At Indiana University Health (IUH) System in Indiana, numbers tell the story. Door-to-balloon (DTB) time. Deaths from inpatient STEMI. Cardiac patients discharged on guideline-recommended medications. Bleeding rates after PCI.

The numbers come from the system's voluntary reporting to the NCDR, which IUH data coordinators relentlessly track. When they see a trouble spot, they spring into action and initiate a performance improvement (PI) protocol.

Over the past decade, these efforts have substantially improved the quality of care that cardiovascular patients receive throughout the system's seven hospitals and brought national attention to IUH and its process improvement teams.

In fact, IUH Methodist Hospital has received the ACC's annual ACTION Registry Performance Achievement Award at the platinum level every year since the program began, with other hospitals in the system also recognized with the achievement award most years.

IUH: Early Adopter

The health system was an early adopter of using registries and databases to improve performance thanks, in part, to Roxanne L. Kovacs, RN, MSN, CCA. Kovacs, who started at IUH as a critical care/coronary care nurse in 1978, became director of cardiovascular quality in 2009 after a 10-year hiatus working at Eli Lilly in clinical trial management.

She quickly realized the treasure trove of data available in the NCDR registries and its potential for quality improvement.

"It helps when you can see your score," she says.

At the time, most hospitals were focused on acute myocardial infarction and DTB time, which IUH also addressed. But Kovacs went farther, mining the PCI and ICD databases as well.

"She really laid the foundation for what we do today," says Director of Quality Databases Andrea Price, MS, CPHQ, RCIS, AACC, who Kovacs trained. "She pushed us to think beyond what everyone else was doing."

Which is why IUH showed "huge improvements" long before the national quality improvement movement, Kovacs says.

Today, 13 clinical data coordinators are part of a team that scours NCDR registries to review the hospital's performance and identify areas for improvement. As Kovacs put it in a 2016 ACC profile: "My day is filled with data, data, and more data."

The teams are multidisciplinary, including "anyone you think of as part of the care team that touches the patient during their care or electronically after discharge," Price says. That may mean as many 40 people at a bimonthly team meeting. During the meetings, she adds, "we share the NCDR performance, drill down into areas we need to take a closer look at, and provide operational program updates."

The key is not just reporting to the registries, the two women say, but using the data to improve outcomes. "There's a lot of data in the registries and we've prioritized how we look at it from an organizational perspective," Price explains. That means focusing first on what's best for the patient, followed by changes that can have an organizational impact and affect reimbursement.

Cardiovascular Care Team as Data Analysts

While many hospital systems have data coordinators abstracting information from databases and registries, few have coordinators like IUH's – all of whom have years of clinical experience in cardiovascular medicine as echocardiographers, cath lab technicians and nurses.

Thus, notes Price, "They do more than just obtain the data. They own the data and they understand the metrics." They are also considered an integral part of the team, responsible for working with the physician champion and operational leaders to create content and present actionable data.

"This differs from an automatic data pull," says Kovacs. "It's actually reviewed data by people who understand it."

Key to success is empowering the coordinators, Price says. "We recruit for their clinical experience and keep the team very diverse on purpose." The coordinators are also trained to know the evidence base and protocols so they can identify system failures.

One challenge, both women state, is that "no one wants to believe the data." That's another area where the data coordinators shine. Their experience in the cardiovascular realm means "there's already a professional trust and understanding that we just want everyone to improve," Price says.

Also crucial to getting physician buy in is not to assign blame when the data shows disparities. "Unlike a morbidity and mortality review, which is designed to educate people on a case and be a learning environment," Price says, "our review is not a learning environment; it's a root cause analysis on system defects."

Improvements in Patient Care

Of course, the ultimate goal of any PI program is improved patient care – an investment that has paid off handsomely, with the quality improvement team presenting more than 20 abstracts in the past five years documenting their successes. Table 1 highlights results from several such programs. Others include:

• Post-PCI bleeding events. The team used several strategies included in ACC's Reduce the Risk: PCI Bleed quality campaign to reduce its 2012 performance non-risk adjusted rate from 6.8 percent to 2.1 percent in 2017.¹ "That calculates to approximately 512 patients who have avoided a bleeding event following their PCI procedure since PI efforts began," Price says.
• Door-to-balloon time. The system consistently improved its DTB over the years, with the percentage of patients receiving PCI within 90 minutes of arrival increasing from 80 percent in 2009 to close to 100 percent in 2018.²
• Patients discharged on an ACE/ARB and beta-blocker. In 2006, just 75 percent of the 238 patients at IU Health Methodist Hospital who received an ICD received evidence-based discharge composite medications (ACE/ARB and beta-blocker for ejection fraction <40 percent, as well as beta-blockers for those with a history of myocardial infarction [MI]).³
  
  Today, that figure is nearly 100 percent thanks to a PI project that included physician score cards showing their individual performance, staff education and standardized electronic discharge documents. IU Health Methodist has been at 100 percent for five years and IU West for four years. "That equates to 850 consecutive patients sent home on the right medications," Price says.

When Price thinks about her job, she keeps returning to numbers. Specifically, the number of patients whose lives were saved "just because we changed our processes." And despite years of impressive outcome improvements thanks to this system, she knows there's still plenty to improve. "There's always an opportunity to build upon hard-wired processes."

References

1. Price A, et al. The Real World Experience with Metric #37: Reducing the Occurrence of Observed Post-PCI Bleeding. Paper presented at: NCDR 2014; Washington, DC.
2. Choudhry Muhammad W, Kovacs R, Cook H. Abstract 258: A Novel Process to Reduce Mortality Associated with In-Hospital STEMI. Circ Cardiovasc Qual Outcomes 2015;8(suppl 2):A258-A258.
3. Groh M. ICD Process Improvement Team Leads Process Change. Paper presented at: NCDR 2015; San Diego, CA.
4. Kaul P, Federspiel JJ, Dai X, et al. Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. JAMA 2014;312:1999-2007.

Keywords: ACC Publications, Cardiology Magazine, Clinical Competence, Quality Improvement, Antineoplastic Combined Chemotherapy Protocols, Fellowships and Scholarships, Registries, Percutaneous Coronary Intervention, Critical Care

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