Running a medical care facility is as complicated as caring for an end stage COPD patient. While a doctor will need to find the right balance of medicines to deal with all the facets of lung disease -- bronchospasm, heart failure, anxiety -- hospital administrators need to find the best potion to keep the hospital afloat.
Finding the best potion is accomplished by balancing the following core goals:
In reality, the difference between order set and protocol is similar to the difference between capitalism and socialism. One allows for individualism, and the other creates equality. While one might "sound" like it solves problems better, the other actually does.
So what are hospitals presently doing right, and what can they do better? To answer these questions we must first have some definitions:
Order set: Synonym: Social Justice, socialism. Every patient with a given diagnosis (DRG) is treated the same. Once a patient is admitted with a certain DRG, these sets pre-determine what you order for that patient. The purpose of these is to make sure best practice medicine is followed for every patient. Basically, a committee -- usually in Washington -- determines what is best for the patient, and this assumes that the caregivers at the bedside are not capable of critical thinking. Another advantage of order sets, and the reason they are being initiated in most hospitals, is to make sure intensity of service is met. This assures that the patient will meet reimbursement criteria. In the past physicians were presented with a sheet that listed all the options. Today, however, many of these options are pre-checked and automatically ordered whether the doctor wants to or not. The reason for this is to make sure reimbursement criteria is met (see below).
Cook book medicine: Treating all patients the same. This is generally the theme created to describe order sets, especially order sets that have pre-checked boxes that result in procedures being automatically ordered for a particular DRG.
Protocol: Synonym: Capitalism, individualism. Every patient and every patient situation is treated individually and uniquely given the patient status and the wisdom of the caregivers. The institution has set guidelines, and the caregivers use their education and wisdom to solve the problem at the bedside. Given proper training and well written protocols, best practice medicine should occur by default because protocols encourage critical thinking.
Ideally, according to Egan, a protocol would work like this:
1. Benefits the patient: The medical professionals working with the patient (RT and RN) decide what the patient needs at the moment the care is needed.
2. Less calls to physician: Doctors will receive fewer irritating phone calls
3. Improved morale and apathy: RTs and RNs will be able to use the wisdom they obtained by education and through experience, and this will improve their dignity, mercy and self worth.
4. Less burnout: With only those patients who need therapy receiving it, there is a good chance the RT or RN won't feel so run down and overwhelmed, and the patients who truly need their services will benefit as a result.
Reasons your hospital might choose not to use protocols:
1. Procedure counts: RT bosses need procedure counts to justify staffing load. They fear, and often needlessly so, that protocols will result in less work for the department
2. Reimbursement criteria: Quality Assurance (see below) wants to make sure government quotas are met for each given patient. If the RT decides a patient doesn't need certain procedures (such as bronchodilators), then the hospital may not be reimbursed. This is one of the main reasons many smaller hospitals avoid protocols (note: see reimbursement criteria below).
Order set/ Protocol combination: This is where a hospital committee creates order sets for a given DRG yet allows the medical staff freedom based on well designed protocols to use critical thinking in determining what is best for the patient. Once order sets are initiated, the caregivers at the bedside (RN and RN) decide which ones are to be followed and how. For example, a post operative order set may include an incentive spirometer order. By using the protocol, the RT will decide whether the IS is appropriate, or if cough and deep breathing might be better for that particular patient. An Albuterol breathing treatment is another example. A pneumonia order set may automatically order Q6 breathing treatments. The RT will give an initial breathing treatment and monitor it's effectiveness. If there is no benefit to the patient and the patient the order would be changed to as needed or discontinued. This would save the hospital money (treatments are $80 to 100 each) and allow the RCP an opportunity to help patients with greater needs.
Order sets are the current trent. Personally, I think these have some advantages. It assures that best practice medicine is followed. So, what is best practice medicine?
Best practice medicine: Based on scientific evidence, this is what is proven to work for a given DRG. For example, breathing treatments improve work of breathing for asthmatic patients and should be ordered. Likewise, oxygen should be an option. This also focuses on preventative medicine. Incentive Spirometers use is proven to reduce post operative pneumonia and atelectasis, and therefore an IS order is automatic with post operative order sets.
Intensity of Service: Basically, does the patient meet reimbursement criteria? Is the patient sick enough to be admitted? Doctors would prefer to use their own judgement to decide which patients go home and which patients are admitted for observation. Yet the Centers for Medicare and Medicaid Services (CMS) will refuse to reimburse the hospital for a patient admission unless the patient is sick enough to need certain pre-determined procedures. For example, if a patient admitted with asthma didn't receive any breathing treatments, then why did he need to be admitted? If no treatments are given, CMS has a right to refuse reimbursement. Order sets make sure what is required is given regardless of need.
Keystone Committee: This is a committee formed to make sure intensity of service is met, reimbursement criteria is met, and best practice medicine is met for each DRG. The goal is to reduce costs for the hospital, make as much money for each DRG, and to provide best practice medicine for each DRG that results in improved care for the patient.
Core Measures: These are measures set by the Keystone Committee that work as goals for the hospital to improve patient care and reduce costs. They are based on best practice medicine and reimbursement criteria.
Quality Assururance (QA): This is the fastest growing area of the medical field, especially since the passing of Obamacare. This is the department responsible for checking charts and making sure core measures are met. The goal here is to make sure the hospital is making as much money for a given patient as possible. They also work on committees with other department heads in the hospital to create methods of assuring best practice medicine and reimbursement criteria is met. T'his is a noble department set to make sure the patient is getting the best care possible and the hospital is making a profit. However, because of government regulations on the medical field and new regulations imposed by Obamacare, one of the main emphasis's of late is on meeting these regulations.
This department hides under the guise of best practice medicine, although their real intent is always to make sure the patient is profitable. They're often referred to as the nitpickers of the hospital, or the people who make sure we dot all our i's and cross all our t-s per se.
Quality Assurance Analyzer: This is one member of the QA team who is a former nurse who has the responsibility of reviewing charts to make sure intensity of service is met for each patient. They carry a book around with them created by an independent company that lists all the orders for a given DRG that must be ordered for that patient to meet reimbursement criteria. It is illegal for the QA analyzer to tell a doctor the patient doesn't meet criteria because a certain order was not made. For example, it is illegal for the QA analyzer to observe treatments were not ordered for an asthma patient and to tell the doctor he must order them so the hospital gets reimbursed. However, doing this is part of their job.
Reimbursement criteria: This is criteria set by CMS that must be met for each DRG. If not, CMS has a right to reject reimbursement for that patient. If CMS deems a patient was not sick enough to be admitted, they will not reimburse the hospital. It does not matter that the doctor was worried about the patient and wanted him admitted for observation. This is one of the main reasons many procedures are added to order sets that are not needed: Ted stockings for every patient, neuro checks every two hours, IVs, EKGs every morning times 2 days for chest pain patients, bronchodilators for RSV patients and pneumonia, etc. We must also note that the purpose of reimbursement criteria is to reduce cost to the government, not to reduce cost to the hospital. Since these actually increase the number of procedures ordered to meet criteria, this actually results in increased cost to hospitals.
The only way to reduce costs when you have order sets is to also add protocols.
Public relations: Creating a good image of the hospital in the community and among staff working for the facility.
Diagnosis Related Group (DRG): This is a diagnosis related group and each patient is assigned one. Based on the DRG chosen, the hospital will receive a set payment. Because hospitals know in advance how much they will make for that patient, this may help determine the type of care this patient receives. Because there is a flat profit, hospitals therefore have an incentive to do only those procedures that are essential. Thus, the fewer procedures the hospital does the more money the hospital will have once the bills are paid. This is an incentive to do more with less. One of the best ways to do more with less is to have order sets and protocols.
What are the current trends?
The current trend is for hospitals via keystone committees (or something similar) to create order sets for every DRG. In the past this included a list to remind a physician of his options. However, more recently it's evolved into simply checking options so that nothing is missed. The goal is to meet core measures.
However, we must keep in mind that while the intent is to improve quality and decrease costs, it is my assessment that due to government intervention, not enough common sense is involved in the process. The emphasis is moving away from protocols and toward order sets that make certain orders are mandatory regardless of need.
The result of this is the following:
However, due to government regulations and reimbursement criteria, hospital committee members are forced to make reimbursement criteria a top priority, and, unfortunately, this comes at the expense of patient outcomes and worker morale. Due to order sets that pre-mark and automatically have certain procedures ordered, this results in the staff becoming overwhelmed.
A good example of this is if a patient is admitted with sepsis, COPD, pneumonia, asthma, heart failure and anxiety. The order sets for all those DRGs must be followed. The unit secretary can be bogged down for hours just on one patient, and implementing those orders will bog down a single nurse, and often require a second nurse and a nursing assistant.
With limited focus on creating protocols, there are no methods of getting rid of redundant and unnecessary procedures. This results in staff being overwhelmed, it causes burnout, and it results in apathy. Due to the recession, most hospitals are unable to hire new nurses to help out. Burnout, decreased morale and increased apathy is the result.
This effects public relations too, because a staff that is burned out is going to have a poor view of the institution and the administration, and will be less likely to spread a positive word about the hospital. This makes the job of public relations more complicated.
With any future approach to medical care, you'll obviously want to continue positive trends and get rid of what doesn't work, and add what has worked at other hospitals. The problem is due to government intervention, most hospitals are a) forced to set core measures based on reimbursement criteria, and b) forced to do things the same way.
This takes away individualism. Since all hospitals are doing things the same way, this decreases the implementation of new out of the box ideas that might revolutionize the medical industry in the future. If forces hospitals to focus in one area (reimbursement) and slack in others (worker morale).
I think Keystone Collaborative Core Measures have improved patient care. One recent study shows that critical care core measures have reduced ventilator acquired pneumonia and reduced readmission rates for pneumonia and COPD. Yet gains in this area have not improved worker morale and have not improved hospital image within the institution and the community.
Likewise, when worker morale is low, so too is patient morale. On top of this the patient is needlessly having to be awakened every time a staff has to come into his room to do a certain procedure. Apathetic and overwhelmed RTs and RNs aren't going to care about working together to make sure the patient isn't awakened every hour. Apathetic and overwhelmed staffers are simply going to do what they have to do to get their assigned work done.
They, in essence, become overwhelmed button pushers and automatons. They become robots. This is bad because these RNs and RTs are right at the bedside and provide an image to the patient of the hospital.
I believe the best way to accomplish all of the above four hospital goals this is via the following:
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Finding the best potion is accomplished by balancing the following core goals:
- Improving patient care
- Reducing costs
- Creating a good image of the institution
- Maintaining a good morale among employees
What is the current trend?
The current trend is to focus on 1-3 above, and to incorporate employee morale into a public relations campaign which involves things like midnight meals provided by administrators, summer parties, Christmas parties, giveaways, and having administrators participate in meetings. While this is a step in the right direction, it has done nothing to improve morale. However, studies show the current trend has improved patient care.
All of the above goals can be accomplished through the creation, implementation and monitoring for the following methods:
- Order sets
- Protocols
Quite often these two terms are used as synonyms, and more frequently an order set is called a protocol. I think this is done more as window dressing, because most people in the medical profession believe every patient and every situation must be treated individually. It didn't used to be this way, yet this is the current trend.
In reality, the difference between order set and protocol is similar to the difference between capitalism and socialism. One allows for individualism, and the other creates equality. While one might "sound" like it solves problems better, the other actually does.
So what are hospitals presently doing right, and what can they do better? To answer these questions we must first have some definitions:
Order set: Synonym: Social Justice, socialism. Every patient with a given diagnosis (DRG) is treated the same. Once a patient is admitted with a certain DRG, these sets pre-determine what you order for that patient. The purpose of these is to make sure best practice medicine is followed for every patient. Basically, a committee -- usually in Washington -- determines what is best for the patient, and this assumes that the caregivers at the bedside are not capable of critical thinking. Another advantage of order sets, and the reason they are being initiated in most hospitals, is to make sure intensity of service is met. This assures that the patient will meet reimbursement criteria. In the past physicians were presented with a sheet that listed all the options. Today, however, many of these options are pre-checked and automatically ordered whether the doctor wants to or not. The reason for this is to make sure reimbursement criteria is met (see below).
Cook book medicine: Treating all patients the same. This is generally the theme created to describe order sets, especially order sets that have pre-checked boxes that result in procedures being automatically ordered for a particular DRG.
Protocol: Synonym: Capitalism, individualism. Every patient and every patient situation is treated individually and uniquely given the patient status and the wisdom of the caregivers. The institution has set guidelines, and the caregivers use their education and wisdom to solve the problem at the bedside. Given proper training and well written protocols, best practice medicine should occur by default because protocols encourage critical thinking.
Ideally, according to Egan, a protocol would work like this:
- Therapy can be adjusted more frequently in response to changes in patient status.
- Physicians can still be contacted for major changes, but not minor adjustments, thus reducing nuisance calls.
- Consistency of therapy can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be used.
- RCPs (Respiratory Care Practitioners) become actively involved in achieving good patient outcomes instead of performing rigid tasks. This enhanced responsibility attracts and retains better educated and qualified practitioners.
1. Benefits the patient: The medical professionals working with the patient (RT and RN) decide what the patient needs at the moment the care is needed.
2. Less calls to physician: Doctors will receive fewer irritating phone calls
3. Improved morale and apathy: RTs and RNs will be able to use the wisdom they obtained by education and through experience, and this will improve their dignity, mercy and self worth.
4. Less burnout: With only those patients who need therapy receiving it, there is a good chance the RT or RN won't feel so run down and overwhelmed, and the patients who truly need their services will benefit as a result.
Reasons your hospital might choose not to use protocols:
1. Procedure counts: RT bosses need procedure counts to justify staffing load. They fear, and often needlessly so, that protocols will result in less work for the department
2. Reimbursement criteria: Quality Assurance (see below) wants to make sure government quotas are met for each given patient. If the RT decides a patient doesn't need certain procedures (such as bronchodilators), then the hospital may not be reimbursed. This is one of the main reasons many smaller hospitals avoid protocols (note: see reimbursement criteria below).
Order set/ Protocol combination: This is where a hospital committee creates order sets for a given DRG yet allows the medical staff freedom based on well designed protocols to use critical thinking in determining what is best for the patient. Once order sets are initiated, the caregivers at the bedside (RN and RN) decide which ones are to be followed and how. For example, a post operative order set may include an incentive spirometer order. By using the protocol, the RT will decide whether the IS is appropriate, or if cough and deep breathing might be better for that particular patient. An Albuterol breathing treatment is another example. A pneumonia order set may automatically order Q6 breathing treatments. The RT will give an initial breathing treatment and monitor it's effectiveness. If there is no benefit to the patient and the patient the order would be changed to as needed or discontinued. This would save the hospital money (treatments are $80 to 100 each) and allow the RCP an opportunity to help patients with greater needs.
Order sets are the current trent. Personally, I think these have some advantages. It assures that best practice medicine is followed. So, what is best practice medicine?
Best practice medicine: Based on scientific evidence, this is what is proven to work for a given DRG. For example, breathing treatments improve work of breathing for asthmatic patients and should be ordered. Likewise, oxygen should be an option. This also focuses on preventative medicine. Incentive Spirometers use is proven to reduce post operative pneumonia and atelectasis, and therefore an IS order is automatic with post operative order sets.
Intensity of Service: Basically, does the patient meet reimbursement criteria? Is the patient sick enough to be admitted? Doctors would prefer to use their own judgement to decide which patients go home and which patients are admitted for observation. Yet the Centers for Medicare and Medicaid Services (CMS) will refuse to reimburse the hospital for a patient admission unless the patient is sick enough to need certain pre-determined procedures. For example, if a patient admitted with asthma didn't receive any breathing treatments, then why did he need to be admitted? If no treatments are given, CMS has a right to refuse reimbursement. Order sets make sure what is required is given regardless of need.
Keystone Committee: This is a committee formed to make sure intensity of service is met, reimbursement criteria is met, and best practice medicine is met for each DRG. The goal is to reduce costs for the hospital, make as much money for each DRG, and to provide best practice medicine for each DRG that results in improved care for the patient.
Core Measures: These are measures set by the Keystone Committee that work as goals for the hospital to improve patient care and reduce costs. They are based on best practice medicine and reimbursement criteria.
Quality Assururance (QA): This is the fastest growing area of the medical field, especially since the passing of Obamacare. This is the department responsible for checking charts and making sure core measures are met. The goal here is to make sure the hospital is making as much money for a given patient as possible. They also work on committees with other department heads in the hospital to create methods of assuring best practice medicine and reimbursement criteria is met. T'his is a noble department set to make sure the patient is getting the best care possible and the hospital is making a profit. However, because of government regulations on the medical field and new regulations imposed by Obamacare, one of the main emphasis's of late is on meeting these regulations.
This department hides under the guise of best practice medicine, although their real intent is always to make sure the patient is profitable. They're often referred to as the nitpickers of the hospital, or the people who make sure we dot all our i's and cross all our t-s per se.
Quality Assurance Analyzer: This is one member of the QA team who is a former nurse who has the responsibility of reviewing charts to make sure intensity of service is met for each patient. They carry a book around with them created by an independent company that lists all the orders for a given DRG that must be ordered for that patient to meet reimbursement criteria. It is illegal for the QA analyzer to tell a doctor the patient doesn't meet criteria because a certain order was not made. For example, it is illegal for the QA analyzer to observe treatments were not ordered for an asthma patient and to tell the doctor he must order them so the hospital gets reimbursed. However, doing this is part of their job.
Reimbursement criteria: This is criteria set by CMS that must be met for each DRG. If not, CMS has a right to reject reimbursement for that patient. If CMS deems a patient was not sick enough to be admitted, they will not reimburse the hospital. It does not matter that the doctor was worried about the patient and wanted him admitted for observation. This is one of the main reasons many procedures are added to order sets that are not needed: Ted stockings for every patient, neuro checks every two hours, IVs, EKGs every morning times 2 days for chest pain patients, bronchodilators for RSV patients and pneumonia, etc. We must also note that the purpose of reimbursement criteria is to reduce cost to the government, not to reduce cost to the hospital. Since these actually increase the number of procedures ordered to meet criteria, this actually results in increased cost to hospitals.
The only way to reduce costs when you have order sets is to also add protocols.
Public relations: Creating a good image of the hospital in the community and among staff working for the facility.
Diagnosis Related Group (DRG): This is a diagnosis related group and each patient is assigned one. Based on the DRG chosen, the hospital will receive a set payment. Because hospitals know in advance how much they will make for that patient, this may help determine the type of care this patient receives. Because there is a flat profit, hospitals therefore have an incentive to do only those procedures that are essential. Thus, the fewer procedures the hospital does the more money the hospital will have once the bills are paid. This is an incentive to do more with less. One of the best ways to do more with less is to have order sets and protocols.
What are the current trends?
The current trend is for hospitals via keystone committees (or something similar) to create order sets for every DRG. In the past this included a list to remind a physician of his options. However, more recently it's evolved into simply checking options so that nothing is missed. The goal is to meet core measures.
However, we must keep in mind that while the intent is to improve quality and decrease costs, it is my assessment that due to government intervention, not enough common sense is involved in the process. The emphasis is moving away from protocols and toward order sets that make certain orders are mandatory regardless of need.
The result of this is the following:
- Increased workload on all staff
- Increased ordering of procedures that are not needed
- Increased burnout
- Decreased critical thinking
- Decreased morale
- Increased apathy
- Decreased dignity, mercy and feeling of self worth
- Worsening of patient care (due to burnout and apathy)
What is the best approach to take in the future?
I believe the best approach to accomplishing the four core goals for hospitals is to take a combination approach to public relations, order sets and protocols. I believe order sets will assure core values are met, and protocols will assure costs are reduced and morale is improved.
With a fine balance of public relations, order sets and protocols, the following will be the result:
With a fine balance of public relations, order sets and protocols, the following will be the result:
- Improved patient care results in improved patient satisfaction and outcomes
- Improve individual choice results in improved worker morale and feeling of self worth
- Reduce unnecessary procedures lessens burnout and reduces apathy
- Improved option results in a reduction of redundant and unnecessary phone calls to physicians
- Increase critical thinking at the bedside likewise improves patient care, reduced calls to physicians, and improved worker satisfaction
- Improved morale would result in better word of mouth advertising by staff and physicians
A good example of this is if a patient is admitted with sepsis, COPD, pneumonia, asthma, heart failure and anxiety. The order sets for all those DRGs must be followed. The unit secretary can be bogged down for hours just on one patient, and implementing those orders will bog down a single nurse, and often require a second nurse and a nursing assistant.
With limited focus on creating protocols, there are no methods of getting rid of redundant and unnecessary procedures. This results in staff being overwhelmed, it causes burnout, and it results in apathy. Due to the recession, most hospitals are unable to hire new nurses to help out. Burnout, decreased morale and increased apathy is the result.
This effects public relations too, because a staff that is burned out is going to have a poor view of the institution and the administration, and will be less likely to spread a positive word about the hospital. This makes the job of public relations more complicated.
With any future approach to medical care, you'll obviously want to continue positive trends and get rid of what doesn't work, and add what has worked at other hospitals. The problem is due to government intervention, most hospitals are a) forced to set core measures based on reimbursement criteria, and b) forced to do things the same way.
This takes away individualism. Since all hospitals are doing things the same way, this decreases the implementation of new out of the box ideas that might revolutionize the medical industry in the future. If forces hospitals to focus in one area (reimbursement) and slack in others (worker morale).
I think Keystone Collaborative Core Measures have improved patient care. One recent study shows that critical care core measures have reduced ventilator acquired pneumonia and reduced readmission rates for pneumonia and COPD. Yet gains in this area have not improved worker morale and have not improved hospital image within the institution and the community.
Likewise, when worker morale is low, so too is patient morale. On top of this the patient is needlessly having to be awakened every time a staff has to come into his room to do a certain procedure. Apathetic and overwhelmed RTs and RNs aren't going to care about working together to make sure the patient isn't awakened every hour. Apathetic and overwhelmed staffers are simply going to do what they have to do to get their assigned work done.
They, in essence, become overwhelmed button pushers and automatons. They become robots. This is bad because these RNs and RTs are right at the bedside and provide an image to the patient of the hospital.
I believe the best way to accomplish all of the above four hospital goals this is via the following:
- Reduce government regulations on healthcare industry that discourage innovation and create an emphasis on reimbursement criteria over patient outcomes and worker satisfaction
- Continue the Keystone Collaborative to set core measures that focus mainly on best practice medicine and less so on government regulations and reimbursement criteria.
- Creating a combination of order sets that remind doctors of the core values
- Creating protocols to allow point of care fine tuning of order sets to meet patient needs and improve worker satisfaction which will in turn result in improved patient satisfaction with the hospital
- Reduction of costs because only procedures that are needed will be given
It's a tough balancing act to find at potion that works to improving patient care, reducing costs while creating a positive work environment that lends itself to good worker morale, and lends itself to good word of mouth advertising to compliment a positive public relations campaign.
Yet I truly believe less government intervention will result in more creativity by individual medical institution in accomplishing the four goals: improving patient care and outcomes, reducing costs, creating worker satisfaction, and improving the hospitals image.
A combination of core measures that result in a positive balance of order sets and protocols that assure best practice medicine is met at the same time as worker and patient satisfaction is accomplished.
It is possible to accomplish all the above goals at the same time, yet it will take a collaborative effort on the part of hospital administrators, nurses, respiratory therapists, patients, and Congressmen and Senators on both the state and federal level.
The goal should involve increasing individual thought, and decreasing cook book medicine.
