Creative solutions to patient care from top US healthcare leaders

Addressing patient care issues can be challenging for hospitals and health systems, calling for their leaders to be creative in driving quality improvement. 

Becker's Hospital Review asked some of these leaders to share a time they landed on a unique solution to a patient care issue. Read their responses below, presented alphabetically.

Note: The following responses were lightly edited for length and clarity.

Gene Barnett, MD
Director of Cleveland Clinic's Brain Tumor and Neuro-Oncology Center
Director of the Cleveland Clinic Health System Gamma Knife Center
Vice chairman of the department of neurological surgery

Despite advances in cancer care, many brain tumors have remained a challenging form of cancer to treat. We have recently made progress with some innovative strategies.

Stereotactic radiosurgery has become the mainstay for treatment of small brain metastases — tumors that spread from other cancers. Larger tumors, however, need to be treated with a lower dose of radiation than small tumors to avoid radiation injuries. Consequently, the control rate is poor using conventional radiosurgery. Some have adopted fractionated radiosurgery — where treatments are spread over three to five days, but with an additional day for planning. This can be inconvenient for patients. We adopted a two-stage technique where patients are treated with the typical dose for their larger tumor, and then come back in a month for a "boost" or second-stage treatment, bringing the total radiation dose to the equivalent of what smaller tumors are getting. We recently reviewed our results published in Journal of Neurosurgery, which showed a very high control rate and low complication rate, thereby sparing these patients the discomfort and recovery of surgery, or failure of a single-session radiosurgery treatment.

Efforts to treat difficult to access brain tumors with laser ablation — laser interstitial thermal therapy — date back to the 1990s, but the technology to make this approach successful didn't exist then.  Due to my expertise in neuro-navigation, I was approached by a startup company, Monteris Medical, in 2006 to help develop their laser ablation technology for use in humans. After considerable preclinical testing and product development, I helped design the clinical trial and was the first to use this in humans for brain tumor, ultimately leading to FDA clearance of the device. This showed the technology worked and was safe, and subsequent work by my colleague Ali Mohammadi, in cooperation with surgeons at some other centers, have shown it to be an effective treatment when the tumor undergoes a complete ablation. We were also the first to report on its use to treat radiation necrosis — a radiation injury — from stereotactic radiosurgery — now considered to be a mainstream indication for laser ablation.

Carolyn Carpenter
President of Sentara Norfolk (Va.) General Hospital

At Sentara Healthcare, we live our mission to "improve health every day." As a tertiary teaching hospital, we manage high-acuity clinical scenarios while also implementing community programs to prevent and reduce the events that lead patients to our hospital in the first place.

We see about 3,000 trauma patients annually. Over 400 of those patients have penetrating wounds — either gunshots or stabbing. It is a far too common scenario, taking a toll on the victims and our broader community's productivity and well-being.

Sentara Norfolk General Hospital recently started "community empowerment" as one of our trauma program strategic initiatives. Last fall, we gathered more than 50 community groups to discuss the problem of gun violence in our region.

In order to tackle this public health threat, we leveraged philanthropic funds and partnered with our local United Way of South Hampton Roads. One subset of our partner organization, United for Children, offers summer programs for neighborhoods with at-risk youths. We collaborated with them to sponsor four classrooms, with 60 students participating, at one of our high-risk middle schools in Norfolk. The United for Children group leads the morning program of science, technology, engineering and mathematics education. Sentara supports the curriculum and supplies for the afternoon leadership program consisting of a course that covers life skills, making smart choices, and de-escalating conflict. The course is taught by an individual who resonates with them and they trust — a member of their own community who was a victim of gun violence.

We intend to be a long-term, committed partner with the school to support the futures of our youths. We feel confident this program will have a positive and lasting impact on the health and quality of living in our community.

Phillip Chang, MD
CMO of UK HealthCare (Lexington, Ky.)

[At UK HealthCare], we started on the inpatient side, focusing on the prevention piece [of the opioid crisis]. We know a majority of patients for whom prescription opioids serve as a gateway drug. Many of them started with an inpatient experience. We observed that when I was chief of trauma and started working on minimizing opioid use in 2013.

If you think about the traditional pain management, in the acute phase, everyone gets IV morphine and then we transition to oral opioids, and then if that doesn't work, you add more opioids. If that doesn't work you add sustained release [of opioids]. If that doesn't work, somebody will come up with the idea [of], "Let's add Tylenol and ibuprofen." The other part to it is, as physicians we tend to wean [the patient] off the last thing that was added, first. So if the last thing we added was Tylenol, we wean off of Tylenol first, and then ibuprofen, and then sustained release opioids. But invariably, the patient goes home with some type of opioid.

So what we've done is we start with ibuprofen, Tylenol, maybe some kind of muscle relaxant, and then [other non-opioid treatment such as regional block, medication and alternative adjunctive treatment]. And then if none of that works, then you add opioids, and then when the patient recovers, the opioid is weaned off first because that was the last thing added. That's been tremendously effective, particularly with opioid naïve [trauma] patients [who aren't used to those medicines].

[By] match[ing] cases based on the type of injuries [patients] have, we were able to reduce the opioid prescription at the time of discharge by about 50 percent. We were able to reduce what we classified as the harmful use of opioid — or a combination of opioid and Benzodiazepine —we were able to reduce that by almost 60 percent. And we estimated we reduced the number of opioid pills dispensed by about 250,000 pills per year.

Mark Cohen, MD
CMO of Piedmont Atlanta Hospital

Piedmont Atlanta Hospital is a 500-bed tertiary referral community hospital with a case mix index among the highest in the country. Like many hospitals, we struggled with reducing Foley catheter-associated urinary tract infections. We worked with our medical staff on indications for catheter placement and on staying aware of when catheters could be removed. Despite this, our utilization remained high, and our infection rates were unacceptable. As we continued our 'Plan, Do, Check, Act' process, we realized that much of the management of catheters could be handled through protocols, allowing us to change the process from physician-driven to nurse-driven. With a urologist physician champion and front line nursing teams, we built a 'urinary retention and drainage' protocol that involves bladder scanning for retention, intermittent straight catheterizations as needed, Foley insertion only for continued inability to void, and automatic removal of the Foley in 48 hours, with appropriate checks in place for catheters that must remain, such as following prostate surgery. This represented a fundamental change, allowing the nurses to practice at the 'top of license,' and freeing the physicians from being involved in repetitive formulaic decisions. Our medical executive committee ratified the change, although with concern about cutting the doctors out of the loop.

The outcomes have been spectacular. Our Foley utilization has dropped by 75 percent. Our CAUTI rate has dropped by this much, to the point where in our last annual summary we had only six CAUTI cases total for the entire hospital. Our physicians have grown confident in the nurses' critical decision-making and knowledge that their patients are well taken care of. Some patients push back on the need for straight caths, but we explain the safety implications, and they are understanding. This case example of empowering our nurses has been a teaching moment for us on the power of thinking 'outside the box.'

Patrick Courneya, MD
Executive vice president and CMO of Kaiser Permanente (Oakland, Calif.) 

As CMO, part of my role is to help ensure that Kaiser Permanente is the best at getting better when it comes to safety, experience and quality of care. Continuous learning requires curiosity about what could be improved, as well as the creativity to develop solutions to challenges that others may not yet recognize as problems.  Seeing that happen across Kaiser Permanente is one of the most rewarding things about my work.

For example, we know that opioid overuse is a national concern, and abuse often starts in the teenage years. Additionally, prescribing codeine, an opioid, for tonsillectomies can lead to serious side effects in children. So, even before the FDA issued a black box warning, we started looking for alternatives to increase safety for our youngest and most vulnerable patients while successfully managing their pain.

A new approach, developed by a team lead by Dr. Anna Grosz, a head and neck surgeon with Northwest Permanente in Oregon, specifies the use of non-opioid painkillers, acetaminophen and ibuprofen, instead of opioids for pain management after removing tonsils. It leverages the electronic health record to encourage and facilitate non-opioid prescriptions. The care team also checks in frequently during recovery to make sure each child is comfortable and recovering well.

Within 18 months of implementing this new protocol in Kaiser Permanente's Northwest region, opioid use among pediatric patients who had a tonsillectomy decreased by 67 percent. Today, this protocol has been adopted throughout the Kaiser Permanente system with meaningful reductions in overall pediatric opioid use — accompanied by better pain control and fewer side effects.

Kim DeRoche, MD
Physician chief for Fairvew Health Services' primary care service line
Practicing family physician at Fairview (Minneapolis)

It's no secret winter weather in Minnesota can be treacherous. I like to help my patients — especially older patients — see how their home can become a simplified fitness center, so they can fit exercise into their daily lives, especially when they can't go outdoors.

A few examples of simple exercise tools I prescribe include the indoor stairs and canned food. Stair walking is a great form of exercise for people who can navigate stairs. Also, various weights of canned foods can be used for arm weights and lifting. This is especially helpful for maintaining strength and bone health.

I encourage people to use natural daily triggers to remind them to exercise twice per day. Those triggers can differ for everyone, such as prior to meal times, or when they take coffee breaks, or ahead of favorite TV shows. I also suggest similar memory triggers to serve as reminders for people to take their daily medications.  Very simple solutions can often be very helpful to one's health.

Gara Edelstein, MSN, RN
CNO of Catholic Health Services of Long Island
Senior vice president of patient services and CNO of
Good Samaritan Hospital Medical Center (West Islip, N.Y.)

Many hospitals across the U.S. experience frequent admissions and readmissions of patients with chronic diseases. Those struggling with congestive heart failure, COPD or pneumonia sometimes forget to take their medication, don't have a car or money to secure their prescriptions and may not be qualified for follow-up home care services. To address this concern, Catholic Health Services of Long Island's Good Samaritan Hospital Medical Center in West Islip ensures a patient care navigator and a pharmacist meet with each patient who has one of these diagnoses and discusses discharge needs, particularly focusing on their medication regimen. When a need is identified, patients are given a supply of medication to take home, along with extensive education about how and when to take these meds.  Dubbed "Meds to Beds," this program meets CHS's goals of ensuring patients are clinically prepared for discharge and have the appropriate medication and information they need to prevent being readmitted to the hospital.

Denise R. Linder, MSN, RN
National director of clinical quality at Catholic Health Initiatives (Englewood, Colo.)

Catholic Health Initiatives has been on a journey, like all healthcare facilities across the nation, to improve the care provided to our patients.  In order to drive to higher performance, CHI embraced the leadership construct of alignment, action and accountability to achieve year-over-year improvements.  All facilities, divisions and national are aligned to the same goals that are reported from 'single source of truth' analytics.  It is the expectation that all leaders embrace ownership and transparency of the outcomes in order to share and learn from each other across the enterprise. 

Actions to improve the outcomes are multidimensional, as the complexities in which care are provided are many.  Implementation of evidence-based practices, routine collaboratives to share improvements across the enterprise and standardization of processes to improve patient outcomes are a few of the expectations.  Monthly outcomes are published, and quarterly, senior leaders are held accountable for the outcomes by attending performance reviews where the facilities that need the most improvement share their action plans. During these performance reviews and monthly collaboratives, facilities share their work to improve outcomes. 

These learnings are then cascaded back through the organization.  One of the most creative solutions noted this past year was how CHI Health in Nebraska addressed the incidence of healthcare associated central line-associated bloodstream infections. They changed the terminology from bath to treatment to reduce patient refusal for the daily Chlorhexidine bath for patients in the intensive care with central lines.  By changing how they framed the CHG bath, the patients were receiving the best practice treatment to prevent an infection. A simple but effective change.

The art of improvement is not to overengineer or layer on interventions. Sometimes, the simplest change in how we express our work to our patients can make the biggest difference.  And funny thing: It didn't cost a thing.

Abby Metzler, MD
University of Minnesota Health neurologist and assistant professor of neurology at the University of Minnesota Medical School (Minneapolis)

As a headache specialist at a referral center, I see patients suffering from a wide variety of headache disorders daily. Many of these patients come to me for a second or third opinion or have maximized their care locally and are seeking additional resources and alternatives and require the expertise of several specialties.

In order to meet the needs of the patients, I have worked with colleagues in several departments to optimize headache care through our headache care program. A team of physicians in multiple disciplines has been developed to allow for quick and reliable consultations for patients with complex needs. In addition, we have created a multidisciplinary clinic for headache patients, allowing them to see a neurologist, physiatrist, behavioral health specialist and pharmacist in a single visit. This unique clinic has allowed the care team to be able to collaborate directly to create a plan for the patient together, and it has been well-received by patients.

Denise Mihal, BSN, RN
Executive vice president, chief nursing and clinical operations officer for Novant Health (Winston-Salem, N.C.)

To prevent unnecessary catheter-associated urinary tract infections at our facilities, Novant Health launched a multifaceted attack with bold practice changes. We locked up catheters, limited those who could insert, required a buddy, empowered nurses, held leaders accountable and instituted new training.

Necessity criteria must be documented by a house supervisor before a catheter is released for insertion by a handful of highly proficient clinicians who insert. A second set of eyes, or a "buddy," monitors the insertion, reads the steps out loud and halts the insertion if there is any break in technique.

We also empowered our nurses to allow RNs to remove catheters when no longer clinically needed and provided four hours of infection training to set foundational knowledge and validate skills of all incoming clinical team members.

Accountability for every CAUTI in our facilities is also important. All leaders, up to hospital president and CNO, report weekly to the executive team the possible cause of every CAUTI.

All of this diligence has paid off. We have created a hypervigilant culture and reduced our CAUTIs by 38 percent.

Robert S. Pugliese
Director of innovation design at Thomas Jefferson University and Jefferson Health (Philadelphia)
Director of the Health Design Lab

When saving minutes means another patient can get a life-changing surgery, where do you find minutes? Our head and neck cancer surgeons from Jefferson Health teamed up with the Jefferson Health Design Lab to find a way to cut down on the time it takes to perform reconstructive surgery while on medical missions in Haiti. For the past five years, staff at Jefferson's Department of Otolaryngology – Head and Neck Surgery have traveled to Haiti to provide complex head and neck care and education. Each of these surgeries typically takes an entire day, and staff rely on supplies they bring with them to get through these complex procedures. In partnering with the Health Design Lab, they were able to 3D-print patient-specific models of the Haitian patients' anatomy using CT scans that were mailed to the lab ahead of time. This allowed the team to better plan the procedures prior to arrival, thereby saving precious minutes and resources while in the country. As a bonus, in Haiti, the models were used as patient decision aids to help overcome language barriers and explain the upcoming procedure to the patients and families.

Joanne Roberts, MD
Senior vice president and chief value officer of Providence St. Joseph Health (Renton, Wash.)

When I practiced inpatient palliative medicine at Providence Regional Medical Center Everett (Wash.), I was called to the ICU to deal with an older woman who was ventilator-dependent due to chronic lung disease. She was terrified, as were her son and her 8-months-pregnant daughter-in-law. As the nursing team and I met with her and her family, it became apparent that she was not terrified of dying. She was terrified of dying before she met her first grandchild.

Our solution? Let's have them meet.

On a Saturday morning, we arranged for a baby shower and birthday party for the baby, complete with ultrasound so that the patient and her family could all enjoy seeing this new life who was about to enter the world at a time when her grandmother was about to leave. The ICU staff brought balloons and other decorations and made the room a place of joy and celebration. Family stories were told, and laughter was common.

Later that afternoon, the patient summoned me back to the bedside and indicated through a writing board that she was at peace, now that she has seen and celebrated her new granddaughter, and she asked to be weaned from the ventilator and be allowed to die a natural death.

With her son and daughter-in-law – and her granddaughter – at the bedside, she died peacefully after celebrating a new life.

Eric Stevens
CEO of acute care services at AdventHealth Orlando (Fla.)

The emergency department at AdventHealth Orlando sees about 300 patients per day in 45 beds, and managing the flow of traffic to best serve our patients was a real challenge that called for a creative solution.

That's why we instituted a bed traffic controller in the emergency department and re-engineered the way patients and staff are managed, with a holistic real-time perspective. The concept was developed by nursing director Lorinda Stahley, who spent time as an air traffic controller in the Army before coming to AdventHealth. Acute care teams of doctors, nurses and support staff are broken up into "pods" and the BTC manages their patient load to make sure the more severe cases are spread among the pods. The controller can also reassign staff, if because of the order cases come in, one pod gets overloaded with extremely acute cases.

The physical space in the emergency department is also configured in such a way that the more acute cases are on the interior of the building and patients who may be spending less time with us can stay on the periphery of the facility. We have scaled down exam rooms right off the lobby, where patients can be seen by a midlevel provider quickly, so they can be seen and discharged quickly or moved into a more interior area for more prolonged care.

The results have been remarkable. We have met or exceeded the standard metrics for 15 months in a row and exceeded EMS offload metrics for three consecutive years.

One of AdventHealth's service standards is to "make it easy," and that includes innovating and continually seeking ways to improve patient care.


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