What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Academic Medical Center?

Crew Resource Management (CRM) training has been used successfully within hospital units to improve quality and safety. This article presents a description of a health system-wide implementation of CRM focusing on the return on investment (ROI). The costs included training, programmatic fixed costs, time away from work, and leadership time. Cost savings were calculated based on the reduction in avoidable adverse events and cost estimates from the literature. Between July 2010 and July 2013, roughly 3000 health system employees across 12 areas were trained, costing $3.6 million. The total number of adverse events avoided was 735-a 25.7% reduction in observed relative to expected events. Savings ranged from a conservative estimate of $12.6 million to as much as $28.0 million. Therefore, the overall ROI for CRM training was in the range of $9.1 to $24.4 million. CRM presents a financially viable way to systematically organize for quality improvement.

What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Academic Medical Center?

Crew Resource Management (CRM) training has been used successfully within hospital units to improve quality and safety. This article presents a description of a health system-wide implementation of CRM focusing on the return on investment (ROI). The costs included training, programmatic fixed costs, time away from work, and leadership time. Cost savings were calculated based on the reduction in avoidable adverse events and cost estimates from the literature. Between July 2010 and July 2013, roughly 3000 health system employees across 12 areas were trained, costing $3.6 million. The total number of adverse events avoided was 735-a 25.7% reduction in observed relative to expected events. Savings ranged from a conservative estimate of $12.6 million to as much as $28.0 million. Therefore, the overall ROI for CRM training was in the range of $9.1 to $24.4 million. CRM presents a financially viable way to systematically organize for quality improvement.

The journey from precontemplation to action: Transitioning between electronic medical record systems.

BACKGROUND: Health care organizations, in response to federal programs, have sought to identify electronic medical record (EMR) strategies that align well with their visions for success. Little exists in the literature discussing the transition from one EMR strategy to another. PURPOSE: The analysis and planning process used by a major academic medical center in its journey to adopt a new strategy was described in this study. We use the transtheoretical model of change to frame the five phases through which the organization transitioned from a best-of-breed system to an enterprise system. METHODOLOGY/APPROACH: We explore the five phases of change from the perspective of a maturing approach to new technology adoption. Data collection included archival retrieval and review as well as interviews with key stakeholders. FINDINGS: Although there was always a focus on some enterprise capabilities such as computerized physician order entry, the emphasis on EMR selection tended to be driven by specialty requirements. Focusing on the patient across the continuum of care, as opposed to focusing on excessive requirements by clinical specialties, was essential in forming and deploying a vision for the new EMR. PRACTICE IMPLICATIONS: This research outlines a successful pathway used by an organization that had invested heavily in EMR technology and was faced with evaluating whether to continue that investment or start with a new platform. Rather than focusing on the technology alone, efforts to reframe the discussion to one that focused on the patient resulted in less resistance to change.

Diagnosis-specific readmission risk prediction using electronic health data: a retrospective cohort study.

BACKGROUND: Readmissions after hospital discharge are a common occurrence and are costly for both hospitals and patients. Previous attempts to create universal risk prediction models for readmission have not met with success. In this study we leveraged a comprehensive electronic health record to create readmission-risk models that were institution- and patient- specific in an attempt to improve our ability to predict readmission. METHODS: This is a retrospective cohort study performed at a large midwestern tertiary care medical center. All patients with a primary discharge diagnosis of congestive heart failure, acute myocardial infarction or pneumonia over a two-year time period were included in the analysis.The main outcome was 30-day readmission. Demographic, comorbidity, laboratory, and medication data were collected on all patients from a comprehensive information warehouse. Using multivariable analysis with stepwise removal we created three risk disease-specific risk prediction models and a combined model. These models were then validated on separate cohorts. RESULTS: 3572 patients were included in the derivation cohort. Overall there was a 16.2% readmission rate. The acute myocardial infarction and pneumonia readmission-risk models performed well on a random sample validation cohort (AUC range 0.73 to 0.76) but less well on a historical validation cohort (AUC 0.66 for both). The congestive heart failure model performed poorly on both validation cohorts (AUC 0.63 and 0.64). CONCLUSIONS: The readmission-risk models for acute myocardial infarction and pneumonia validated well on a contemporary cohort, but not as well on a historical cohort, suggesting that models such as these need to be continuously trained and adjusted to respond to local trends. The poor performance of the congestive heart failure model may suggest that for chronic disease conditions social and behavioral variables are of greater importance and improved documentation of these variables within the electronic health record should be encouraged.

Infection control link nurse program: an interdisciplinary approach in targeting health care-acquired infection.

BACKGROUND: We describe a successful interdisciplinary liaison program that effectively reduced health care-acquired (HCA), methicillin-resistant Staphylococcus aureus (MRSA) in a university hospital setting. METHODS: Baseline was from January 2006 to March 2008, and intervention period was April 2008 to September 2009. Staff nurses were trained to be liaisons (link nurses) to infection prevention (IP) personnel with clearly defined goals assigned and with ongoing monthly education. HCA-MRSA incidence per 1,000 patient-days (PD) was compared between baseline and intervention period along with total and non-HCA-MRSA, HCA and non-HCA-MRSA bacteremia, and hand soap/sanitizer usage. Hand hygiene compliance was assessed. RESULTS: A reduction in MRSA rates was as follows in intervention period compared with baseline: HCA-MRSA decreased by 28% from 0.92 to 0.67 cases per 1,000 PD (incidence rate ratio, 0.72; 95% confidence interval: 0.62-0.83, P < .001), and HCA-MRSA bacteremia rate was reduced by 41% from 0.18 to 0.10 per 1,000 PD (incidence rate ratio, 0.59; 95% confidence interval: 0.42-0.84, P = .003). Total MRSA rate and MRSA bacteremia rate also showed significant reduction with nonsignificant reductions in overall non-HCA-MRSA and non-HCA-MRSA bacteremia. Hand soap/sanitizer usage and compliance with hand hygiene also increased significantly during IP. CONCLUSION: Link nurse program effectively reduced HCA-MRSA. Goal-defined metrics with ongoing re-education for the nurses by IP personnel helped drive these results.

Development and assessment of quality improvement education for medical students at The Ohio State University Medical Center.

This study tested the feasibility of a quality improvement (QI) program that provided first and second year medical students with education in QI processes and demonstrate their utility within the framework of a real-world QI project. Medical students assessed the use of the Surgical Safety Checklist at The Ohio State University Medical Center. Before performing audits students were required to complete a self-paced online program that provided preliminary education in QI, patient safety, leadership, teamwork, and patient-centered care. A 2.5-hr orientation introduced basic operating room protocol, and the surgical checklist audit tool. Orientation included a multimedia simulation of checklist usage and a role-playing exercise simulating its use. Students completed pre- and postparticipation assessments. Results included an increased knowledge of QI methodology, an improved understanding of the evidence supporting the need for QI projects within health systems, and a greater awareness of available QI projects. Students' perspectives changed to indicate an increased belief that QI is the responsibility of all health professionals including physicians, administrators and other staff. This study concluded that QI education can be effectively disseminated to medical students early in their education using existing online tools and experiential QI projects, and can result in actionable QI data supporting hospital improvement initiatives.

Developing a multidisciplinary robotic surgery quality assessment program.

The objective of this study was to test the feasibility of a novel quality-improvement (QI) program designed to incorporate multiple robotic surgical sub-specialties in one health care system. A robotic surgery quality assessment program was developed by The Ohio State University College of Medicine (OSUMC) in conjunction with The Ohio State University Medical Center Quality Improvement and Operations Department. A retrospective review of cases was performed using data interrogated from the OSUMC Information Warehouse from January 2007 through August 2009. Robotic surgery cases (n=2200) were assessed for operative times, length of stay (LOS), conversions, returns to surgery, readmissions and cancellations as potential quality indicators. An actionable and reproducible framework for the quality measurement and assessment of a multidisciplinary and interdepartmental robotic surgery program was successfully completed demonstrating areas for improvement opportunities. This report supports that standard quality indicators can be applied to multiple specialties within a health care system to develop a useful quality tracking and assessment tool in the highly specialized area of robotic surgery.

Information warehouse - a comprehensive informatics platform for business, clinical, and research applications.

Since its inception in 1997, the IW (Information Warehouse) at the Ohio State University Medical Center (OSUMC) has gradually transformed itself from a single purpose business decision support system to a comprehensive informatics platform supporting basic, clinical, and translational research. The IW today is the combination of four integrated components: a clinical data repository containing over a million patients; a research data repository housing various research specific data; an application development platform for building business and research enabling applications; a business intelligence environment assisting in reporting in all function areas. The IW is structured and encoded using standard terminologies such as SNOMED-CT, ICD, and CPT. The IW is an important component of OSUMC's Clinical and Translational Science Award (CTSA) informatics program.

Reversal of neurological deficit after chemotherapy in BCL-6-positive neurolymphomatosis. Case report.

Neurolymphomatosis, the infiltration of the peripheral nervous system (PNS) by malignant lymphatic cells, is a rare condition whose prognosis and treatment are not fully characterized. The authors report the case of a 69-year-old, previously healthy man who had a 1-month history of progressive pain in his right arm and associated weakness of several muscles of the right upper extremity when they first examined him. Initial MR imaging of the right brachial plexus showed no abnormalities, but over 3 months, symptoms gradually progressed to almost complete plegia of his right upper extremity. Subsequent MR imaging of his right brachial plexus showed an enhancing mass of the posterior cord of the plexus that encroached on the other cords. Positron emission tomography confirmed the presence of a hypermetabolic lesion in the right axillary region and also detected an asymptomatic hot spot in the gastric wall. Biopsy of the gastric lesion demonstrated a CD20+, diffuse large B-cell lymphoma that was immunohistochemically positive for BCL-6 and negative for p16. The patient underwent 6 cycles of dose-adjusted etoposide-vincristine-doxorubicin-cyclophosphamide-prednisone (EPOCH) and rituximab, intermixed with 3 cycles of high-dose intravenous and intrathecal methotrexate, and followed by 6 monthly doses of rituximab for consolidation. Follow-up MR imaging and PET of the plexus showed complete radiological response after 3 months of treatment, as demonstrated by normalization of brachial plexus caliber, contrast enhancement, and metabolic activity. Twenty-eight months after symptom onset and 20 months after beginning therapy, the patient was disease-free, had recovered most upper extremity neurological function, and had only minimal remaining weakness of the right wrist and finger extension.

Integrating systems requires balancing act.

A Web-based patient record system at The Ohio State University Medical Center dramatically speeds up interactions with referring physicians.

Predicting patient volume in cardiac catheterization laboratory to improve resource management.

Using historical data within the Information Warehouse of the Ohio State University Medical Center, prediction on daily patient volume to catheterization laboratory was attempted to facilitate resource management and planning.

Identification of potential surgical site infections leveraging an enterprise clinical information warehouse.

At The Ohio State University Medical Center (OSUMC), infection control practitioners (ICPs) need an accurate list of patients undergoing defined operative procedures to track surgical site infections. Using data from the OSUMC Information Warehouse (IW), we have created an automated report detailing required data. This report also displays associated surgical and pathology text or dictated reports providing additional information to the ICPs.

A comparative analysis of the dissemination of best practice measures for key populations.

In collaboration with the department of Quality and Operations Improvement, Clinical Applications and the Information Warehouse, we have leveraged available Information Warehouse data to build a Best Practice Compliance Measurement Dashboard. This tool combines information from our operating room charting system, our order entry system and coding information from the patient billing and management system to provide 'previous day', data on a patients current course of treatment.

ICD9 Code Assistant: A prototype.

At The Ohio State University Medical Center (OSUMC) patient reports are available in real time along with other clinical and financial data in the OSUMC Information Warehouse (IW). Using the UMLS Meta Thesaurus we have leveraged the IW to develop a tool that can assist the medical record coders as well as administrators, physicians and researchers to quickly identify clinical concepts and their associated ICD-9 codes.

Using data mining tools to discover novel clinical laboratory test batteries.

Using statistical analysis and data mining tools, we examined possible associations among clinical laboratory orders placed at the Ohio State University Medical Center between January and October of 2006. Upon applying the Frequent Itemset data mining technique to this data set, the results indicated that, while the most frequently ordered battery of tests was not associated with others, some highly associated orders may be good candidates to comprise new test batteries.

Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients.

BACKGROUND: Critically ill patients require rapid care, yet they are also at risk for morbidity from the potential complications of that care. Computerized physician order entry (CPOE) is advocated as a tool to reduce medical errors, improve the efficiency of healthcare delivery, and improve outcomes. Little is known regarding the essential attributes of CPOE in the intensive care unit (ICU). OBJECTIVE: To assess the effect of CPOE on ICU patient care. DESIGN: Retrospective before and after cohort study. SETTING: An academic ICU. PATIENTS: Patients admitted to the ICU during use of the initial CPOE application and those admitted after its modification. INTERVENTIONS: Comprehensive order interface redesign improving clarity, specificity, and efficiency. MEASUREMENTS: Orders for complex ICU care were compared between the two groups. In addition, the use of higher-efficiency CPOE order paths was tracked. RESULTS: Patients treated with both the initial and modified CPOE system were similar for all measured characteristics. With the modified CPOE system, there were significant reductions in orders for vasoactive infusions, sedative infusions, and ventilator management. There was also a significant increase in orders executed through ICU-specific order sets after system modifications. LIMITATIONS: This retrospective study cannot assess issues related to learner expertise and is meant to only suggest the importance of developing CPOE systems that are appropriate for specialty care environments. CONCLUSION: Appropriate CPOE applications can improve the efficiency of care for critically ill patients. The workflow requirements of individual units must be analyzed before technologies like CPOE can be properly developed and implemented.

Using an information warehouse to screen patients for clinical trials: a prototype.

Success of a clinical trial recruitment process for drug discovery and new treatments depends on screening and identifying eligible patients in a timely manner. This can be a complex and tedious process that in many instances requires a research nurse to manually track patients that may be eligible. At the Ohio State University Medical Center (OSUMC) we have developed a web-based functional prototype that uses the data stored in the Information Warehouse (IW) to screen patients that meet the eligibility criteria for clinical trials. Using this prototype, a researcher can apply a set of inclusion/exclusion criteria pertinent to a research protocol and instantly find patients that may qualify for the clinical trial without revealing their identity. A researcher has access to all detailed historical clinical information such as lab results, diagnosis codes, pathology reports and clinical notes.

Impact of computerized physician order entry on clinical practice in a newborn intensive care unit.

OBJECTIVE: To study the impact of computerized physician order entry (CPOE) on selected neonatal intensive care unit (NICU) practices. DESIGN: Retrospective review. SETTING: Nursing units in an academic health system where CPOE has been implemented in adult services since 2000 and in the NICU since 2002. STUDY POPULATION: Data from 111 very-low-birth-weight (VLBW) infants born consecutively within 6 months before and 100 VLBW infants born within 6 months after the implementation of CPOE were evaluated. The study is based on pre- and post-CPOE comparisons in medication error rates and on the initiation to completion time intervals for pharmacy orders and radiology procedures. The specific data subsets that were compared included caffeine and gentamicin. Radiology turn-around time (order to image display) for the first chest and abdominal X-ray taken following endotracheal intubation and/or umbilical catheter placement was studied. RESULTS: Statistically significant (p<0.01) reductions were seen in medication turn-around times for the loading dose of caffeine in pre-CPOE (n=41, mean 10.5+/-9.8 SD hours) and post-CPOE (n=48, mean 2.8+/-3.3 SD hours). After CPOE implementation, the percentage of cases during each period where caffeine was administered before 2 and 3 hours increased from 10 to 35% and 12 to 63%, respectively. Accuracy of gentamicin dose at the time of admission for 105 (pre-CPOE) and 92 (post-CPOE) VLBW infants was determined. In the pre-CPOE period, 5% overdosages, 8% underdosages, and 87% correct dosages were identified. In the post-CPOE, no medication errors occurred. Accuracy of gentamicin dosages during hospitalization at the time of suspected late-onset sepsis for 31 pre- and 28 post-CPOE VLBW infants was studied. Gentamicin dose was calculated incorrectly in two of 31 (6%) pre-CPOE infants. No such errors were noted in the post-CPOE period. Radiology response time decreased significantly from the pre-CPOE (n=107, mean 42+/-12 SD minutes) to post-CPOE (n=95, mean 32+/-16 SD minutes). CONCLUSION: The implementation of CPOE in our NICU resulted in a significant reduction in medication turn-around times and medication errors for selected drugs, and a decrease in ancillary service (radiology) response time. In spite of the complexities of medication orders in pediatric populations, commercially available software programs for CPOE can successfully be adjusted to accommodate NICU needs and to beneficially impact clinical practice.

Development of a Web-based event reporting system in an academic environment.

In pursuit of a strategy for patient safety and error reduction, The Ohio State University Health System developed and implemented a standardized voluntary event reporting system. The Web-based application is user friendly as well as context-sensitive and encompasses a broad range of errors, events, and near misses. A full organizational transformation was required to effectively implement the system, which involved process reengineering for event entry and for postentry automated workflows. This system serves as the foundation for efficient and consistent reporting processes, which are essential for encouraging a culture of commitment to patient safety.