A Q and A on the Care Signature

An interview with Deborah Rhodes, MD, vice president of Care Signature and associate chief medical officer, Yale New Haven Health System, and internist, General Internal Medicine Division, Yale School of Medicine.

 

What is a Care Signature?

Yale New Haven Health’s Care Signature is its recognizable stamp of the highest-quality care delivered by every caregiver in our health system at every site, every day. It is our pledge to patients that no matter where they enter our doors and who delivers their care, they will receive our collective best practice. 

I saw many elements of Care Signature when I arrived here shortly after YNHHS’ first COVID admission. I observed groups with representation from all of the health system’s delivery networks meeting daily to review the evolving COVID evidence, share resources, streamline processes and reach and communicate consensus on how best to care for COVID patients. 

Why is a Care Signature important?

Every patient’s outcome depends upon a collection of many different clinical decisions and processes implemented by many different care providers. There is an enormous amount of variation in these decisions and processes. Some variation is necessary to provide individualized care that meets each patient’s unique needs. But variation can be harmful if it leads to inefficiencies, excess costs or unsafe decisions. Standardizing the things that can and should be standardized is just as important in medicine as it is in other environments where lives are at stake – like the airline industry, which was among the first to embrace this. 

How does having a Care Signature help healthcare professionals?

Medical advances happen so quickly, no clinician can absorb and recall all the knowledge necessary to make the many complex decisions involved in patient care. So we have to build a system – our Care Signature – to support the safest, most current processes. That system still embraces the judgment and experience of individual patients and clinicians. Our Care Signature must be built by and for our own care providers to harness our unique resources, processes and expertise.

What are Care Signature pathways?

Care Signature pathways are like the GPS for clinical navigation – they guide our clinicians and their patients safely and efficiently from diagnosis to treatment to monitoring. Pathways provide all clinicians – from those in training to seasoned experts – all the resources they need, when they’re needed, right in Epic. Care Signature pathways can improve the quality and safety of care, promote patient education and equity, reduce unnecessary tests and consults (which saves time, money and the environment), and save clinicians time. 

What is an example of a Care Signature pathway?

The ICU Clinical Consensus Group has developed multiple Care Signature pathways to guide care for patients requiring mechanical ventilation. The group comprised physicians from different specialties, advanced practice providers, pharmacists, nurses, rehab services and respiratory therapists. They identified 15 steps involved in caring for mechanically ventilated patients, but found considerable variation in these steps across YNHHS. The group developed consensus statements on best practice for each of the care steps, which covered pain management, choice of sedative, ventilator settings and other aspects of care. The consensus statements were incorporated into the Care Signature pathway to guide care providers’ orders and management going forward. 

How have these ICU Care Signature pathways improved care?

Since going live in Epic a few months ago, the pathways have been used more than 600 times across 19 YNHHS ICUs. Results include a 29 percent reduction in average sedation exposure and a 21 percent increase in the type of ventilation designed to protect the lungs. Both of these can help to reduce patients’ time on the ventilator and improve their outcomes. 

How are Care Signature pathways developed?

Each pathway begins by convening a Clinical Consensus Group with experts from every relevant specialty and service. This group includes members from every relevant site, including all YNHHS delivery networks, along with provider groups, such as NEMG, Yale Medicine and the Community Medical Group. The consensus group reviews all the medical evidence and guidelines for a particular condition, then maps each step in care. Mapping shows areas where we do not have consensus throughout the health system. To create the pathway, the consensus group builds evidence and consensus into each care step, adds whatever resources are needed to complete each step and works with Information Technology Services to incorporate the pathway into Epic. 

Who is involved in developing Care Signature pathways?

We have a team of clinicians who are incredibly skilled at building these pathways, and an army of experts who have generously given their time and expertise. We have built more than 100 pathways in about 10 months, with input from more than 700 experts across YNHHS. We hope to engage everyone involved in patient care across the health system in identifying opportunities to promote Care Signature through pathway development and clinical redesign. 

What role do non-clinical employees play in ensuring a consistent Care Signature?

Care Signature is about much more than pathways. Each of us has an important contribution to make to the patients who entrust us with their care. The health system’s current advertising campaign focuses on how YNHHS does things “… with the greatest of care.” Care Signature helps to define what that ‘greatest of care’ is, so we can build it into everything we do for every patient.