JOURNAL ARTICLE
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Multidisciplinary rounds (MDR): an implementation system for sustained improvement in the American Heart Association's Get With The Guidelines program.

INTRODUCTION: Hospitals throughout the United States face the challenge of developing implementation systems able to sustain improved clinical care over years. The American Heart Association's Get With The Guidelines (GWTGs) program helps hospitals address this challenge with a comprehensive approach to quality improvement for patients with CAD, heart failure and stroke. The Department of Medicine at Berkshire Medical Center, a 300-bed community teaching hospital, developed a clinical care improvement implementation system called multidisciplinary rounds (MDR). We report our performance in GWTGs using MDR.

METHODS: MDR is a patient-focused communication system integrating care delivered by multiple providers using concurrent feedback, redundancy, and rapid cycle improvement. Providers from multiple disciplines meet for 1 hour 3 times per week to coordinate care and assure adherence to evidence-based guidelines for all non-ICU medical patients. Following brief focused presentations, participants view our electronic medical record (EMR) projected on screens, which includes orders, diagnoses, laboratory, medications, cardiology reports, consultations, nursing documentation, smoking and immunization status, and other information. The leaders emphasize the importance of evidence-based order sets in our computerized provider order entry system (CPOE), checklists, and tools. Specific suggestions for interventions and documentation based upon AHA/ACC guidelines are provided.

RESULTS: MDR has rapidly improved adherence to evidence-based measures in all GWTGs programs. In addition, MDR has been associated with sustained improvement in all modules. Berkshire Medical Center has received more performance achievement awards than any other hospital in the United States. These awards include 6 consecutive awards in GWTGs CAD, 3 in stroke, and 2 in heart failure. Cardiovascular process improvements have been associated with a reduction in inpatient AMI mortality from 8.75% to 5.20% (with an expected severity-adjusted mortality of 10.18%). Berkshire Medical Center provides about 80% of the acute care in Berkshire County and thus influences the outcomes of a large proportion of our community's patients. Between 1999 and 2004, Berkshire County had a 26.3% decrease in major CVD deaths compared with a Massachusetts decrease of 17.3% and a US decrease of 17.8%. We have seen a 44.4% decrease in AMI mortality, a 34.5% decrease in stroke mortality, and a 33.9% decrease in heart failure mortality. We have assisted multiple organizations in implementing GWTG and MDR.

CONCLUSIONS: MDR at Berkshire Medical Center is a clinical quality-improvement implementation system that has driven sustained high-level performance in the American Heart Association's GWTGs. MDR has changed our culture, improved coordination of care, been flexible, and facilitated rapid and sustained process improvement. Improvement in evidence-based cardiovascular processes for CAD, stroke and heart failure have been associated with improved in hospital AMI mortality and decreased overall community cardiovascular, AMI, stroke and heart failure mortality. MDR can be used by multiple organizations to drive care improvement.

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