title: ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery.
abstract: OBJECTIVE
  To test whether an integrated delivery system could, through the application of process redesign methodology and reliability science, implement multiple evidence-based medical practices across the continuum of care for a specific surgical intervention and deliver these practices consistently.
  
  
  METHODS
  The programme-ProvenCare--had three components: establishing best practices for elective coronary artery bypass graft (CABG) patients; assembling a multidisciplinary team to "hardwire" these best practices into everyday workflow; and implementing the programme with real-time data collection, feedback and focused redesign to reach high reliability. Surgeons reviewed all class I and IIa 2004 ACC/AHA guidelines for CABG surgery and translated them into 19 clinically applicable recommendations. A frontline multidisciplinary team "hardwired" these, resulting in 40 measurable process elements. Feedback of gaps in care was given and the process redesigned as needed. Clinical outcome data on consecutive elective CABG patients seen in the 12 months pre-intervention were then compared with a post-intervention group.
  
  
  RESULTS
  Initially, 59% of patients received all 40 elements. At 3 months, compliance reached 100%, fell transiently to 86% and then reached 100% again, and was sustained for the remainder of the study. The overall trend in reliability was significant (p = 0.001). 30-day clinical outcomes showed improved trends in 8/9 measured areas (eg, patient readmissions to ICU decreased from 2.9% to 0.9% and blood products usage decreased from 23.4% to 16.2%). Operative mortality decreased to zero, but only likelihood of discharge was significant (p = 0.033). Frequency and length of readmissions fell, as did mean hospital charges.
  
  
  CONCLUSIONS
  Frontline medical care providers, led by process design specialists, can successfully redesign episodic processes to consistently deliver evidence-based medicine, which may improve patient outcomes and reduce resource use.
authors.affiliation: Geisinger Health System, Division of Clinical Effectiveness, Danville, Pennsylvania 17822, USA. saberry@geisinger.edu
authors.forename: S A
authors.initials: SA
authors.lastname: Berry
authors.forename: M C
authors.initials: MC
authors.lastname: Doll
authors.forename: K E
authors.initials: KE
authors.lastname: McKinley
authors.forename: A S
authors.initials: AS
authors.lastname: Casale
authors.forename: A
authors.initials: A
authors.lastname: Bothe
mesh_terms: D000368:Aged; D003266:Continuity of Patient Care; D001026:Coronary Artery Bypass / Q000592:standards*; D017558:Elective Surgical Procedures / Q000592:standards*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team; D010359:Patient Readmission / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D016730:Program Development / Q000379:methods*; D011785:Quality Assurance, Health Care / Q000379:methods*; D015203:Reproducibility of Results; D014481:United States