At its core, Choosing Wisely revolves around the idea of high-value care—providing valuable care while minimizing the costs associated with it.
While there is still work to do toward raising greater awareness about the importance of high-value care, a number of institutions across the country are championing the Choosing Wisely campaign and its concepts. Here are three of their stories.
Vanderbilt University Medical Center
April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, is the associate chief nursing officer in the Office of Advanced Practice at Vanderbilt University Medical Center and acute care nurse practitioner. She first heard about the Choosing Wisely campaign from a Vanderbilt colleague who called Kapu and asked to speak with the nurse practitioners. As soon as Kapu learned about the campaign, she realized that the nurses shouldplay a much more active role in spreading the word. “I realized the nurse practitioners and physician assistants should not just be told about it, but they should be able to take the lead in their particular areas,” Kapu said. And that is exactly what they did. In 2015, the advanced practice registered nurses (APRNs), in conjunction with an interdisciplinary Choosing Wisely committee, launched an initiative to track laboratory and radiography use in six intensive care units and several specialty units.
The nurses helped develop promotional flyers about the initiative, used e-mail to announce it, and created customized slide decks to be used for presentations. The goal was to see whether educating staff about Choosing Wisely could lead to a reduction in the number of unnecessary tests.
The result was exactly what the nurses hoped. Not only were they able to increase clinician awareness, but they helped develop better ordering practices with a decrease in unnecessary tests and procedures.
The success of the initiative showed the impact APRNs can have on the number of unnecessary tests. With that in mind, the Vanderbilt Advanced Practice Registered Nurse Choosing Wisely Collaborative (www.mc.vanderbilt.edu/nursingoap/49500) was launched to bring together APRNs from institutions across the country to discuss how to implement Choosing Wisely initiatives, track the results, and learn from each institution’s experiences. The collaborative received a grant from the American Association of Nurse Practitioners to facilitate the work.
“The key is everybody is coming to the table from their own institutional culture and climate,” Kapu said. “The way their teams are set up is different. Their challenges are different. And yet there are similarities that come up in the conversation that everyone can take away.”
One of the lessons Kapu and her colleagues shared is the importance of having stakeholder buy-in on the project. When the Vanderbilt APRNs first led their internal Choosing Wisely initiative, some of the teams were not successful because they did not get support from key decision-makers. “There was an assumption early on that everyone would support the project, and we didn’t realize there would be some people who would be super-opposed to it,” Kapu said. It became clear that much of the opposition resulted from misunderstanding the project’s objective. Some believed the goal was to completely eliminate certain tests. The APRNs reassured them that this was not the intent.
The team revised the educational materials to clarify that no tests were being eliminated. Instead, they were simply encouraging staff to ask themselves whether a test they routinely order is actually needed. For example, the cardiovascular intensive care unit (ICU) at Vanderbilt used to have a chest radiography order rate of approximately 130%, meaning that patients were having more than one radiograph per day. By simply asking whether or not a patient with a certain type of surgery needed to have a morning radiograph, the cardiovascular ICU team not only reduced the number ordered, but also showed a cost savings of approximately $55,000 per month.
Today, approximately 20 different organizations from around the country participate in monthly calls as part of the collaborative. They talk about challenges with collecting data. They talk about ways to better promote their respective initiatives. Most importantly, they talk about lessons learned through their experiences. The collaborative’s leadership team created guides for other institutions to start projects of their own. The guides contain notes about methods that work and tips for all types of projects. The collaborative also features an online discussion boardwhere members have day-to-day conversations.
More than anything else, the collaborative provides structure for other institutions and their project development, implementation, and evaluation. “For me,” Kapu said, “the biggest success is being able to help clinicians who are actively engaged in patient care be a part of a project like this, or lead a project like this and see it through to the end, and then disseminate the findings.”
Mayo Clinic Jacksonville
Mayo Clinic’s campus in Jacksonville, Florida, USA, joined the collaborative in July 2017. According to Ami A. Grek, MSN, ACNP-BC, the lead advanced practice provider (APP) in the Department of Critical Care, the decision to join was pretty easy. “Hearing all the projects other APPs were leading at other institutions was pretty inspiring,” she said. “It motivated our group.”
As Grek and her team considered potential projects to focus on, they turned their attention to the liver transplant unit. Mayo Clinic’s liver transplant program is housed in three Mayo Clinic campuses—Florida, Minnesota, and Arizona—and is considered one of the foremost in the field. Jacksonville’s program has performed more than 3,000 transplants and is recognized as one of the best hospitals for digestive disorders by U.S. News & World Report.
The team discovered that, within the liver transplant unit, numerous complete blood counts (CBCs) and CBCs with differential were ordered routinely—often daily—whether they were needed or not. “We recognized that as a gap,” Grek said, “and perhaps there were some things we could do to help reduce the number of CBCs.” The team got stakeholder input and was met with overt encouragement. According to Grek, that is due to the culture within the Mayo Clinic. “Physicians and administrators are used to APPs really being engaged, so we got positive feedback and support,” Grek said. “If you’re not getting buy-in from your key stakeholders—these are the people who are going to help you implement the project or the improvement—I think you have less chance of being successful.” Grek and her colleagues relied on a variety of Choosing Wisely tools to help educate themselves and their colleagues, from sending memos to colleagues about the project to posting “tip sheets” about high-value care in various work areas.
The project goal is to reduce the number of CBCs and CBCs with differential by 15% over the course of six months. Although the implementation phase, which began in January, is still in process, Grek said she has already learned a valuable lesson, one she is sure to share with her collaborative colleagues. “In order to be successful, you need to pick something that you’re interested in and where you recognize there’s agap,” she said. “The main key is having interest in the problem and making sure you’re able to see the project through.”
Cedars-Sinai Medical Center
Rodrigo Alban, MD, recognized a gap soon after he arrived at Cedars-Sinai Medical Center in Los Angeles, California, USA. Alban, a surgical intensivist and the associate director of surgical performance improvement and the general surgery residency program, was struck by the number of times tests were ordered for patients in the surgical ICU whosimply did not seem to need them. “One thing I noticed after coming here was the culture for ordering laboratory tests was a little unusual,” Alban said. “A lot of lab tests in the ICU.”
There are a number of aspects to Alban’s professional role at Cedars-Sinai, but they all stem from either implementing high-value care practices or being a leader in the area of surgical education. Putting these two elements together, Alban saw an opportunity to engage his residents and educate them on the importance of high-value care and the potential downsides, both physical and financial, of ordering excessive laboratory tests.
The plan was to have the residents determine whether implementing high-value care processes within the surgical ICU would affect the number of common ancillary tests being performed. The processes residents introduced included daily checklists, staff education, and visual reminders about the importance of ordering a laboratory test only when necessary.
The project ran from July 2014 through June 2015. It was an enormous success. The residents saw a significant decrease in the number of laboratory tests ordered without seeing an impact on the condition of patients in the surgical ICU. Specifically, the group focused on five laboratory tests: arterial blood gas analysis, complete blood count, basic metabolic profile, coagulation profile, and chest radiography. All five tests saw a reduction of more than 10% after implementation of the new processes. The reduction in arterial blood gas analyses was more than 50%.
Not only did the project reduce the number of laboratory tests without affecting medical outcomes, but it resulted in a monetary savings of more than $700,000 per year. The project received the Best Residency Initiative Award at the 2017 High Value Practice Academic Alliance national conference. “We were surprised and excited,” Alban said of the award. “We didn’t really expect so much recognition. It went from a small internal project to a nationally recognized project that I think a lot of other institutions can learn from and apply and be successful.”
One of those key lessons is the same as what April Kapu and her colleagues at Vanderbilt realized: you need to have approval and encouragement from leadership. “If you want to make a dent in high-value care, there has to be institutional support from leadership,” Alban said. “Otherwise, it’s just one person trying to move the needle one way or another, and it won’t be as impactful.”
This project was just one of a number of ways Cedars-Sinai has embraced the Choosing Wisely campaign. As of August 2017, the hospital had integrated roughly 100 different Choosing Wisely recommendations into its electronic medical records system that produce an alert whenever a laboratory order conflicts with Choosing Wisely guidelines.
The integration of the guidelines had produced an overall annual savings of more than $6 million as of 2016. Alban also recently worked on an initiative with other ICUs to examine the rise in use of continuous renal replacement therapy (CRRT) and, more significantly, the increase in time patients spend on CRRT. At that time, there were no standardized guidelines to address CRRT use and, while there was tremendous use of CRRT, there were also tremendous increases in cost with no real significant change in patient outcome. Alban helped develop guidelines within Cedars-Sinai for CRRT use and, in the process, was able to save the hospital money.
That is what high-value care is all about. “We all need to really change the way we practice medicine,” Alban said. “The healthcare environment is changing. We need to understand that waste is a problem. At the same time, we can’t compromise patient care.”