MQS Brings Results

Communication is the key to a stress-free discharge, according to a team of caregivers and administrators who work on unit 5B in University Hospital.

When they talked to patients about discharge procedures, the team from 5B found some problems. They learned that patients often didn’t know their doctors’ names. Patients were packed and ready to leave, but unsure of when they could go home. Getting final dressing changes, test results, prescriptions, follow-up appointments and other items could cause end-of-day bottlenecks that were frustrating for staff and patients. And delays rippled out to affect incoming patients waiting for beds.

“We learned that a lot of pieces need to be brought together for discharge to work well,” says Robert Chang (M.D. 2002, Residency 2005), 5B’s medical director.

Team 5B is one of many teams involved in the Michigan Quality System, or MQS, an effort to “improve everything we do in patient care, education and research,” says Jack Billi, M.D. (Residency 1981), associate dean for clinical affairs and the MQS program director. The philosophy underlying MQS is based on “Lean Thinking,” an approach developed by Toyota and later adapted by GM and other manufacturers.

“We chose lean thinking as a philosophy because it represents a holistic approach,” Billi adds. MQS focuses on reducing overburden, uneven workload, variability and waste. Involving frontline workers in spotting problems — and finding solutions — improves quality, safety and service. Managers support workers by giving them time to investigate the root cause of glitches. Lean thinking isn’t about downsizing or cost-cutting, Billi explains, but about freeing up caregivers and staff to provide the best, most appropriate care and service to patients. That’s hard to do when you’re putting out fires, he says, or fixing the same problem time after time.

During MQS meetings, teams brainstorm possible solutions called countermeasures. If a countermeasure is implemented, the team watches to see if it helps or causes other problems. One countermeasure tested by the 5B team was the installation of white boards to serve as a communications hub in each patient’s room. Nurses use the white boards to record the names of the patient’s caregivers, the anticipated discharge date and time, and a daily plan for getting to discharge, so patients know what to expect. The team also developed an online form which prompts a scheduling coordinator to call the patient. Together they make an appointment for follow-up care before the patient leaves the hospital.

Early data evaluating the success of the 5B team’s countermeasures are promising: In the past, only 60 percent of patients went to their follow-up appointments; now 71 percent do. The percentage of patients visiting the emergency room within two weeks of discharge dropped from 4 percent to less than 1 percent. And readmissions to the hospital declined from the UMHS average of 11 percent to 8 percent for 5B patients. —KIMBERLEE ROTH

Ask about Your Catheter

Most people who are hospitalized for surgery or a serious illness expect treatment will make them better, not worse. Unfortunately, it doesn’t always work that way. Being in the hospital has risks, and one of the most significant is the risk of infection.

Forty percent of all hospital-acquired infections occur in the urinary tract, and 80 percent of these are associated with the use of indwelling urinary catheters. The longer the catheter stays in the bladder, the higher the risk of infection.

Michigan physicians were surprised to discover that most American hospitals don’t have a consistent strategy in place to monitor catheter use and prevent urinary tract infections, called UTIs, in their patients. Sanjay Saint, M.D., a professor of internal medicine and a research scientist at the VA Ann Arbor Healthcare System, and his co-researchers, surveyed 719 U.S. hospitals about practices used to prevent UTIs.

The researchers found that less than half of hospitals responding to the survey kept track of which patients had a urinary catheter, and only 26 percent kept track of how long catheters had been in place.

Until more hospitals start taking urinary tract infections seriously, Saint advises patients to speak up. “The bottom line for hospitalized patients and their families is, if you have a catheter, ask the doctor or nurse every day if you still need it,” he says. —SP

Counting Lymph Nodes

How do you measure the quality of medical care? It can be tricky, especially when it comes to cancer. For example, how many lymph nodes should be tested after colon cancer surgery to determine whether the patient’s tumor has spread?

The National Quality Forum, an organization that sets health care quality standards for hospitals and physicians, says the right answer is at least 12 lymph nodes. But a recent U-M analysis of medical records from 30,625 patients undergoing colon cancer surgery found no statistically significant difference between patient survival times in hospitals that examined 12 or more lymph nodes compared to hospitals that checked fewer lymph nodes.

The bottom line is that valid indicators for the quality of hospital care must be clearly correlated with patient outcome, according to Sandra Wong, M.D., a surgical oncologist in the U-M Comprehensive Cancer Center.Wong was first author on the study which was published in the Journal of the American Medical Association. —SP

More on lymph node counts in colon cancer

Focus on the Caregiver

In 2005, Bob Collins and his wife, Carolyn, received devastating news. The prostate cancer he fought four years earlier had spread to his lymph nodes and was now incurable. As Bob’s primary supporter and caregiver, Carolyn kept many of her fears to herself. “He has enough on his plate without worrying about me falling apart,”; she says.

“The spouse of a patient with advanced cancer experiences as much distress, if not more, than the patient,” says Laurel Northouse (Ph.D. 1985), R.N., the Mary Lou Willard French Professor of Nursing at the School of Nursing and co-director of the Cancer Center’s Socio-Behavioral Program. “Often, they don’t get the support they need to carry on their care-giving role.”

Recently, the Collinses agreed to be part of a pilot education and support program called FOCUS. The program was created by Northouse and her colleagues to study the effects of cancer on patients and their caregivers.

Specially trained nurses met with more than 200 couples participating in the FOCUS study. During three 90-minute home visits and two 30-minute phone sessions, nurses tailored the program to address each couple’s needs. In the Collinses’ case, Bob and Carolyn discussed their worries openly. “We had been pretty open about talking about tests and things,” says Carolyn, “but fear about what the end will be like and how I will hold up — those we hadn’t really dealt with.”

Northouse found that FOCUS had positive effects on both patients and partners, but partners actually benefited more. After being in the program, caregivers reported feeling less hopelessness and uncertainty, and more confidence in their role, as well as better mental and physical quality of life. Northouse is now working on a larger study, involving other types of cancer and looking at different ways to offer caregiver support at a lower cost and to a broader audience, perhaps using the Internet.

That would please Carolyn Collins who, with Bob, concentrates “on living every day as fully as we can.” The two recently returned from a trip to India and visiting grandchildren in Wisconsin. FOCUS helped them through some rough patches, she says, “and it makes me sad to think others who are fearful wouldn’t have the opportunity to participate.” —KIMBERLEE ROTH

More on the caregiver support study

More than Diabetes

Controlling diabetes is never easy, but older adults who must cope with diabetes in addition to other chronic diseases find it especially difficult. According to a research study led by Eve Kerr, M.D., and John Piette, Ph.D., 92 percent of diabetics over age 55 have at least one other serious medical condition — often hypertension, heart disease, stroke, lung disease, cancer or arthritis. Nearly 50 percent have three or more diseases.

Dealing with multiple conditions can affect a patient’s ability to manage their diabetes effectively and prevent complications, adds Kerr, an associate professor of internal medicine and acting director of the Ann Arbor VA Center for Clinical Management Research. “It’s important to treat the whole patient,” she says. “In addition to talking about diabetes, physicians also need to talk about how heart failure, hypertension or other diseases can affect self-management.” —SP

More about diabetes and co-existing conditions

Health Briefs

Are you looking for an easy way to add more fruits and vegetables to your diet? Then the Comprehensive Cancer Center has a Web site for you. Do you love asparagus, but loathe eggplant? Enter your preferences, and the site brings up recipes that include only the fruits and vegetables you like. Recipes were developed by Graham Kerr, TV’s “Galloping Gourmet.”

Cancer Center Recipes Just for You

David Stutz (M.D. 1971, Residency 1974) is the creator of a Web site called “Ask the Podcast Doctor” (www.askthepodcastdoctor.org). Stutz interviews Health System experts to provide answers to health and medical questions submitted by e-mail. A new podcast is posted every Thursday.

Ask the Podcast Doctor

So you’ve tried antihistamines, antibiotics and sprays, but the drainage and stuffed-up feeling keeps coming back? The good news is there’s a cheap, safe and easy treatment that can help. It’s called nasal irrigation or nasal lavage. U-M researchers found that flushing warm salt water through the nasal passages reduced the severity of symptoms more than a saline spray. All you need is salt, warm water, a bulb syringe and a little practice. —SP

More on the nasal irrigation study
UMHS video on nasal irrigation