More Than a Process Thing: Frontline Lessons in Cardiovascular Quality Improvement

So much of clinical success — and especially care value — resides not just in clinical expertise but in implementing systems to deliver that expertise consistently every time. That’s a key responsibility of Cleveland Clinic cardiologist Umesh Khot, MD, in his role as Chief Quality Officer for Cleveland Clinic’s Heart & Vascular Institute. Cleveland Clinic Cardiovascular Medicine Chair Steven Nissen, MD, recently interviewed Dr. Khot about lessons gleaned from recent quality improvement successes in the institute. An edited transcript of their conversation follows.

Dr. Nissen: Let’s start by defining exactly what we mean when we talk about clinical effectiveness.

Dr. Khot: I look at it as how we thread everything together from the standpoint of quality operations and, increasingly, reimbursement. It’s something that needs to be done at all levels of the organization, from the institute level to the department level to the section level. Quality initiatives can even be applied at the individual physician level.

Dr. Nissen: Give me examples of some of our successful quality initiatives from the past few years.

Dr. Khot: One of the most notable things has been our STEMI [ST elevation myocardial infarction] program, which we are now connecting across the entire Cleveland Clinic health system. Since we started on this in 2014, we’ve been able to show very consistent reductions in door-to-balloon time, which ultimately has led to nearly a 50% reduction in mortality from STEMI.

Dr. Nissen: So what approaches were used to drive this improvement?

Dr. Khot: We started by developing a list of key things we could do to address areas identified as challenges. We came to some agreements about how to move patients through the system and how to standardize care to make sure all patients receive the same care every time. Then, starting in 2014, we deployed those changes. After that, the job is basically to make sure you follow through on what you agreed to. [For more on this initiative, see this prior Consult QD post.]

Dr. Nissen: Your team has published some of the results achieved. Can you tell us about that?

Dr. Khot: One of the papers [J Am Coll Cardiol. 2018;71:2122-2132] looked at the impact our new protocol had on women. Women are known to receive worse STEMI treatment than men and to have worse STEMI outcomes. We were able to show for the first time that standardizing STEMI care substantially improved the treatment that women received and significantly narrowed the traditional mortality gap that’s seen between men and women with STEMI.

Dr. Nissen: Can you share some metrics? What was the median door-to-balloon time when you started, and how did it change as this process improvement was initiated?

Dr. Khot: Our median door-to-balloon time went from good — about 70 to 80 minutes — to what we consider excellent, as we are now approaching 45 minutes. Also notable has been the reduction in treatment variability. All patients are now getting the same treatment every time, including consistency in administration of recommended medications.

Dr. Nissen: Exactly how did you drive this process improvement?

Dr. Khot: We developed a checklist to organize all that information together so everyone was aware that this was the way we were going to manage STEMI patients moving forward. Then we started to meet with the emergency department team on a monthly basis to review the information to make sure we were actually doing all those things.

Dr. Nissen: Everybody around the country is struggling with readmissions. Can you share some approaches we’ve taken to tackle this challenge throughout our large and complex organization?

Dr. Khot: One of the things we noted early on is that readmissions are very front-loaded: Peak readmissions are typically within one to two weeks after hospital discharge. So doing a lot of things three to four weeks after discharge doesn’t make sense because you’ve already missed the readmissions peak.

So what we’ve focused on is standardizing care while the patient is in the hospital to make sure they receive optimal care at that time. In heart failure, for example, we developed what we call our Heart Failure Checklist, an EMR-embedded electronic tool that presents a series of steps that need to be taken while patients are in the hospital to make sure they receive optimal care. The result has been a sustained reduction in heart failure readmissions [as detailed in this prior Consult QD post].

Dr. Nissen: At what point during the patient’s hospitalization is that checklist completed?

Dr. Khot: It’s something we want to have done by discharge, but many of the steps have to happen earlier. We initially called it the “Heart Failure Discharge Checklist,” but then everybody tried to do it on the day of discharge and they couldn’t get it done. So now it’s simply the Heart Failure Checklist, which reflects that it includes things that need to happen throughout the course of the hospitalization.

We developed the checklist by bringing together input from all the disciplines involved in heart failure care — nursing, pharmacy, case management and physicians. So the checklist includes items related to patient education about heart failure, which is done by nursing, as well as items related to pharmacotherapy for physicians, ensuring appropriate social support for case managers, etc.

Dr. Nissen: There’s sometimes a gap in pharmacotherapy right after heart failure patients are discharged. How have we handled that?

Dr. Khot: One strategy we increasingly use is called bedside delivery. This gives us an option to send prescriptions electronically to a pharmacy here on our main campus for delivery to the patient on the day of discharge. This way we know that patients have their medications as they go home, and delays in filling prescriptions become a nonissue.

Dr. Nissen: That’s an important innovation. I would think that medication noncompliance in heart failure is probably a fairly common contributor to readmission. Has that been your experience?

Dr. Khot: It has. To address this, we use a nontraditional concept involving shared medical appointments in the hospital. Most shared medical appointments are offered in outpatient settings, but for several years we’ve been conducting shared appointments right in the hospital where hospitalized patients with heart failure go through education regarding diet, medications and so forth together with other heart failure patients.

Dr. Nissen: Your responsibilities extend beyond cardiovascular medicine into other areas of our Heart & Vascular Institute, such as cardiovascular surgery. What are some notable quality initiatives that extend to these other areas?

Dr. Khot: We have been working with cardiac surgeons to standardize their patient workup process. There has been a lot of individual variability, and we’ve found that if you bring surgeons into a room with a cardiologist or two, it’s not hard to come to a general agreement about what the various types of patients need.

Another project that extends across all areas of our institute involves the quality of discharge summaries. All around the country, the modern discharge summary has become a big problem, and we’ve had success in terms of standardizing these summaries so that someone who reads a summary can actually quickly learn what happened during the hospital stay.

Dr. Nissen: Yes, I’ve noticed that one side effect of the electronic medical record is that sometimes people will simply cut and paste from all the hospital notes and make that the discharge summary. The result is a summary that looks like an encyclopedia but leaves the reader with no clear recap of what actually happened with the patient.

Dr. Khot: Right. In order to get the discharge summary down to its essentials, we have removed most of the copy-and-paste capabilities and we just allow for the key information that’s required, either for regulatory reasons or for clinical care — i.e., why the patient was in the hospital, what was done for the patient in the hospital, what remains to be addressed, etc.

Dr. Nissen: What barriers has your team run into when introducing these kinds of changes? What are the issues that typically slow down these processes?

Dr. Khot: The biggest challenge in any healthcare setting is likely to be an inherent resistance to change. In healthcare we often like to do things the way we’ve always done them. But we’ve found two broad principles to be helpful in overcoming resistance to change.

First is that accurate data matters. Before we talk to anybody about anything, we make sure we have the most relevant information and that it’s as complete as possible so that we’re not talking about something that’s incorrect.

Second is to try to look at any situation as some type of partnership, because whoever you’re working with, ultimately you’ll need them to help deliver whatever you’re trying to do. So involving them in reviewing the data and creating the solutions — then working with them side by side to actually get it done — is key.

This Q&A was derived from an episode of Cleveland Clinic’s “Cardiac Consult” podcast for healthcare professionals.