCO will put together a program to retrain or reeducate the providers as necessary.
By following the four steps, celebrating successes and leveraging technology to help its clinicians, CHE Trinity Health ensures the evidence-based guidelines are being implemented — consistently.