Standardization: Great in theory, but hard to achieve

We help health systems large and small improve their operating performance in four key areas, addressing both cost reduction and revenue enhancement. This is how we make healthcare run better.

Our featured case study focuses on improving quality by limiting variation in care. Getting everyone to practice the same way is challenging. It’s not that staff are unwilling to learn something new or act differently. It’s more about the barriers that get in their way: too many product choices and uncertainty on when and how to use them.

We helped Riverside Healthcare create a simple change model—standardized formulary, education and guidelines—all to make it easier for staff to do the right thing every time.

Across all industries, organizations of every size try to deliver a consistent consumer experience. For healthcare systems, that means:

• Providing the same care quality and experience for all patients, residents and employees
• Consistent education and training for clinicians, nurses and caregivers across all units
• All areas of an organization are working toward the same goals
• Consistency of processes, protocols and outcomes throughout the organization
• Alignment of reimbursement and financial incentives system wide

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Riverside Healthcare provides care across the continuum, functioning as an Integrated Delivery System, a Level II Trauma Center and a seven-time Truven Health 100 Top Hospital with Magnet designation from the American Nurses Credentialing Center. This large health system took a closer look at their operations with the goal of becoming more cohesive. Riverside set out to reduce care variation throughout their nursing home, home care, assisted living, rehabilitation, skilled nursing, wound center, medical group and durable medical equipment company, as well as their 318-bed community hospital.

President and CEO Phillip Kambic is an advocate of continuous improvement and embraces new ideas and innovations that will help his organization thrive. Although already an award-winning organization with strong quality metrics, Kambic enlisted Medline to help bolster Riverside’s standardization efforts. Medline worked with Riverside’s leadership team to discuss a strategic partnership project that aligned goals and demonstrated the value of a collaboration between providers and vendors.

Michael Mutterer, senior vice president and chief nursing officer at Riverside, believed the key to standardization centered on the behavior of their clinicians and caregivers. Mutterer, who was previously responsible for the system’s post-acute services, had recently taken on responsibility for all Riverside staff. Mutterer’s unique position leading both post-acute and acute teams gave him a global outlook of the care process, regardless of setting. He wanted to work on standardizing the behavior of Riverside providers as part of an effort to deliver improved, consistent care.

“As we started looking at what areas we wanted to focus on, one question we asked was, ‘Where do we find opportunities for improvement that span our continuum?’” he said. “And then we looked at which ones were the largest cost savers or cost avoidance.”

We helped Riverside take a closer look at their system’s various services and identified wound care as a significant opportunity for standardization across the system. Mutterer noted the service line was a logical area to focus on given a serious lack of standardization in products. Patients were being treated with one product line but encountered different products if they were transferred to treatment through a skilled nursing facility or home health service.

“Product variation made it difficult to educate patients on their wound care and to maintain consistent processes and outcomes throughout the continuum. As I sat back and looked at it as a consumer, not as CNO, I realized how confusing that must be for our patients,” said Mutterer.

But products weren’t the only problem. In a detailed study following patients receiving treatment for wounds throughout the system, Medline and Riverside identified inconsistencies in assessment, assessment tools, diagnosis, practice and outcomes.

We then performed a deep-rooted assessment that further revealed the stark differences in how Riverside units were approaching wounds, even in how caregivers and clinicians were bathing patients. The differences in wound care were traced back to provider education, which proved to be just as inconsistent as the products used.

This was frustrating for management, who did their best to train clinicians and caregivers in evidence-based practices. For example, the skilled nursing facility used different electronic education programs than the hospital and the home care division.

Staff were participating in online educational programs, but they were not being educated the same way throughout the system. And, the education did not include how to select or use a formulary product. “We wanted to hit the reset button,” Schiltz said. “We realized we needed to educate nurses on how to best provide wound care the same way at each level of care.”

“When we looked at the number of products we were using, it was mind-blowing,” Mutterer said. “To be honest, I didn’t have any idea the variation was to that extent.”

The use of different products at different levels of care confused patients. “Patients said they did not like the products being switched,” said Rebecca Schiltz, director of rehabilitation services at Riverside. “There was lots of anecdotal information. The more we dug in, we discovered nurses had over 100 products they could order from 15 different suppliers.”

Riverside management realized that improving product consistency across the system would not only create a better patient experience, but also a better experience for nurses. Standardization would make nurses feel more comfortable in working across the continuum of care and increase their confidence in the patient’s treatment success as they transitioned from one care setting to the next.

So, together we set out to create a product formulary to be used across the system. After reviewing all wound and skin care products used at each facility across Riverside, we determined they were able to reduce the number of unique products used across the system by more than 50%, offering a significant opportunity to reduce product costs and standardize treatments and outcomes.

Mutterer also pushed for the health system’s 12 skilled nursing partners to adopt the same practices. Even though these providers weren’t part of the Riverside Healthcare organization, they made a significant contribution to the care continuum, he noted.

Teaching standardization in wound care

Education would also be key to ensuring staff were treating patients and residents properly and consistently. “In general, most nurses are not certified in wound care,” Mutterer said. “Their training for basic wound care can vary from A to Z. Standardizing training on a standardized product line helps them feel more confident and comfortable in assessing and treating wounds.”

Implementation of a formulary created a substantial learning curve as the system had to convince clinicians and caregivers that moving to a standard line of products was good for both staff, residents and patients.

“It was rough because we were taking away products that people knew,” Schiltz said. “At first, the teams did not understand all the new products. We had to get the teams to embrace them.”

As a part of the education program, registered nurses and certified nursing assistants from select units learned a standardized method for preventing skin damage such as pressure injuries, moisture-associated skin issues and skin tears. RNs received further training on wound care and the system’s new formulary of products.

“The fact that, from the top down, all staff got trained—even aides—shows a real commitment from Riverside,” said Sue MacInnes, Medline’s Chief Market Solutions Officer. “Changing a protocol or a formulary is a process. Changing the behaviors of people means those people want to know why: ‘What do I get out of this and how does it help my patients?’ The leadership of the organization has to demonstrate both commitment and a passion for better patient care. Riverside never took their eye off the greater good for the patient and that filtered down to every staff member.”

The new training had a noticeable impact on patient satisfaction, in part because it improved treatment efficiency. For Schiltz, a major ‘aha moment’ came when, through education and changes in protocol, bedside rehabilitation nurses were empowered to triage wounds upon admission in the rehabilitation unit, instead of waiting for a specialty nurse to do so.

Medline and Riverside also devised a new, more consistent education platform for wound care patients. This was a crucial part of ensuring outcomes remained consistent even after patients were discharged from the hospital, Mutterer noted.

“Education is a means for us to teach patients to care for themselves once they leave our four walls,” he said. “Poor patient education can lead to poor outcomes.”

Faster healing

The biggest win for Schiltz came in the rehabilitation unit, where she was able to watch bedside nurses treat wounds on “day one,” which helped speed up the healing process. Because patients often come to the rehabilitation unit after major surgery, it’s a frequent provider of wound care.

“To see people go home from rehab with their wounds fully healed is amazing,” Schiltz said. “We never tried to heal before. We tried to stop them from getting worse.”

In 2015, Riverside’s wound center ranked just below the national average of 78 days to fully heal arterial ulcers. That number dropped consistently throughout 2016, and today those wounds take just 30 days to heal when treated at Riverside. Nationally, diabetic foot ulcers take an average of 86 days to heal, but Riverside’s wound center has lowered that number to 40 days. Meanwhile, Riverside is also healing venous leg ulcers faster than the national average.

Skin assessments on admission: A key component of a hospital standardization program and avoiding HAPIs

Early attention to wound issues has also helped Riverside avoid hospital-acquired pressure injuries (HAPIs). In one notable case, nurses immediately identified two patients that were discovered to have a deep tissue pressure injury (DTPI) upon admission to the rehabilitation unit. Many of these DTPI wounds develop into full-thickness pressure injuries while a patient is in the hospital and must be reported to state authorities as a HAPI. But because the newly-trained nurses identified these wounds early on in the admissions process and addressed them accordingly, they were able to prevent a reportable HAPI.

“The keen eye and awareness of the rehab staff has proven to be beneficial for Riverside,” MacInnes said. “The staff indicated that those types of wounds, prior to their training and focus on skin health, would certainly have been missed.” That’s part of the value of hospital standardization.

Increased number of wound center patients

By improving care quality, Riverside’s wound center was able to treat more patients. It produced results that demonstrate its value as a care resource and a revenue driver within the health system and the entire community:

• Wound care volume rose by 32% to 451 patients in the fiscal year 2016
• Visits to the wound care center increased by 17%

The team closed 57% more wounds in 2016 than the year before.

Reduced wound care costs

Riverside’s success can also be seen in avoided costs.

Pharmaceutical costs for debriding wounds are almost a hidden cost. The new product formulary and provider education helped bring those costs down. Riverside was able to reduce the annual cost for an enzymatic debriding agent by 71% through training staff on alternative treatments that produce similar care outcomes.

Healthcare costs related to HAPIs increase annually and are estimated to be between $44,000 and $128,000 per pressure ulcer, according to the AORN Journal. HAPIs have been reduced at Riverside as the result of provider training on proper skin assessments and early identification of skin issues during the Medline program.

“This is just one example of the staff’s knowledge and the ability to apply it to practice. Using the patient assessment skills combined with product knowledge, the staff was able to look for the best option for their patient. The staff demonstrated time and time again the value of empowerment,” said Margaret Falconio-West, Medline’s senior VP of clinical education and a member of the project team.

Nurse satisfaction

Nurses gave an overwhelming thumbs up to the transformation process. In a survey of nursing staff about Medline’s standardization program:

• 74% said they were very satisfied and 19% said they were satisfied with the education provided
• 93% said they were either very satisfied or satisfied with the Remedy Skin Care product line included in the new formulary
• 92% said they were either very satisfied or satisfied with the advanced wound care products
• 87% rated their comfort with staging a wound at three or higher on a five-point scale

It took time, persistence and patience to implement these changes and measure their impact, but the experience was necessary in order for the system to improve. “It was a lot of work,” Schiltz said. “We needed to upgrade policies, education, products. We needed to get everybody reset.”

Although product variation was a major factor in Riverside’s lack of standardization, it wasn’t the only one. The system couldn’t have accomplished its multi-faceted standardization plan without a partner that could also improve the care process.

“Medline is truly not just a product or education company,” Mutterer said. “We believe our partnership is deeper than that. Medline offers a partnership with the ability to advance our ability to treat patients. A product-only company just sends you the products.”

Standardization of any complex system isn’t easy, Mutterer noted, but it teaches executives a lot about the organization they think they know well. “Coming into the project, I believed that because we are a healthcare system we were more standardized than we actually were. It was eye-opening to me as a CNO to see how different all areas of our organization were. None were right or wrong. They were just different.”

Addressing those inconsistencies was clearly possible, but very challenging, Mutterer said. “The span of control was all within my reach. The difficulty we had was getting people to see and understand why we were doing it. We had to help people across the care process understand we were doing this for the betterment of our patients, for quality and for the continuum of healthcare in our system.”

Bill Douglas, CFO of Riverside, said measuring the success of the project wasn’t difficult because he predicts the system’s financial results based on its quality indicators, which improved. “Nonetheless, the return on investment for standardization can’t necessarily be measured on cost or quality indicators alone,” he said.

“My common sense tells me that a well-run wound care program will improve quality indicators, reduce intake, improve quality of life for the community and make physicians happier,” Douglas said. “My ROI is all of those things coming out in a positive fashion. I’m a happy CFO. I can’t put an exact dollar figure on it, but I can tell you intuitively it is huge. It’s bigger than we even believe.”