Methods for Improving Care
Methods for Improving Care
Hackensack University Medical Center will implement vanguard approaches to healthcare delivery in order to attain the goals of the Pursuing Perfection grant program and improve patient care. These new approaches redefine the roles of physicians, nurses, allied health professionals — and even patients — and foster better communication, coordination, and collaboration among all parties, including the departments within the organization. Strengthening the Patient Care Process
The Institute for Healthcare Improvement cites several factors that contribute to the deficiencies in the patient care process:
  lack of medical care coordination.
  lack of active follow-up care to ensure the best outcomes.
  practitioners whose time restraints prevent them from following established practice guidelines.
  patients inadequately trained to manage their illnesses.

In each of its targeted areas of care, Hackensack University Medical Center will focus on improving the weaknesses and deficiencies that have been identified in the Institute of Medicine’s published reports about the need to improve healthcare in America. (See Stimulus for the Grant Program. )

Redefined Roles for the Healthcare Team
It takes a unified team effort to excel in outstanding patient care and attain the goals of Pursuing Perfection. Hackensack University Medical Center has developed new models for care care that rely on a multidisciplinary team approach to healthcare delivery. Essential to a teamwork philosophy are redefined roles for the healthcare professionals – especially the nurses — who work in tandem with the physicians to identify, communicate, and execute an evidence-based plan of care that ensures the desired outcome for the patient.
To view a graphic about Hackensack Medical Center's care model that displays the collaboration of efforts that are needed to realize improved patient care, click Performance Improvement Infrastructure.
This collaboration of team members assures an effective, cohesive delivery of healthcare services. In the past, physicians were captains of their own ships, braving the sometimes-rough waters alone. New models of care have the physician as captain of the ship and of a professional crew of many “shipmates and deck hands” who make certain that things work properly and assure “smooth sailing.” This was not possible under the old system that involved professional autonomy and control.

Physicians can now rely on advanced practice nurses (APNs) and senior staff nurses (SSNs) to assist them in implementing group-determined practice guidelines that propel the standard of care higher. This approach is in stark contrast to the days when nurses were taught a philosophy of quiet servitude whereby they would assist physicians without question, even if their experience told them otherwise. The teamwork approach establishes the nurse as another valuable healthcare practitioner who can make recommendations to the physician based on the group-determined guidelines.

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New Models for Patient Care
The new patient care models will be implemented into each targeted area of care program that is selected by Hackensack University Medical Center to be part of the Pursuing Perfection improvement initiatives. The successful implementation plans will be emulated by healthcare organizations across the country once the medical center shares the results of the grant program experience.

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The new models for patient care emphasize the collaboration of physicians, advanced career nurses, and other health professionals.
The common thread woven into each new care model is the development of group-determined practice guidelines that serve as the compass for the healthcare team. Evidence-based standards of care assure that all patients receive the latest, state-of-the-art treatment for their specific disease. The implementation of these guidelines by a multidisciplinary healthcare team will assure achievement of the Pursuing Perfection goals.

Group-Determined Practice Guidelines
Advanced Practice Nurse (APN) Model
Senior Staff Nurse (SSN) Model
Multidisciplinary Rounds (MDR) Model
Chronic Care (CC) Model

Group-Determined Practice Guidelines
The compass for the healthcare provider teams in the new patient care models is a group-determined set of evidence-based practice guidelines for each targeted area of care. “Evidence based” means that the recommended treatment plans are based on undisputed medical research that demonstrates optimal patient outcomes. Established practice guidelines are endorsed by national specialty societies, the federal Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA), and the New Jersey Peer Review Organization (PRO).

Practice guidelines are adapted into performance measures, which are extracts of the best recommendations that have been condensed into a half-page, easily comprehendible summary. Each targeted area of care has a unique set of performance measures that form a framework for the evaluation of improved care processes and serve as indicators for monitoring the achievement of the Pursuing Perfection goals. (See Measuring Performance. )

Development of these group-determined guidelines requires:
  physician consensus conferences to select indisputable practice guidelines for specific diseases, modify them for buy-in, and devise performance measures for monitoring purposes.
  the creation of disease-specific order sets by the healthcare team and all relevant departments who may be involved in the care process.
  a plan for an Advanced Practice Nurse (APN) and/or Senior Staff Nurse (SSN) to implement the predetermined guidelines so that the desired performance measures are achieved.
  a plan to train the front-line staff nurses to maintain performance measure levels.
  a commitment to maintain the vision of the Pursuing Perfection goals.
  applying multidisciplinary care coordination to assure performance consistency for all inpatient care processes. (See Multidisciplinary Rounds (MDR) Model. )

Advanced Practice Nurse (APN) Model
One of the innovative models for patient care developed by Hackensack University Medical Center emphasizes the role of the Advanced Practice Nurse (APN), whereby the APN facilitates the implementation of predetermined practice guidelines for disease-specific patient populations. This model of practice is applied to both inpatient and outpatient programs. (See Building on Success: Pilot Programs Using the New Care Models. )

The primary responsibilities of the APNs in this model are to:
  closely monitor the progress of patients treated for a specific diagnosis; maintain detailed progress notes; consult with physicians; provide and coordinate appropriate services.
  intervene when the predetermined practice guidelines are not followed.
  contribute clinical expertise during daily multidisciplinary rounds for care coordination.
  collaborate with attending physicians to assure the achievement of performance measures and Pursuing Perfection grant goals for the targeted area of care that applies to a specific patient population.

Senior Staff Nurse (SSN) Model
The Senior Staff Nurse (SSN) Model facilitates the coordination of care on each nursing unit. It is applied to inpatient initiatives, whereby senior staff nurses assume the role of either staff educator or care coordinator for their assigned patient care unit and facilitate the implementation of predetermined practice guidelines for disease-specific patient populations.
Career Advancement Program: The medical center's Department of Patient Care cultivates this expanded role of the professional nurse through its Career Advancement Program. This program supports clinical bedside nursing by providing recognition for clinical expertise and creating opportunities for career advancement. For more information, click Career Advancement Program.
Similar to the APN model, the primary responsibilities of the SSNs in this model are to:
  closely monitor the progress of each patient treated for a specific diagnosis; maintain detailed progress notes; consult with physicians; provide and coordinate appropriate services.
  intervene when the predetermined practice guidelines are not followed.
  provide patient and staff education.
  communicate and coordinate the patient’s plan of care during daily multidisciplinary rounds.
  collaborate with attending physicians to assure the achievement of performance measures and Pursuing Perfection grant goals for the targeted area of care that applies to a specific patient population.

Multidisciplinary Rounds (MDR) Model
The roles of the Advanced Practice Nurse and Senior Staff Nurse (see Career Advancement Program ) are woven into the Multidisciplinary Rounds (MDR) Model whereby:
  a team physician works with the nurse manager, staff nurses, APNs, pharmacists, social workers, nutritionists, case managers, and discharge planners to communicate, coordinate, and facilitate the implementation of the patient’s plan of care as prescribed by his or her physician.
  if multiple consultants are involved, the “captain of the ship” is identified so that a coordinated and cohesive treatment plan is implemented.
  the progress of each patient is closely monitored; detailed progress notes are maintained.
  an Advanced Practice Nurse or Senior Staff Nurse consults with attending physicians, intervenes when the predetermined practice guidelines are not followed, and coordinates services, thereby assuring the achievement of performance measures and Pursuing Perfection grant goals for the targeted area of care that applies to a specific patient population.
  a group focus and emphasis on discharge planning assures safe, adequate follow-up care and the continuation of services into the outpatient setting: medication needs are assessed and prescriptions are provided; discharge instructions are reviewed with the patient; home care is coordinated when needed; and a schedule for recommended follow-up medical visits is reinforced.

Chronic Care (CC) Model
A fourth model, the Chronic Care (CC) Model, is based on the APN, SSN, and MDR models. The Chronic Care Model encourages highly effective chronic care management for such diseases as those selected targeted areas of care undertaken by Hackensack University Medical Center for the Pursuing Perfection grant. It focuses on regular, productive interactions between an informed, active patient and a prepared, proactive provider team.

The CC Model incorporates an approach that includes:
  early and accurate diagnosis.
  state-of-the-art, evidence-based treatment with proactive case management and monitoring.
  patient education with counseling about effective lifestyle changes that can assist with improving symptoms and prolonging life.
  computerized technology that maintains a patient registry and database of relevant clinical information for each disease and reminds providers when to contact patients for follow-up visits.
  the monitoring of outcomes so performance can be measured. (See Measuring Performance. )
The Robert Wood Johnson Foundation sponsors a national program to help the chronically ill through quality improvement and research. To read more about the development of care models for those with chronic conditions, click Improving Chronic Illness Care.

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The Patient’s Role: Education
and Active Decision-Making
Providing education for patients about their disease supports the goals of the Pursuing Perfection grant program. Education empowers patients and family members by fostering more productive interactions with their healthcare team. Better-informed patients are able to become more involved in the decisions of their healthcare. Patient education efforts are a main component for many of the targeted areas of care launched through the Pursuing Perfection grant program.

Hackensack University Medical Center provides patient education in a myriad of ways:
  patient educators provide individualized counseling for patients with specific diseases for both inpatient and outpatient programs.
  inpatients have access to computers and educational materials in the HUMC Medical Library.
  educational literature is available on each nursing unit and at each outpatient program location.
  the medical center’s web site has become an educational source for patients with certain procedures, diseases, and conditions described in detail.
  the medical center provides patient education through its extensive network of external communication vehicles. (See Sharing Results: Publicity. )

The Organization’s Role: A Foundation
of Support Services
In order to affect the internal competencies that enable superior clinical care and attain Pursuing Perfection goals, Hackensack University Medical Center (and other organizations wishing to emulate its successes) must integrate a four-tier commitment to provide: Patient Centered Care
Hackensack University Medical Center has long been committed to the concept of patient-centered care, which is an essential ingredient of the Pursuing Perfection formula for dramatically improved healthcare delivery. (See Criteria for the Selection of HUMC. )

The medical center strives for patient centered care in many ways, including a commitment to:
  • respect the rights and concerns of all patients.
  • create the flexibility to meet each patient’s unique needs.
  • keep patients well-informed about their condition.
  • involve the patient in care decisions.
  • educate patients to enable them to make decisions about their healthcare.
  • establish and communicate high quality standards of behavior to all employees and reward those who provide exemplary care. (See Employee Incentives. )
  • identify and resolve patient issues. (See Patient Advocacy. )
  • create an environment that promotes healing. (See A Soothing Environment Designed for Healing. )
Employee Incentives for Pursuing Perfection: The medical center encourages its employees to participate in patient-focused interactions, an initiative that is driven by a recognition program that recognizes and rewards employees who provide outstanding, high quality care. To encourage Pursuing Perfection goals, human resources specialists teach communication skills, patient/customer service, teamwork, conflict management skills, innovation, cultural competency, coaching and mentoring, patient rights, and confidentiality.

Patient Advocacy: The Consumer Affairs Department’s complaint management process, patient advocacy, and patient satisfaction initiatives exemplify the medical center’s commitment to its patient-centered philosophy.

A Soothing Environment Designed for Healing
Hackensack University Medical Center has an active Complementary Medicine Program that integrates healing philosophies into the organization. This approach is reinforced by its affiliation with Planetree, a non-profit organization that is considered a pioneer in personalizing, humanizing, and demystifying the healthcare experience. Planetree’s organizational goals mirror the Pursuing Perfection goals in their quest to nurture a human connection between patients and those who care for them and change the way patients and their families traditionally experience healthcare.

The medical center cultivates a healing environmental in many ways, including:

  the interior design has been carefully planned to promote relaxation and tranquility, aspects that benefit patients as well as their families and the caregivers. From the living room-like lobby to the gardens and water features throughout the campus, the medical center’s facilities are inviting and foster a soothing experience. (To view the interior designs of Hackensack University Medical Center, click Virtual Tours. )
  patients are provided with gowns, robes and night clothes, specially designed by Nicole Miller, that cover patients more appropriately and preserve their dignity. (For more information, click Nicole Miller Gowns. )
  Beyond, a full-service day spa, is available to outpatients, inpatients, families of patients, staff, and the public. (See Beyond Day Spa. )
  healthy food selections are encouraged for both patients and staff.
  a large, multi-denominational Pastoral Care Department is available around the clock to provide spiritual and emotional support for patients, family members, and staff. (See Pastoral Care Department. )
  the medical center uses environmentally safe cleaning products throughout its campus. Strategic Reorganization to Support Perfection Goals
The fundamental groundwork required to achieve the Organizational Goals and Promises of the Pursuing Perfection grant program begins with system redesign and organizational transformation. Aside from the application of medical science, internal reorganization is vital to the delivery of outstanding patient care. Administrators will continue to focus on improving areas such as reliability engineering, human factors engineering, human resource development, communication, and employee morale.

The primary improvement goals within the organizational structure include: Back to Top

Information Technology Upgrades
Hackensack University Medical Center’s pursuit of high quality healthcare initiatives is supported by the resources of the Department of Information Technology (IT) — a commitment that is underscored by the medical center’s $40 million investment in the IT infrastructure. The Role of Information Technology in Pursuing Perfection: Information Technology is important to the Pursuing Perfection grant program because it enables:
  development of disease-specific patient registries for all targeted areas of care.
  the ability to track the performance measures of Pursuing Perfection initiatives.

These abilities are essential to sharing the results of the grant program so that other healthcare institutions across the country can emulate its successes. As part of the ongoing grant program initiatives, the medical center will:

  develop a computerized physician order entry system.
  create an electronic medical records system.
  hire a Senior Informatics Physician to work closely with clinical staff on Information Technology initiatives.
  add computer checks to ensure that a patient’s proposed treatment is appropriate.
  provide home telemonitoring of patients registered in select outpatient programs, when appropriate. This information will be electronically transferred to physician offices using Web-based technology.

HUMC’s Advanced Technology: Hackensack University Medical Center has been recognized with an award by HOSPITALS AND HEALTH MAGAZINE as “Most Wired – for Effective Use of Technology.” Its cutting edge IT operations include: Proven Strategies: Successful Pilot Programs Using New Models
Hackensack University Medical Center’s new models of care, which were proposed to the grant sponsors as ways to dramatically improve healthcare services, are based on proven strategies first applied to two difficult service areas — telemetry and community-acquired pneumonia (CAP). The redesign of the care processes for these service areas using the new models of care validated the effectiveness of the vanguard approaches. Management of Telemetry
The overuse of telemetry monitoring adversely affected Hackensack University Medical Center’s ability to admit patients from the emergency room to telemetry-equipped beds in a timely fashion. Using the Advanced Practice Nurse (APN) Model, physicians in the Department of Internal Medicine agreed to have an APN monitor in-hospital telemetry use. When telemetry was no longer necessary, based on pre-determined practice guidelines, the APN called the physician to request discontinuation of telemetry. The program met with great success. The number of hours that a patient received telemetry was significantly reduced and the availability of telemetry-equipped beds increased.

Community-Acquired Pneumonia (CAP)
Based on the success of telemetry management, the Advanced Practice Nurses (APN) Model was applied to community-acquired pneumonia (CAP) with the goal of decreasing costs and length of stay for patients with this diagnosis. The Department of Internal Medicine endorsed a plan for an APN to:
  closely monitor the progress of each patient treated for CAP.
  call physicians when compliance with the predetermined practice guidelines was incomplete.
  upon conferring with the physician, order the agreed-upon services.

Each quarter, the success of the project was fed back to the physicians at department meetings. Through this redesigned care process, Hackensack University Medical Center achieved 90 to 100 percent compliance with the predetermined guidelines in less than a year.

The effort was then extended to reducing the length of stay and decreasing the cost per admission. The development of practice guidelines that supported an earlier switch from intravenous to oral antibiotics and earlier discharge criteria achieved significant results within a six-month period — a 1.33 day reduction in the length of stay per case and a $444 decrease in cost per case.

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