The \\\'vital signs\\\' of Performance Improvement in Cardiac Outcomes

Lewis G Hutchison

Lewis G Hutchison

Quality Management Accreditation Director Sheikh Khalifa Medical City UAE.


Every healthcare executive, administrator and clinical staff member has heard and understands the phrase 'vital signs'. The vital signs play an important role in monitoring the well-being of the patient. Using the analogy of 'vital signs', author explains the importance of identifying Key Performance Indicators (KPI) to improve the healthcare services offered by the hospitals.


Every healthcare executive, administrator and clinical staff member has heard and understands the phrase ‘vital signs’. Temperature, blood pressure, heart rate, and respiration, and come to mind. Vital signs are used to assess and measure the state of the patient and monitor their progress to a desired ‘cure’ or outcome. But what about your organisation’s ‘vital signs’ and ‘outcomes’? What organisational disease states will you improve or ‘cure’?

Sheikh Khalifa Medical City (SKMC) is located in Abu Dhabi City, the capital of UAE. SKMC consists of a 550-bed Acute Care Hospital and 14 Specialised Outpatient Clinics accredited by the Joint Commission International (JCI). SKMC also operates 120-bed Behavioral Sciences Pavilion, an 88-bed Rehabilitation Center, 9 Primary Healthcare Centers and 2 Dental Centers distributed over the city of Abu Dhabi. SKMC employs over 4,600 caregivers and administrators from different nationalities. SKMC is a Governmental Healthcare Institution managed by Clinic Cleveland in partnership with HAAD and SEHA, the Abu Dhabi Health Services Company. Cleveland Clinic is consistently named one of the top hospitals in the USA by U.S. News & World Report.

Diseases and disorders of the circulatory system rank as the number one diagnostic category at SKMC. This tertiary care programme offers comprehensive surgical, cardiac and interventional care for adult patients with acquired heart disease. The programme offers the entire scope of modern adult cardiac diagnostic and cardiac surgery including mechanical circulatory support but excluding heart transplantation. Given the scope, volume and complexity of such an important service line, it is imperative that the performance of this department be monitored, measured and managed with patient and process outcomes at the ‘heart’ of ones focus.

Process Improvement is defined by Joint Commission as “The continuous study and adaptation of an healthcare organisation’s functions and processes to increase the probability of achieving desired outcomes and to better meet the needs of patients and other users of services” and outcomes as “the effect an intervention has on a specific health problem’. So instead of stethoscope and blood pressure cuff one can select from a variety of Performance Improvement tools to take its operational ‘pulse’ and improve outcomes. Current methodologies and literature identify many Performance Improvement tools including Plan Do Study Act (PDSA), Total Quality Management (TQM), Six Sigma and Lean Sigma processes are available for use in assisting an organisation in its outcome management process. The overlay below compares the various systems.

In a multidisciplinary approach, the PDSA process uses a centralised Quality Department, an oversight body, the Quality Improvement and Patient Safety Committee, and through the placement of Quality Review Officers (QROs) designated in each department or area, including Cardiac Sciences. The QRO’s role is to facilitate and direct departmental process improvement activities. Each QRO is made aware of performance improvement methodologies, tools and team building techniques to enable and empower departmental ownership. This process is coordinated and monitored to ensure that six steps of alignment are maintained.

Alignment involves, first, reviewing the process to identify the Key Performance Indicator (KPI) or performance outcome to be achieved. Outcomes may include, but are not limited to mortality, complications, readmissions, distribution of appropriate discharge instructions, Door to PCI time and ‘All or none compliance’ to evidence-based quality measures. Second, determine the pivotal actions in the process to achieve the desired outcome. Documenting the flow of the process to be monitored is critical. This allows for a point-by-point or action-by-action review and visually illustrates the intended and actual process. Third, identify who performs the pivotal actions and ensure communication and documentation of expectations. Fourth, determine the wherewithal and resources needed to achieve the actions. Fifth, establish the time lapse between when a pivotal action does not occur and notification of follow up (i.e. feedback loop). This is most easily done by face-to-face communication, simply paging or telephoning a colleague for clarification or comment.

Other effective ways of closing the feedback loop include the use of Grand Rounds, Peer-conducted Mortality and Morbidity Review (M&M), Failure Mode Effects Analysis (FMEA) and Root Cause Analysis (RCA). Lastly, validate the alignment of the process. Validation includes measuring and analysing whether your organisation has met its goal, improved outcomes, reassigned thresholds and benchmarks or implemented an improvement process change.

Documentation is important. The outcome, its metric and definition are recorded on a PI template tool (see Figure 1) and a record of action documented through the use of a QRO template. Dashboards are then used to compile the results into an easy-to-use, simple graphical representation. Hyperlinks are provided to move between dashboard and PI Template views. This gives the user the ability to review the outcomes at the macro and micro level. Each of these tools is available and recorded on the SKMC intranet to provide access (feedback) and enhance ease of use. SKMC & Cleveland Clinic use an intranet-based format to share and disseminate results throughout the system.

Registries are also widely used in the compilation, management, analysis and comparison of performance outcomes and data. According to the Agency for Healthcare Quality and Research (AHRQ), a patient registry is defined as “an organised system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves a predetermined scientific, clinical, or policy purpose(s)”. Cardiac Science registries currently used at SKMC include the European Society of Cardiology Euro Heart Survey PCI Registry, Euro Heart Survey—ACS Registry, Global Registry of Acute Coronary Events and The Get with the Guidelines-Heart FailureSM (GWTG-HF) programme.

With over 140,000 registered patients and more than 450 hospitals participating, it is the largest hospital-based heart failure registry in the US. Recently published studies of GWTG-HF, and its predecessor, by Fonarow, et al. OPTIMIZE-HF, “have clearly demonstrated the ability of this programme and the GWTG-HF PMT® to improve care.”

Sheikh Khalifa Medical City is the first institution outside of the US to be permitted to attempt the first use of the American Heart Association’s Get with the Guidelines programme to analyse and describe HF epidemiology and outcomes. The programme emphasises protocols created to ensure that cardiovascular patients are cared for according to accepted standards and current evidence-based guidelines and recommendations. Over 140 elements are recorded for analysis and comparison. In addition, this programme was modified to include 36 additional elements unique for the Middle East and Asia. GWTG is effective as hospital and achieved quantifiable care improvement in a short time. Globally, More than 50 clinical trials have shown that process affects outcomes. These include studies regarding ACE inhibitor, Angiotensin Receptor Blockers (ARBs), and beta blockers and their performance in reducing mortality, readmission and reduce symptoms.

In the interest of transparency, SKMC shares its operational ‘pulse’ with patients, caregivers and community. A health-related publication is in print and was distributed to healthcare providers and interested parties. Outcomes books for each of our major clinical service lines are in the process of being published. One outcomes book will be ready for issue each quarter of 2009 with the first of these centering on Cardiac Sciences. Four (4) SKMC Performance Improvement Projects received awards at the 2008 Arab Health Awards, recently held in Dubai, UAE. Of the four, three received were “Highly Commended.” The Cardiac Science Performance Improvement Project “Four years of Delivering Primary Angioplasty in the U.A.E” was named the winner of Arab Health 2008 Achievement and Innovation Awards in Emergency Medical Services. This process used most of the techniques previously described, including, PDSA, Lean, Morbidity and Mortality Review, feedback through weekly team meeting and registries to document the reduction of Door to PCI times from 101 minutes in the year 2006 to 85.5 minutes in the year 2007 to an average of 82.6 minutes in 2008.

Anecdotally, teams using similar processes have won three out of four top awards in the Cleveland Clinic Patient Safety Best Practice Awards programme in 2007 and 2008. This included a programme Called ‘Code Crimson’, a Door to Balloon (PCI) improvement process, which is now the recommended best practice for PCI and AMI care in the Cleveland Clinic Healthcare system.

In addition, 86 ‘vital signs’ or KPIs are monitored throughout the Sheikh Khalifa Medical City. In 2008, 86 quality-related Key Performance Indicators were monitored with 68 or 79 per cent showing improvement or achieving their target value. New outcomes and KPIs are currently being reviewed and revised for 2009.

Through a multidisciplinary process SKMC created and implemented a comprehensive Quality and Leadership Education Programme. All presentations are posted on the SKMC intranet and are available for use by any interested party at SKMC, its parent organisation and the Government of Abu Dhabi. Courses are open to not only SKMC employees but also other SEHA hospitals, HAAD and other medical facilities. A curriculum of 31 topics covering all aspects of continuous process improvement and leadership was initiated in 2008 and is continuing in 2009. CME credits are approved and awarded. As of 2008, 14 courses have been conducted with over 770 persons having attended with approximately 11 different content experts contributing to them. Overall satisfaction scores and individual speaker evaluations are quantified and forwarded for speaker use. Courses have been very well received with 90 per cent of the scores in the ‘Good’ to ‘Excellent’ categories.

Our organisational ‘vitals’ are strong, but we’ll continue to ‘take our pulse’ (monitor) and administer ‘treatment’ (performance improvement practices) in the interest of improving our organisational ‘well-being’ and enhance the health status of the patients and communities we serve.

Performance through 6 Step Alignment:

Identify a KPI or performance outcome to be achieved
Determine the pivotal actions in the process to achieve the desired outcome
Identify who performs the pivotal actions and ensure communication and documentation of expectations
Determine the wherewithal and resources needed to achieve the actions
Establish the time lapse between, when a pivotal action does not occur and notification of follow up (i.e. feedback loop)
Validate alignment

Author Bio

Lewis Hutchison joined Sheikh Khalifa Medical City (SKMC) in January 2008 as the Director of Quality Management Department and resides in Abu Dhabi, UAE. He is currently focussed on the application of Performance Improvement techniques and evidence-based practice in the provision of International Healthcare services, outcomes improvement and patient safety.