A Collaborative Model for Hospital-Based Cardiovascular Secondary Prevention

This article presents a collaborative model for hospital-based cardiovascular secondary prevention. The model employs a stake holder consortium to provide hospitals with a unified approach to improve care and conform to regulatory requirements. Hospital teams use a Web-based tool that embeds data collection in the process of care and supports rapid cycle improvement. Recognition of participation and achievement by the American Heart Association helps to obtain administrative support for the program.

Despite well-defined guidelines for secondary prevention of cardiovascular disease published by the American Heart Association (AHA) and the American College of Cardiology (ACC) in 1995 and recently updated,¹ there are considerable data to demonstrate that many patients with acute coronary syndromes leave the hospital without these evidence-based therapies.^2,3 Evidence from the outpatient arena demonstrates that even when knowledge and intention to treat elevated cholesterol levels are present in 95 percent of physicians questioned, chart abstraction from their patients demonstrates that low-density lipoprotein cholesterol is at goal only 18 percent of the time.⁴ This dichotomy between knowledge and intention on the one hand and practice behavior on the other suggests that a change in systems of care rather than more education is needed to improve performance.⁵

The AHA's Get with the Guidelines (GWTG) program is designed to address this need by providing hospitals with a turnkey solution to quality improvement in cardiovascular care. The program conforms to the AHA/ACC Secondary Prevention Guidelines, the Centers for Medicare & Medicaid Services (CMS) performance measures for acute myocardial infarction and congestive heart failure, and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)-ORYX core measures for these conditions. The model for this program is a hybrid collaboration and consultation model based on the Breakthrough Series of the Institute for Healthcare Improvement (IHI).⁶ Because the program is based on a set of already developed guidelines,¹ AHA staff and volunteers provide consultation related to the guidelines' science and clinical issues. The program features an Internet-based point of service data collection tool that is used both for reminders in real time and for feedback to hospitals to track their own performance and to compare their data to aggregate data from the entire project or a large group of similar hospitals.⁷

The model and tools were developed and tested in 24 Massachusetts hospitals in the initial pilot.⁸ After demonstrating the ability to achieve breakthrough change, the program was refined in a beta test market in Southern California and is now undergoing a phased national rollout.

Components of the program include (Table 1):

Table 1

1. Organizational stake holder meetings to build consensus and create a common approach in each state by developing buy-in from organizations interested in promoting quality improvement in hospital based secondary prevention.

2. Identification of key cardiovascular opinion leaders in each community to advocate for program.

3. Recruitment of hospitals to participate with multidisciplinary teams.

4. Continuing Medical Education (CME)-based learning sessions, which include didactic, science-based sessions, best practice presentations, interactive, collaborative workshops, individual hospital team planning sessions, and poster sessions.

5. Program follow-up via E-mail and telephone consultation.

6. Monthly conference calls for hospital teams, including guest speakers and interhospital collaboration.

7. Ongoing, real-time feedback of hospital performance to support rapid cycle improvement.

Stake Holder Meetings

There are frequently a number of organizations working with hospitals to improve cardiovascular care. These projects often include data collection for some of the AHA guideline recommended treatments. Typically the Quality Improvement Organization (QIO), state hospital association, state health department, and various professional groups have run improvement programs. Although the goal is to improve care, these programs are often more limited in the scope of improvements sought and tend to compete with each other for hospital attention and resources. This is particularly true when multiple data collection tools are in use. Experience with multiple organizations locally and with parent national organizations has demonstrated a willingness to join forces with the AHA to create a common goal and optimize resource utilization by hospitals in pursuing quality improvement. This top-down approach with national organizations such as the CMS, the Centers for Disease Control and Prevention, the AHA, the ACC, and several large hospital networks has helped to promote additional focus on consensus at the state level.

The key elements on the state level are perceived benefits to organizational collaboration, which include the ability to recruit more hospitals, to be more comprehensive in cardiovascular secondary prevention, and to increase the willingness of hospitals to agree to share hospital-level data with appropriate collaborating organizations. In Massachusetts, the Massachusetts Secondary Prevention Partnership, and in California, the California GWTG Consortium became influential groups to support the program and advocate for change.

Opinion Leader Consensus Meetings

Local AHA divisions, QIOs, and other organizations identify individuals who are influential and well-respected in the community. A meeting of these individuals is then held in which the basics of the program are presented, including statewide or communitywide performance data. The evidence base and current performance enhancement opportunities are translated into lives saved and care improved at the local level. Because the AHA/ACC Secondary Prevention Guidelines are evidence-based and widely supported, the role of the opinion leaders is to disseminate the guidelines to front-line practitioners and set the stage for change.⁹ A facilitated discussion then seeks to obtain support for the program. Each individual is asked to personally commit themselves and their hospitals to the program and to influence others to participate. A specific implementation plan is developed in the meeting to create ownership by the group. A few hospitals ready for change and represented by key opinion leaders are encouraged to be early adopters. As these hospitals develop success, they can become the best practice hospitals for others to emulate, creating a sense that, If they can do it, I can do it.

Hospital Recruitment

Hospitals are recruited for local implementation by invitations sent to senior leaders (chief executive officer, chief operating officer), clinical leadership (director of nursing, vice president for medical affairs, and chiefs of cardiology and cardiovascular surgery), and the quality improvement staff. When these letters have referred to the consortia of the AHA with multiple state groups, coupled with the influence of local opinion leaders, including active AHA volunteers in hospitals and the communities they serve, attendance at meetings has been high. We have also explicitly identified the business case for the program as part of this process. The ability to collect JCAHO Core Measures in acute myocardial infarction and heart failure is a significant advantage of program participation. AHA recognition (see the following section) has been cited by many hospital leaders as an important marketing opportunity and helps to build support. Hospitals are asked to build teams that may include physician champions, care managers, pharmacists, quality improvement directors, cardiac rehabilitation directors, and nurse managers in appropriate clinical areas.

GWTG CME Meetings

The meeting agenda includes a welcome by AHA volunteers and recognition of supporting organizations. A review of the recently updated secondary prevention guideline is then presented. It should be emphasized that the didactic, traditional CME part of the program is a review of the science and forms the background for what is to follow. The package for change is presented, including the specific data points collected based on the guidelines. The change package includes CMS and JCAHO measures for acute myocardial infarction and heart failure is explicitly reviewed and helps to provide the business case for support. It is clearly articulated that the presence of guidelines is not sufficient for their implementation.⁹ The major emphasis of the program is not on the what to do, but on the how to do it. A discussion of the step-by-step implementation process in the hospital is followed by a best practice example.

Best practice presentations allow early adopters to present initial results and discuss barriers to implementation with a demonstration of solutions. The ability to be positioned as leaders among their peers provides incentive and rewards for these early adopters and helps create momentum in the community. In an environment without early adopters, successful hospitals from other areas can share their experiences to create that sense that the project is doable.

The Patient Management Tool (Outcome Sciences, Inc., Boston, MA) is introduced in this meeting. The tool provides easy entry via the Internet and can be completed with 25 clicks. Drop-down screens provide guidelines summaries for each risk determination and intervention on demand. When the form is completed, a final check guidelines screen prompts the health care professional to correct omissions before the patient leaves the hospital. A risk and intervention summary is automatically generated and can be printed and given to the patient as part of patient education and can be used to facilitate the completion of other required forms and summaries. A summary letter is generated with a single click and can be faxed centrally to the referring physician for outpatient continuity of care. The reminders and ease of collecting data prospectively with point-and-click technology has become a solution to many of the initial barriers envisioned by the hospital teams.

The interactive workshops are typically composed of five to six hospital teams of from five to seven members. Each group is lead by a facilitator with prior experience in hospital implementation. At the outset of the workshop, each team leader introduces the members of the teams and provides the group with information about hospital characteristics and current status of implementation of the guidelines. A discussion of barriers to implementation with potential solutions allows for interaction between participants and establishes the collaborative nature of the program. Typical barriers to implementation have been described by Cabana and colleagues¹⁰ and are typically heard in each of our sessions. Physician-related issues include lack of awareness or lack of agreement with specific guidelines or lack of agreement with guidelines in general. This often results in resistance to the use of preprinted orders and reminders. Lack of motivation to change and lack of belief that guidelines can be implemented are also common. The creation of system changes such as checkoffs and preprinted orders to lessen physician time and minimize the need to rely on memory are often sited as solutions. Some institutions have framed guideline implementation as a patient safety issue of omission to leverage physician buy-in.¹¹ The most common areas of concern are environmental factors including lack of time, resources, and organizational support. The recent development of JCAHO core measures creating the need to collect data for accreditation and the ease of using the prospective Web-based patient management tool help to address these issues. Our experience, explicitly shared with the participants, is that collectively hospital teams are the best source of expertise about the day-to-day barriers. Frequently, otherwise competitive hospitals have been willing to share solution with their neighbors when addressing the basic care that all patients should receive.

Hospital teams then meet individually to develop a specific implementation plan for their hospital, to start on the next Monday morning. This sense of urgency is communicated throughout the meeting and reinforced at the end of the workshop. After producing a written plan, each hospital team shares its plan with the other hospital teams in the session. This serves to create significant peer pressure to follow through on their intentions. In one recent workshop the teams displayed this sense of urgency as they sequentially presented their hospital action plans. The first team indicated that a first meeting was planned for the end of the following week, the second team planned to start midweek, and the third team on Monday morning. Not to be outdone, the next physician champion held up his Palm devise equipped with E-mail capability and indicated his team had already started to implement their plan!

After Meeting Follow-Up

After the meeting hospitals receive information, demonstrations, and training for the use of the Patient Management Tool. Communication with the AHA regional directors for quality improvement occurs via E-mail and as needed by telephone consultation. Presentations by AHA volunteers and local champions to assist with buy-in from the hospital staff are also arranged when needed.

Monthly conference calls are initiated for meeting participants. The calls include a brief presentation by an expert in a specific area as determined by hospital needs. Some past topics include a review of the update of the Secondary Prevention Guidelines, hospital-based smoking cessation programs, and the use of prospective data collection to reach perfect performance.

Rapid-cycle improvement is encouraged and greatly aided by the Patient Management Tool. The tool can be used to run small cycles one patient at a time. By entering information at the point of care, drop-down reminders serve as prompts to complete necessary assessments and interventions as the patient moves through the hospital. Completion of the form at discharge serves as a final safety net to minimize the chance of omissions for that patient while they are still present in the system. This is in striking contrast to the common practice of retrospective quarterly chart review, which seeks to use the errors of the past to alter future care, but does not address the omissions from the prior quarter. The hospital aggregate feedback can also be used to support more macro changes in care systems such as changing preprinted orders and protocols. This can be done in a monthly, quarterly, or other timeframe, limited only by the volume of patients moving through the system.

Subsequent Meetings

Subsequent meetings are held every 3 to 4 months. The format is similar but the specific content areas for the didactic portion are determined by assessing the needs of the hospital teams. The general session includes one or more best practice examples from the group. As more hospitals experience success, poster sessions are introduced to allow for wider best practice participation. The focus for the posters is on overcoming one or more significant barriers.

The collaborative workshops continue to support group problem solving to overcome barriers. In structuring the workshops it has been possible in follow-up sessions to place one or two hospitals that excel in a specific area, such as smoking cessation counseling, with several hospitals who are struggling in this area but excelling in other areas to try to enhance the collaborative interaction (Figure 1). The knowledge that strengths and weaknesses are often complementary creates a sense of something to gain for everyone by sharing solutions and helps to move hospitals forward more rapidly than if each hospital had to solve every barrier by themselves. The substantial increase in performance in the pilot hospitals demonstrates the ability to change rapidly.

Figure 1

As hospital teams become more familiar with each other and have access to more data from their hospitals, the workshops become much more focused and collaborative. The perceived barriers are now better understood and solutions have begun to be implemented. At this point the facilitator plays a less active role in providing consultative expertise and focuses more on supporting the group process and including all participants in the discussion. Hospital teams use their planning time to update their current preprinted orders and protocols based on gaps identified by the reports they are accessing from the Patient Management Tool. Feedback from these sessions indicates the workshop, particularly the individual team planning time, is seen by many groups as the most valuable part of the meeting. Hospital teams often state that this is their best opportunity to work together without the myriad distractions present in the hospital setting.

Recognition Program

A common barrier for hospitals is obtaining and maintaining the support of senior leadership. The IHI Breakthrough Series relies on a highly selected group of hospitals willing to invest a significant fee and travel to four national meetings. Senior leaders are also expected to attend two of the national meetings. The goal of GWTG is to involve a large number of hospitals, embedding data collection and quality improvement in the daily process of delivering cardiovascular care. To achieve this, cost of the program is minimal and training meetings are held locally. To help hospital teams receive the support they need, the AHA will recognize their work at two levels. The first level recognizes meaningful system change and can occur relatively early in the program. To achieve recognition of a GWTG hospital a champion must be identified and a multidisciplinary team put in place.

Preprinted orders and protocols must be created or updated to reflect the GWTG measures and data from 30 consecutive patients must be submitted via the PMT. In addition, hospitals must commit to ongoing data collection and continuous quality improvement.

The second level of recognition is the Performance Achievement Award. For the coronary artery disease module, this requires hospital performance at least 85 percent for smoking cessation counseling in smokers, and the use of angiotensin-converting enzyme inhibitors, beta blockers, aspirin, and lipid-altering therapy for all patients without contraindications.

These recognition awards are presented at regional and national meetings and provide hospitals with the opportunity to share this recognition with their local communities. The attendant publicity associated with this has been very helpful in developing and maintaining support for the program.

Discussion

We believe that the primary motivation for pursing excellence is the impact of fewer deaths and cardiovascular events in each local community. Hospitals are encouraged to create a climate of excellence in their communities. This approach has been used to engage medical house staff in the program by creating a tradition of excellence in their training program that will endure after they graduate.¹² The sense of pride in community by feeding back cumulative hospital data to health care professionals has generally been sufficient to create appropriate peer pressure. Few of our hospitals have needed to assess the performance of individual physicians to produce change. This is consistent with the message in the Institute of Medicine report emphasizing that errors of omission and commission are largely rooted in systems not individual practitioners.¹³

GWTG relies on collaboration at multiple levels including organizations and hospitals. National organizations have provided support and recognition of the program, which facilitates the development of consensus at the state and local level. The Department of Health and Human Services and the Centers for Medicare & Medicaid Services recently recognized GWTG and the New England pilot developed with MassPRO (the Massachusetts Peer Review Organization, Inc.) with the Common Knowledge Award. The program was cited for providing a standardized model that can be shared across the country to improve the quality of care.

Collaboration among hospital teams coupled with a point-of-service Patient Management Tool has produced significant improvement in the use of the secondary prevention guidelines in the New England pilot in less than 12 months.⁸ It is clear that data collection alone has not been able to produce substantial change. Recently reported data from the National Registry of Myocardial Infarction demonstrate that only 31.7 percent of patients with acute MI are discharged on lipid-lowering therapy despite quarterly measurement.¹⁴ In the New England pilot the use of lipid therapy rose from 47 percent to 78 percent in less than 1 year.⁸

The model described here, and now being implemented nationally, is designed to produce significant, rapid widespread change. We estimate that if 85 percent of patients hospitalized with a cardiovascular illness were treated with aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and lipid-altering therapy, 80,000 lives could be saved each year.