American College of Cardiology

(BETHESDA, MD)—Members of the cardiovascular community are using a new approach—and a series of handy tools—to make sure they're doing everything they should to protect their patients' health.

"There is a great deal of evidence to show that when clinical guidelines are implemented, the quality of care improves," said American College of Cardiology (ACC) President Douglas P. Zipes, MD, of Indianapolis. "Unfortunately, there is also evidence to show that all too often guidelines aren't implemented."

The College and other medical societies are working to change that. The ACC's Guidelines Applied in Practice (GAP) initiative helps providers follow clinical guidelines from the time patients arrive at the hospital until the time they are discharged. The American Heart Association's (AHA) new Get With the Guidelines Program on secondary prevention begins at the point of hospital discharge, providing an Internet-based tool that simultaneously provides a discharge checklist, additional information for practitioners, and a data-collection tool.

Dr. Zipes, AHA Past President Lynn Smaha, MD, PhD, and several others shared good news about these projects in a satellite broadcast titled, "Improving Cardiovascular Care Through Local Partnership Efforts: The GAP Initiative in Southeast Michigan" in July. Cosponsored by the College and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), the broadcast reached hundreds of physicians, nurses, administrators, and other health care professionals participating at more than 60 sites around the country.

A GAP Tool Kit
The main focus of the broadcast was the GAP initiative's successful project on acute myocardial infarction (AMI) in Michigan. Launched in 1999, the project brought the ACC together with the Greater Detroit Area Health Council and the Michigan Peer Review Organization. Working collaboratively, they created various tools to help 10 area hospitals bridge the gap between what clinical guidelines recommend and what physicians, nurses, and patients actually do. The project saw positive trends or significant improvements in almost all of the quality indicators it targeted.

At the core of the Michigan project is a set of tools designed to remind users of key elements in the 1999 update of the ACC/AHA Guidelines for the Management of Patients With AMI. "In the heat of the moment, it's very difficult to remember everything you need to do, every time—especially in a health care setting where the amount of knowledge is increasing exponentially," said Kim A. Eagle, MD, of Ann Arbor, Mich., co-principal investigator of the Michigan GAP Project and chair of the ACC/AHA Task Force for the Development of Performance Measures in Cardiovascular Care. "We need to help health care providers remember the key things they need to do and embed those reminders right in the care itself."

Targeting what Dr. Eagle calls the "triangle of care" consisting of physicians, nurses, and patients, the GAP tool kit consists of templates for the following items:

• Standard orders that remind physicians what to do when they admit a patient with AMI;
• A critical pathway that reminds nurses of the critical milestones in care that should occur within 24 hours of admitting a patient with AMI, after the first 24 hours, and at discharge;
• A pocket guide/pocket card that distills the guidelines down to a dozen key points;
• A one-page patient information form that tells patients what to expect during their hospitalization;
• A patient discharge form that outlines the lifestyle modifications and other steps patients need to take once they go home;
• Chart stickers that go on the front of patients' charts to act as visual reminders of the GAP Project; and
• Hospital performance charts with data that indicate how well a hospital has adhered to guidelines in the last year or two.

To download these tools, simply click on the GAP area of the College's Web site. If you don't already have the software necessary for reading PDF files, follow the site's directions for downloading a free copy of Adobe Acrobat Reader.

A Culture of Quality Improvement
Hospitals don't have to use all of the tools or use them just as they are, said Dr. Eagle. The GAP initiative doesn't tell hospitals how to provide care at their own institutions, he said. Instead, it encourages hospitals to choose the elements they need, modify the tools to suit local conditions, and customize them with their own logos.

"One thing hospitals should do is embed the tools in an overall context of quality improvement," emphasized Dr. Eagle. "You can't just hand over a tool and expect it to work," he said. "You have to help hospitals, doctors, and nurses understand the philosophy of guidelines-based medicine that underlies the tools."

One way to achieve that goal is to enlist the help of "opinion leaders." Cardiologists and other opinion leaders from inside a hospital can help convince others in the institution of the importance of practicing evidence-based medicine. Opinion leaders from outside a hospital can use their fresh perspectives to help identify barriers that are hindering providers' ability to adhere to guidelines.

Physicians and nurses aren't the only ones who need to understand the project's importance, however. Because the GAP model requires unusually fast processing of medical records, opinion leaders also need to convince medical records departments how important quality-improvement efforts are.

Getting everyone on board with quality improvement demands partnership at all levels, said co-principal investigator Cecelia K. Montoye, RN, MSN, CPHQ, of Ypsilanti, Mich., who was the Michigan Peer Review Organization's AMI GAP Project manager and is now the ACC's project manager for GAP Projects in Michigan. "None of the partners involved in this project could have done it on their own," she said. "Partnership was critical for the project's success." The ACC's participation got the local cardiologists excited about the project, she explained. The Health Care Quality Forum of the Greater Detroit Area Health Council brought its history of quality-improvement efforts. The Michigan Peer Review Organization brought its expertise with data.

Future Goals
Now the GAP Program is expanding into new areas. In Oregon, principal investigators Mark M. Huth, MD, PhD, and Ruth Medak, MD, will use the GAP model to find ways to improve adherence to the heart failure guidelines in the physician office setting. In Alabama, principal investigators John G. Canto, MD, MSPH, and Catarina I. Kiefe, MD, PhD, will focus on stable angina. In coming years, the College hopes to expand these ongoing GAP projects and launch new ones.

In Michigan, the momentum inspired by the GAP Project is still going strong. "The GAP Project doesn't just say, 'Yes, quality improvement is a great thing like motherhood and apple pie.' It carries that idea forward into an initiative that has seen measurable improvement," said Bob Parrish, of Detroit, the senior vice president of restructuring delivery at the Greater Detroit Area Health Council. "Perhaps as important as the 10 participating hospitals improving the quality of their care was the fact that the project reinvigorated people's commitment to quality improvement. Now we're going to build on that success."