Henry Ford Health System
Detroit, MI
2306 staffed beds
Henry Ford Health System is an integrated, not-for-profit hospital system in southeastern Michigan with seven acute care hospitals that admit approximately 93,000 patients each year.
STEEEP
Efficient - The system standardized its patient education practices across inpatient and outpatient settings.
Safe - Pharmacists and physicians carefully monitor patients' anticoagulation therapies both in the hospital and following discharge.
Team Members
Beth Anctil, RN
Principal Management Engineer
William Conway, MD
Chief Quality Officer
Jack Jordan
Director of Quality
James Kalus, PharmD
Senior Pharmacy Manager of Patient Care Services
Combating Coagulation
The Problem
Errors in prescribing anticoagulation medication can lead to adverse events, and improper communication with discharged patients at risk of anti-coagulant related adverse events (such as bleeding or thrombosis) has been associated with hospital readmissions. Reducing harm from anticoagulation therapy was included in the Joint Commission’s 2010 National Patient Safety goals. The Institute for Clinical Systems Improvement recommends that clinicians carefully analyze patients’ risks and benefits of anticoagulation therapy based upon the individual’s risk for thrombosis weighed against the risk of bleeding.
The Solution
During a review of procedures, Henry Ford Hospital leaders identified a need to improve guidelines around anticoagulation protocol. In 2007, a multi-disciplinary work group, comprised of members of the pharmacy department and physicians, began meeting to develop new standards.
In August 2009, the work group initiated a hospital-wide, pharmacist-directed anticoagulation service (PDAS), with new standards for dosing and monitoring, administering patient education and handling the transition of patients following discharge.
The new initiative charges pharmacists with appropriate dosing and monitoring of anti-coagulant medications to ensure patients safely transition from the inpatient to outpatient setting. In complex cases, physician champions help determine appropriate use of anticoagulation medications.
At discharge, patients are instructed to visit any of Henry Ford Health System’s outpatient clinics to monitor their international normalized ratio (INR) value, a measurement of anti-coagulation, to avoid adverse effects that could lead to readmission. Staff at both the hospital and its affiliated outpatient clinics now use a standardized communication bundle to educate patients and their families about their medication regimens and their testing schedules.
The Results
Patients who participated in the program were 21 percent more likely to enroll at an outpatient clinic within 5 to 7 days of discharge. Those patients also had a 26 percent reduction in related readmissions within 30 days of discharge. In addition, the rate of INR values more than 5, a measurement of coagulation, declined more than 80 percent. The hospital’s PDAS initiative was also honored as a finalist in the American Society of Health System Pharmacists 2009 Award for Excellence.
Background
Several years ago, the hospital’s quality committee identified a need to improve guidelines around anticoagulation protocol, according to James Kalus, senior pharmacy manager of patient care services at Henry Ford Hospital.
The hospital subsequently formed a work group comprised of pharmacists, internists, cardiologists and hematologists; ultimately, the team chose a pharmacist-directed management system for the dosing and monitoring of patients in need of anticoagulation therapy. Physician champions were charged with advising the pharmacists in determining treatment regimes for complex cases.
With the aim of reducing preventable readmissions, the work group also discussed strategies to ensure patients that were prescribed anticoagulation therapies continued to follow their treatment regimens following discharge and were monitored for coagulation with regular testing.
Today, a standardized process is used by pharmacists to develop an anti-coagulation discharge note for all patients that is included in their electronic medical record. All patients discharged on an anticoagulant medication are automatically enrolled in anticoagulation programs at outpatient clinics; 70 percent of the time, there is a follow-up communication from Henry Ford Health System within 5 days.
“Focusing on transitions could help to reduce readmissions,” Kalus says.
The initiative is supported by Henry Ford Health System’s comprehensive harm reduction campaign. William Conway, the system’s chief quality officer, notes that efforts like the PDAS initiative are marked by a combination of clinical expertise and executive support.
“If we engage in an initiative, there’s a senior sponsor in the C-Suite and a clinical champion,” Conway says.
Principles of Performance Excellence
Reducing process variation
Before the initiative began, patients would often receive differing information about their medication regimen from the hospital and the outpatient clinics they were enrolled at following discharge, Kalus says.
“The pharmacy would educate new patients,” Kalus says. “They would go to the outpatient side and hear a similar, but slightly different message.”
To remedy the problem, the anticoagulation work group created a communication bundle, or a series of instructions for talking with patients about their medication regimens and need for regular coagulation testing. The script is now used by both Henry Ford Hospital and its outpatient affiliates.
“The education was standardized across the continuum,” Kalus says.
Continual improvement
After achieving success at Henry Ford Hospital, Henry Ford Health System is adapting the initiative for use at Wyandotte Hospital, West Bloomfield Hospital and Macomb Hospital.
In addition, Kalus believes the PDAS model could ultimately be adapted to help manage the treatment of other chronic conditions, especially those which require coordination between inpatient and outpatient environments.
“The model is something that could apply to different types of patients,” Kalus says. “We’re focusing on anticoagulation, but the same issues exist with diabetes and other chronic disease states.”
