In early 2018, Northwestern Medicine will launch Project One, a bold initiative to create a unified electronic health record (EHR) platform across the entire health system. Currently integrating data from myriad clinical, research and educational entities to form a greater whole, Project One continues to be more than just a technological tool.
From averting falls to identifying risk for sepsis, Project One is already having a direct impact on patient care by helping clinicians across the health system adopt “best of the best” practices systems-wide. Clinical collaboratives — multidisciplinary teams focused on quality improvement and safety — have played a starring role in developing standardized protocols for Northwestern Medicine’s Epic-based EHR system.
“Collaboratives bring together clinicians from all our different sites to share successes and challenges on a variety of clinical situations,” says David Cooke, MD, vice president of quality for Northwestern Medicine HealthCare. “From these discussions, we form multidisciplinary teams to implement best practices.”
Of the 30 clinical collaborative projects currently underway, half have focused on Project One. They’re accelerating collaboration and providing critical content for the unified Epic system. From the downtown Chicago medical center to west and north suburban locations, these teams are recommending the essential “mouse clicks” in the electronic record that will ultimately direct patient care throughout Northwestern Medicine.
Accidental stumbles never feel good, but a fall could be devastating for the hospitalized patient.
“In the inpatient setting, we are concerned not only about the patient’s risk of falling but also the risk of significant injury,” says Dave Chilicki, a nurse clinician at Lake Forest Hospital. “If a cancer patient on blood thinners, for example, falls and hits their head, that event could lead to a subdural bleed and possible death.”
Given that falling is a leading cause of hospital-acquired injury across the country, fall prevention made Project One’s short list of critical must-haves for system standardization. “There were different philosophies,” explains Cooke. “Representatives from each of Northwestern Medicine’s regions came together and found the goodness in each of their approaches.”
Prior to the fall prevention collaborative, the west suburban facilities employed the evidenced-based Johns Hopkins Fall Risk Assessment Tool (JHFRAT). They also used a manual color-coded signage system outside patient rooms to alert clinical staff as well as “extended caregivers” such as members of environmental services or engineering who might be able to intervene if they see a patient at risk of falling. At Lake Forest and Northwestern Memorial Hospital (NMH), a modified JHFRAT or “homegrown” version was used with no established signage. Finding common ground under Project One, the group has voted to exclusively use the original JHFRAT protocol, with a plan for signage in the works. Meanwhile, within the unified EHR, new banner bars and alerts will enhance fall prevention interventions.
“The biggest change will be the ability to electronically designate fall risk and history,” says Chilicki, who represented Lake Forest in the clinical collaborative. “That information will be flagged in the patient’s chart and follow them wherever they go, whether to the doctor’s office or other ambulatory setting within our system.”
WARDING OFF SUICIDE
Suicide ranks as the 10th leading cause of mortality in the United States, according to the Centers for Disease Control and Prevention. Tragically, most people who end their lives have had healthcare-related encounters as little as three months to a year before dying.
“Suicide is truly a public health problem,” says Danesh Alam, MBBS, medical director of Behavioral Health Services at Central DuPage Hospital (CDH). “It’s the responsibility of all providers, not just mental health professionals, to screen patients for suicide risk.”
Preventing suicide remains one of the top safety concerns of the Joint Commission. Like many medical centers around the nation, Northwestern Medicine has long implemented suicide risk screening at the greatest entry for acute care: the emergency department. Screening typically involves asking questions that elicit state of mind. The exact questions asked, however, varied from institution to institution until Project One’s Suicide Prevention Project was born to create a system-wide uniform suicide screening tool.
“We were asked about the current screening tool at NMH,” says Patricia Roberts, MSN, RN, director of Psychiatry. “We’ve used validated questions from the VA system.”
Enlisting the help of key multi-location stakeholders such as Alam and Roberts, the Suicide Prevention Project decided to adopt questions used by NMH — one inquiring about feelings of hopelessness and the other about suicidal thoughts. Built into the unified EHR system, this official Northwestern Medicine screening protocol went live at CDH, Delnor Hospital and Kishwaukee Hospital in late April. When Project One fully launches, all ER patients — no matter what their ailment — will undergo the same system-wide suicide screening when their medical histories are taken by the attending emergency department nurse.
“Any major medical condition or event, whether chronic or acute, is fraught with depression, anxiety or both,” says project participant Allison Johnsen, manager of Business & Program Development for the Behavioral Health Services group at CDH and Delnor. “By asking these simple questions and screening for one of the most dangerous forms of mental health, we can save lives.”
MOVE IT OR LOSE IT
Amy Leonard, RN, doesn’t want to be overly dramatic, but putting someone in a hospital bed for even a couple days might be tantamount to a “death sentence.”
“The body confined to bedrest starts to decondition very quickly,” says Leonard, program manager for the Performance Improvement Office based at CDH in Winfield. “If we do not aggressively get patients moving, they are at risk of developing secondary issues from pneumonia to bed sores and are slower to heal.”
In 2011, Anne Drolet, RN, a nurse practitioner at CDH, spearheaded “Move to Improve,” nursing-driven mobility protocol to get patients up and about and ultimately out of the hospital faster. She and her colleagues created an algorithm that gave the nursing team direction and autonomy to advance patient mobility within 72 hours of being admitted. Physical activity could mean many things, from sitting up in bed or standing for a few minutes to walking down the hospital hallway. Says Drolet, “The gold standard is to initiate ambulation activities three times a day.”
Exclusion criteria ensure patients who require bed rest, such as for pregnancy complications or certain critical injuries, stay put. But for most patients, getting their bodies — and spirits — in motion does a body good. “Being able to walk to the bathroom on your own, for example, helps alleviate a lot of frustration for patients,” says Leonard. “Plus, moving around can help with pain control.”
While the mobility protocol has been in play at CDH for seven years, it wasn’t being used to its full capacity. It required a doctor’s order and a literal click of a box in Epic to initiate. Enter Project One. In the process of adapting the mobility protocol system-wide, the clinical collaborative charged with this task determined that the majority of physicians supported early ambulation but didn’t always think to order it.
“So we rebuilt the order in Epic and made it the default,” explains Leonard, who worked with the Project One team. “Now physicians must deselect the mobility protocol if they think it’s not appropriate for their patient. With this change, we’re getting back to the basics of good care.”
On the surface, Project One may seem like a project for IT professionals, but it has always been about much more than tech. Now less than a year away from completion, the process of coming together under one electronic platform is engendering one cohesive culture of quality and excellence at Northwestern Medicine.
“Project One is not just about the record,” says Alam. “It’s really an unprecedented effort to standardize quality procedures and protocols so that any patient who walks into any one of our institutions can expect the same caliber of care.”