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Hernia Repair : The Care Map Hernia Repair : The Care Map Reducing unnecessary local variation in care Reducing unnecessary local variation in care
through agreement and partnershipthrough agreement and partnership
Dr A. Garcia Dr N. Schaad Mme C. Chetif M. C. Wille Mme S. Malherbe Mme A. CuissinatDr H. Probst Mme G. Müller Mme S. Opoix M. J-M Keller Mme S. Marjanovic Mme Z. RomagnoliDr C. Vallet Mme L. Friedli Mme S. Van der Vlis M. C. Engeli Mme C. Devriese Mme C. DerendigerDr B. Depierraz M. B. Holz Mme I. Monteilhet M. Y. Stehle Mme V. Tabligan Mme C. Farah
30.11.201130.11.2011
Introducing our Hospital
� L’Ensemble Hospitalier de la Côte is a multisite 400 bed public hospital.
� We are situated on the shores of lake Geneva in between the cities of Geneva and Lausanne.
Care Map: the Concept
� DefinitionStructured, multidisciplinary plan of care designed to support the implementation of clinical guidelines over a given time period.
� AimEnsure safe, reliable and efficient care
� Objectives1) Avoid unjustified differences in patient care2) Apply clinical guidelines according to evidence-based medicine 3) Reinforce communication and coordination among the different teams
� Benefits- Improve quality of care- Rationalise patient care and risk management- Clarify the role and responsibility of each professional involved- …
Open clinical. Knowledge management for medical care. Clinical Pathways: March 2006
www.openclinical.org/clinicalpathways.html www.has-sante.fr
The Care Map in 10 steps
Multidisciplinary working group
1. Pathology or surgical intervention
2. Patient inclusion criteria + indicators
3. Pre-measurement
4. Actual process description with the key interventions
5. EBM recommendations
6. Process definitive version
7. Training the health care professionals
8. Implementation of the care map and post-measurement
9. Analysis of the results and improvement actions
10. Ensuring the continuity of the improvement process in the hospital
Convention relative à la coordination de la qualité et de la sécurité du patient 2008-2009. Service publique fédéral belge.
The Care Map in Surgery
� Our first surgical intervention was selected becaus e it is simple, predictable and has few complications � Creation of a multidisciplinary working group � Networking with the teaching hospitals in Geneva, Lausanne and Zurich� Belgian Clinical Pathway Network (NKP) and the European Pathway Association (EPA)
� Building the care map « Inguinal Hernia Repair »� Literature search� EBM recommendations� Inclusion criteria:
• Adult patient (>18 years old)• Elective surgery
� Creation of 3 new documents� « Clinical pathway »� « Medical Orders » based on literature and group consensus� « How to use the Care Map »
http://www.nkp.be/franais/le-reseau/index.htmlhttp://www.e-p-a.org/index2.html
Inguinal Hernia Repair. Care map EHC. October 2009
The CM Documents
Developing the Project
� Training the health care professionals (Oct. 2009)- 30 min training of all the doctors and nurses involved- The CM documents were regularly updated with their comments
� Implementing the Care Map and rapid testing (Nov. 2009)
� Optimising key steps of the process (2010)- Patient information leaflet- Methodology approved by IUMSP
- Postoperative monitoring: standardisation of practice based on EBM
IUMSP : Institut Universitaire de Médecine Sociale et Préventive
• Monitoring the indicators- Retrospective analysis of 50 patient charts (2008-2009) before and 100 patient charts after implementation of the Care Map
- 3 charts were excluded during post measurement � 97% of patients eligible
The Care Map: a tool for morecommunication…
… and clarificationof patient care
Measuring the Results
Items to be improved :• Unreadable medical orders
• Variation of medical orders
• Medical orders forgotten
• Prescribing errors
• MO on 5 different documents
• Poor knowledge of the
hospital drug formulary
• Confusing instructions
mailed to the patient
CARE MAP METHODOLOGY
� EVIDENCE-BASED MEDICINE
� MULTIDISCIPLINARY GROUP CONSENSUS
STANDARDISATION
OF CARE
• Avoid unjustified
differences in patient
care
• Reinforce
communication
• Clarify role and
responsibility of each
professional
Indicators monitoring
Results analysis
Feedback to the team
Updating the Care Map
A compass to monitor the indicators
Financial indicators
Clinical indicators
Process indicators
Team indicators
Service indicators
• Postoperative complications• Readmission after 30 days
• Patient satisfaction
• Staff satisfaction• Safe surgery checklist
• Legibility• EBM gaps
• Length of stay
Vanhaecht K & Sermeus W (2003) Leuven Clinical Pathway Compass, Jl ICP 7, 2-7.
Analysing the Results
0%0%Readmission after 30 days
2%2%Postoperativecomplications
70%40%Ambulatory care
AFTER CARE MAP
BEFORE CARE MAP
Complication : any preventable adverse event linked to the operation (pain, nausea and vomiting excluded).
Good-Patient satisfaction
3.2 / 4-Staff satisfaction
17%84%Differences btw medical orders and EBM
0%32%Unclear medical orders
AFTER CARE MAP
BEFORECARE MAP
Analysing the Results
Doctor’s and nurse’s satisfaction
Satisfaction survey - August 2010
0
0.5
1
1.5
2
2.5
3
3.5
4
I know what Ihave to do at
any given time
Standardisationand pre printedmedical ordersmakes my work
easier
I find the patientinformation
leaflet useful
Gathering all themedical orders
in one page suitsme
I notice thatmedical orders
are standardizedbased on EBM
The Care Mapmakes my work
easier
The Care Mapmakes my work
safer
Overall I amsatisfied with this
Care Map
Doctors
Nurses
The Safe Surgery Checklist
Yves Giroud, Sept. 2009
How the CM can integrate other quality and safety projects
Safe surgery CL integrated in the CM
� The Safe Surgery ChecklistFor Inguinal Hernia Repair, 85% of the checklists have their 4 steps signed off.
EHC cheklist based on the Safe Surgery Checklist of the Swiss Patient Safety Foundation, 2009.
99 99
91
89
84
86
88
90
92
94
96
98
100
Pou
rcen
tage
de
sign
atur
es
1 2 3 4
Etapes de la checkliste de sécurité chirurgicale
Signature (%)
Steps of the Safe Surgery Checklist
Percenta
ge o
f sig
natu
res
Conclusion
� Project outcomes after 12 months- Excellent tool for communication and teamwork - Almost doubling the number of patients treated in ambulatory care for inguinal hernia
repair while maintaining very low rates of complications and no readmission within 30 days.
- Patient and staff satisfaction
� The limitations- Rigour in signing the medical orders- Potential lack of critical analysis while signing the medical orders
The family is getting bigger…
� Care map development in general surgery2010- April : « Crural / Umbilical / Epigastric Hernia Repair »- June : « Cholecystectomy »- Sept. : « Varicose Vein »- Nov. : « Haemorrhoidectomy »2011- Jan. : « Implantable Venous device»- April : « Colectomy »- June : « Low anterior resection of the rectum with ileostomy »
� Coming soon- Developing care maps in other interested sectors :
> Orthopaedic surgery> Gynaecology
Warm thanks
• USZ
• CHUV
• HUG
• RIC
• EPA
• IUMSP
Let us share our experiences!
Clinical Pathway Roadmap. www.medscape.org
