Richard Kremsdorf, M.D.

Principal, Five Rights Consulting

Effective Patient Care is the link between the requirement to deliver an operating margin and the expectations of the Board and the Community of excellence.  Effective Patient Care is the result of the coordinated efforts of a patient care team, all of whose members have what they need to provide optimal care. There are five key components that are essential for this system to work smoothly, the Five Rights...  

Right Clinical Data 

Healthcare has increasingly become more data-driven. Simply put, current diagnostic methods are vastly better than previous approaches. Some of these methods are technical and sophisticated, such as MRIs or the many exotic blood tests, while others may be traditional, such as measurements of blood pressure and pulse rate. In either case, the results of those evaluations must be available to caregivers for them to make appropriate decisions. While the testing methods have changed enormously, our methods for delivering and displaying the data have not kept pace. Clinicians make decisions -- whether or not the data available is complete. When an iv infusion requires the next bag of fluid, a bag will be hung--whether or not the morning electrolytes results are available! 

Some types of data are more important than others...

The volume of documentation collected on a hospitalized patient has grown enormously in recent years. Some of the additional data is due to new diagnostic methods. Much of the additional data is gathered for regulatory purposes or to document that care met a community standard in the event of an adverse outcome. The sheer volume of the information to be processed has further stressed the ability of caregivers to find the information they need to make key clinical decisions. Furthermore, some types of observations are more reliable and predictive of an important clinical problem than others, e.g. a Temperature compared to the physical examination of the lungs. For that reason, some data elements are particularly sought after by many different members of the care giving team. Knowing where to focus is critical.

Right Presentation 

Designers of airplane cockpits have known for years that the way in which information is displayed can have a huge impact on how quickly and accurately pilots can understand the significance of the data. The same issues apply in medicine. Even careful caregivers can misinterpret or fail to recognize clinically important patterns in the data, especially when they are fatigued or rushed. 

Timing

The most basic issue is whether the data is available to the caregiver at the Right Time. If the lab has run the test, but the results are not available when clinical decisions are made, then the expense has been incurred without benefit to the patient. In addition, in the event that an adverse event were to occur, legal culpability might be greater as the chart would, in retrospect, document the error. 

Format

The data also needs to be presented in the Right Way. Current clinical events should be interpreted in the context of the patient's prior medical history--which should be immediately available to the caregiver as decisions are being made.  

Show longitudinal data...

When patients have multiple encounters with the healthcare system, the data from one encounter can color interpretation of subsequent events. As much as possible, old and new data should be displayed contiguously--immediately demonstrating that data from a prior event is available and making recognition of the trend--rising, falling, or stable--obvious. 

Show data in context...

Few data elements are appropriately interpreted without the context of other observations. E.g. the impact of a dose of diuretic can't be understood without knowing the urine volume and net fluid balance that followed administration of the medication. Thus, it is essential that disparate data elements be brought together and displayed so that the patterns are easier to discern  

Right Decisions 

Clinical medicine is inherently challenging, due to the complexity of the human body and how it responds to disease. Our understanding of illnesses and what is optimal diagnosis and therapy is continually changing, and doing so faster than ever. Even so, in spite of all of the sophisticated testing now used, clinical decisions are fundamentally only considered judgments, weighing an array of facts and hunches. 

Incomplete data

Should some of the basic information be missing, and the caregiver forced to guess and what a result might indicate, the decision making process is flawed, even if it often turns out ok. An effective system of care uniformly brings together everything needed for an optimal decision.  

Incomplete knowledge

It is not only the facts of the illness that count, but also their significance in light of the latest, best medical knowledge. Unfortunately the cost of rapid progress has been that decision makers are increasingly unable to keep up with the pace of new understandings, and to be able to bring them to bear for the benefit of patient care. It is not an individual failing, but rather a systemic issue. Systematic approaches are required to be sure that the best and most complete knowledge is incorporated into the decision-making process. Computer-based tools can organize information to reflect advances in understanding and present the best protocols to optimize care. 

Right Work Processes

The right decisions are useless unless they are implemented correctly. The process of team-based care depends on a coordinated effort of multiple caregivers, sharing knowledge and communicating flawlessly -- even though each member might be overwhelmed with work. If unnecessary steps are removed from the work processes, the process failure rate can be improved. Computer-based data can enhance communication and make the information available in multiple locations at any time--easing the challenge of coordinated team care. 

Decreased rework...

When caregivers have what they need to do the job right, it is more likely to be done right the first time, at enormous savings in patient suffering and system expense. 

Lower defect rates...

Every process has an inherent failure rate. Systems that depend on the memory of people or non-standard procedures are more likely to be "creative" in sub-optimal ways. Medication errors are a good example of an opportunity for leapfrog improvements. 

Reduction in number of steps...

The right work processes take fewer steps and get done more quickly. 

Integration of different silos into one work process...

The complexity of human illness has led to specialization. However, sometimes, separate processes can be created that don't coordinate well with each other. The right work processes integrate all the care that is needed. 

Work redesign...

In order to optimize care, the processes needed to be re-evaluated from all different points of view. Often, steps are done more out of routine, than requirement. New technology may mean that certain steps can be eliminated or automated. Sometimes, new errors are created when old processes are improved, requiring continual attention to work redesign. 

Team members must work together to figure out enhancements to the care process, biting off a large enough chunk for the improvements to matter, but limiting the scope enough to make it achievable.

Right Outcomes

Ultimately, the only criterion for success is whether patient care became more effective. Often, we base this on opinions, casually gathered, rather than substantive, rigorously collected data. Data gathering and analysis can seem superfluous, but measurement of outcomes is an essential method to recognize which areas need further improvement. 

Measure computer system utilization

When computer-based systems are implemented, it is often assumed that they are being used for their intended purposes. However, this is often not the case. Utilization varies by individual user, by patient care area, by different disease types. Each variation might identify a special need for different reports, processes, or training. 

Measure effectiveness of sub-processes of clinical operations

While the desired measure of success is what happened to the patient, that complex outcome can be influenced by so many factors it can be hard to know what was responsible for the outcome. By breaking the patient care process into smaller steps and measuring the defect rate of the sub-process, the impact on the overall process can be inferred. For example, if patients get their medications late or not at all, it is not a large leap to anticipate an unfavorable outcome. Or, if the wrong medication is used, it is not necessary to have a large enough sample size to demonstrate bad outcomes to know that changes are needed. 

Measure clinical outcomes of aggregate processes

The most compelling data are the clinical outcomes. Indeed, consumers are most interested in the big picture--do patients get better--far more than the details that they would like to assume are always flawlessly executed. 

Track financial metrics

There is never enough money to do everything an institution would like to do. For that reason, stewardship of scarce resources, the financial benefits of system changes must be measured and understood. Such metrics should be designed into the implementation of changes. Effective patient care means better clinical outcomes, but also within the reality of financial constraints. 

(c) 2000 Five Rights Consulting