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Simply implementing software and technology does not assure that an organization's targeted clinical and financial goals will be realized. No longer is it possible to roll out a new system--by solely providing end user training and overlaying it on top of already inefficient workflows and outdated roles--and know with certainty that targets will be met. At Virtua Health's Home Care, based in south New Jersey, implementation of their electronic system initially followed this more traditional approach. Unable to completely attain their earlier identified return on investment, they enlisted the help of a new role within their health system, that of the nurse informaticist. Knowledgeable in complex clinical processes and not bound by the technology at hand, the informaticist analyzed physical workflow, digital workflow, roles and physical layout. Leveraging specific tools such as change acceleration, workouts and LEAN, the informaticist was able to redesign workflow and support new levels of functionality. This article provides a view from the "finish line", recounting how this role worked with home care to assimilate information delivery into more efficient processes and align resources to support the new workflow, ultimately achieving real tangible returns.

The Prospective Payment System had significant impact on home healthcare agencies throughout the nation. Virtua Home Care, located in Southern New Jersey, realized the need for process improvement in order to remain viable. Six Sigma was introduced to the agency and the Define, Measure, Analyze, Improve, and Control processes were initiated to achieve sustainable results, and within 9 months, Virtua Home Care improved regulatory compliance, experienced a deficiency-free survey, and recognized a 1.2 million dollars financial gain.

Background: A rich information environment supports the functioning of the small, functional, frontline units--the microsystems--that provide most health care to most people. Three settings represent case examples of how clinical microsystems use data in everyday practice to provide high-quality and cost-effective care., Cases: At The Spine Center at Dartmouth, Lebanon, New Hampshire, a patient value compass, a one-page health status report, is used to determine if the provided care and services are meeting the patient's needs. In Summit, New Jersey, Overlook Hospital's emergency department (ED) uses uses real-time process monitoring on patient care cycle times, quality and productivity indicator tracking, and patient and customer satisfaction tracking. These data streams create an information pool that is actively used in this ED icrosystem--minute by minute, hourly, daily, weekly, and annually--to analyze performance patterns and spot flaws that require action. The Shock Trauma Intensive Care Unit (STRICU), Intermountain Health Care, Salt Lake City, uses a data system to monitor the "wired" patient remotely and share information at any time in real time. Staff can complete shift reports in 10 minutes., Discussion: Information exchange is the interface that connects staff to patients and staff to staff within the microsystem; microsystem to microsystem; and microsystem to macro-organization.

By using a manufacturing management approach to improving quality and efficiency, a New Jersey health system is transforming its culture of quality and seeing highly positive results.

The Universal Billing Code of 1992 (UB-92) is a standard database used by hospitals to generate itemized charges for patient visits. This study examined the use of UB-92 information to monitor emergency department performance improvement projects. UB-92 data were used to determine whether urine tests had been ordered for emergency department patients. A population of patients at low risk for requiring a urine culture was defined as discharged female patients between 16 and 60 years of age undergoing a urinalysis as part of their emergency department treatment during a 10-month period. Based on UB-92 data, only a total of 2,138 patients were identified who met the study's low-risk criteria. Recommendations for the optimum use of these tests were presented to the emergency physicians as part of departmental performance improvement activities. Additional logistical problems associated with the procedure for ordering this test were identified and corrected as part of this project. After an additional 5-month period, a second analysis of the entire 15 months of UB-92 data was performed. Prior to physician notification, 41.6% of low-risk patients underwent both a urinalysis and a urine culture and sensitivity in the emergency department. In the 5-month follow-up period, the percentage of patients undergoing both tests decreased 18% to only 23%.

Multidisciplinary teams are different from the traditional team format in that representation and participation from various disciplines characterize the structure. In April 1996, a multidisciplinary group from Muhlenberg Regional Medical Center's intensive care unit learned methodology at the Institute for Health Care Improvement (IHI) Breakthrough Series in Adult Intensive Care. With the format learned, improvements in diverse areas such as ventilator management, intermediate care, clinical laboratory utilization, and others were accomplished. Continued support from an expert staff and utilization of on-line communication tools characterized this 15-month quality improvement endeavor. The end of the breakthrough series spurred the development of a hospital-wide collaborative cost containment team.

Background: Decreases in length of hospital stay have increased pressure on staff to provide appropriate patient education. A hospitalwide continuous quality improvement (CQI) program was implemented to improve patient education documentation at Raritan Bay Medical Center (RBMC; Perth Amboy, NJ). IMPROVING THE PATIENT EDUCATION DOCUMENTATION PROCESS: In March 1995 the patient education committee was given the responsibility to develop a CQI program to improve documentation of patient education. Patient interviews revealed that assessment of patients' initial knowledge was inadequate and goal setting was omitted. The committee developed generic and disease-specific patient education documentation forms for educational assessment and patient education. The patient chart was reconfigured to include a central location for patient education., Results: A review of almost 900 patient records established that the percentage of records on which patient education was documented had improved from 41% in summer 1995 to 93% in fall 1996, with an improvement across all disciplines. A follow-up review in fall 1997 of 136 randomly chosen records indicated a slight decrease in rate of documentation of content areas, although nursing services and nutritional care continued to maintain their patient documentation education at a rate of > or = 90%., Discussion: Factors such as providing continuous feedback on patient education documentation performance to all nursing units and disciplines involved, developing additional disease-specific education assessment plans/documentation tools through an interdisciplinary process, and improving the data collection tool after each measurement period all contributed to improved patient education documentation., Conclusions: Patient education is now truly integrated at RBMC, with every pertinent discipline involved in decision making throughout the process of continuously improving the patient education process and documentation.

Using data to meet regulatory and internal standards: Here's an excellent case study of a New Jersey hospital that developed an effective and efficient tracking mechanism to improve patient restraint compliance. The result? Restraint use fell dramatically and administrators learned the real reasons why nurses changed their restraint-use behavior. Here are all the tools and tips you'll need to adopt the same kind of program at your facility.

Physicians need to be involved in organizational decision making, and institutional goals are achieved through the integration of operational quality committees.