(Author’s Note:  Following a hospital survey several questions were raised about how physicians and nurses share their work.  The survey team was alarmed that some physicians were allowing Registered Nurses with Associate Degrees (2 year diplomas) to complete patient evaluations.  While SETMA’s work was lauded, because SETMA is committed to changing how various members of the healthcare team relate to one another, this allowed SETMA to re-think our team-approach to inpatient-healthcare delivery.  This is an analysis of the process SETMA employs in the hospital.)

SETMA’s team approach to inpatient care is a success as demonstrated by the facts that our lengths of stay, quality metrics, cost of care and patient satisfaction are excellent.  And, it is one of the reasons why the indigent, uninsured and unassigned patients for whom we care receive the same quality of care as our private patients.   I would offer the following observations about SETMA’s team.  SETMA has licensed and credentialed healthcare professionals who work to the top of,  but not beyond their legal scope of practice as defined by each of their accreditation agencies..  As a policy issue, the prestigious and influential Health Affairs publication of January 14, 2013,  published an extensive article entitled, Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Non-physicians, And Electronic Communication”   The goal of this transformation is the integrate the teams to increase their efficiency, excellence and economy  This is what SETMA started eighteen years ago.

Fundamental

Fundamental to this entire discussion is the “change of mind” which healthcare providers and surveyors must have.  This metanoia (change of mind) must take place in order for surveyors to distinguish between the excellence of the new and the excesses and abuses of the past, which may at first glance seem similar.  They must know that SETMA’s patients are not treated in isolation, as patients have traditionally been treated.  Traditionally, medical records were locked up in the providers’ offices, or in the hospital’s medical records department.  To judge SETMA by the state of care given by healthcare providers who do not have an integrated delivery system with robust electronic patient management is to do a disservice to all of us.

In the emergency department (ED) and in the hospital, traditionally, the only data continuity was provided by the availability of old hospital admission records.  The problem with those records is that there  may by several years of time and dozens of visits and modifications of the patient’s treatment plan, since the last hospitalization.  So, at best the available records were incomplete and at worst were so outdated they were useless.  And, even when those records were available, they were not interactive. Information had to be extracted from the old record and entered into the new record.  And as mentioned, if the patient had been seen, evaluated and treated fifteen times since the last hospitalization, none of those treatment events was available. 

Not so, with SETMA.  Every encounter, hospital, ED, clinic, all SETMA clinics, physical therapy, etc., are  available to the provider who is assessing the patient.  All of SETMA’s patients’ records are instantly available where ever our patients are being treated and particularly in the emergency department and in the hospital in-patient setting.  That means that there is continuity of care between the ambulatory setting and the ED and inpatient settings, based on the documentation of the patient’s health care in the past.  Medications, diagnoses, treatment plans and plans of care, laboratory data, and physician plans and consultations notes are all instantly available. 

Rarely is a SETMA patient seen in the ED or hospital where the patient has not already had an exhaustive and established diagnoses and plan of care in the clinic.  In addition, the EMR has 29 sets of guidelines for care and each patient has a physician-determined treatment plan in the EMR which plans are easily accessed by any and all SETMA providers.  When the ER physician diagnoses CHF, SETMA has a treatment plan already written for the excellent and expert treatment of CHF.  This is true of COPD, Pneumonia, Respiratory Failure, etc.  Even the treatment orders, which are based on a physician’s diagnoses, are produced by electronic algorithms which are vetted by experts and embedded in our EMR. 

For those patients who are new to SETMA, the diagnostic assessment and the treatment plan is initially determined by the ED physician and not by SETMA’s RN.  There is always a SETMA physician available and typically one is in the hospital until 8 or 10 PM and others come in to the hospital between 2 and 4 AM, leaving only 4 to 8 hours a day when a SETMA physician is not physically available for patient care and collaboration with the SETMA nursing staff either in a personal “huddle” or in an “electronic huddle” by telephone or secure e-mail.. 

Electronic Huddles

One of the elements of Patient-Centered Medical Home is a “huddle.” where a team of providers meet daily to discuss a patient’s care. SETMA is introducing the world to “electronic huddles” made up of multiple communications daily:

1. Morning notes electronically generated and submitted to the hospital care team daily.  These notes give guidance to SETMA’s staff who work in the hospital around the clock to provide continuity of care and quality care to all of SETMA’s patients.
2. iPhone contacts repeatedly during the day and night.  The ability for nursing staff to communicate detailed notes, procedure results or x-ray and lab reports, adds to the continuity of care and to the rapidity with which information is communicated to the entire healthcare team.
3. Secure e-mail allows procedure and test results to be communicated to the provider by the hospital staff allowing adjustments to treatment and initiation of new treatments to occur continuously all day and night.
4. Electronic consultations with consultants and/or specialists can be done efficiently and timely.

Rather than a single point of care once a day, SETMA’s patients receive multiple points of care, multiple times a day, all initiated by physicians and all carried out by members of SETMA’s team.  SETMA’s Model of Care has more physicians and more team member interacting on more patients every day than in any other model.  The reality is that with multiple  “sets of eyes” on a patient’s care, patient safety goes up as it is not unusual for experienced and knowledgeable RNs to bring an issue to the physicians’ attention which has not been addressed.  The physician then gives instructions as how to respond but the real credit belongs to the nurse.  This is only one example as to how the team increases the patient’s quality of and safety of care.  RNs are not being asked or even allowed to operate outside of their licensure, but they are a dynamic and essential part of the healthcare delivery team.. 

On admission, after the history and physician examination is reviewed and approved by the physician, every patient admitted to SETMA receives a Hospital Plan of Care, which is a printed, personalized record of the patient’s diagnoses, consultations, procedures, tests, how long the patient is expected to be in the hospital, the probability of readmission upon discharge, a reconciled medication list and a precise explanation of how to contact both the admitting and attending physician and SETMA’s hospital support time   This is in keeping with the PC-MH Model where our “electronic huddles” even involve the patients and their family. 

Discharge Summaries

As for the discharge summary, that is a function of the chart notes, discharge instructions written by the physician and the morning electronic “huddle,” where a summary is sent to the hospital care team.  Incidentally, if needed, SETMA can produce those documents for the past eight years.  Remember, we don’t do discharge summaries; we do “Hospital Care Summaries and Post Hospital Plans of Care and Treatment Plans” which are produced from the entire written record, “electronic huddles,” oral communications, but NOT from RNs acting independently of healthcare providers.

This is a brief summary of SETMA’s team approach.  We believe this exceeds the current standard of care in our community.  The accreditation visit has given us the opportunity to think about what we are doing.   And, as is our nature, we will continue to improve the process as a result.

The Future