Module 08 Written Assignment – Case Study – Reducing 30-day Readmissions

USING GUIDELINES TO DRIVE QUALITY

In the health care system with which I am associated, the quality management department works with administrative and clinical leadership toward reaching the goal of providing safe quality care regardless of the point at which the patient interacts with the system, from ambulance emergency medical service (EMS) through home care. The standard of care should be the same, that is, excellent, at every level of the continuum of care. Success in this goal requires oversight of the care delivered at every stage of each episode of illness and hospitalization, and also effective communication among staff and others at different levels of care. Our health system uses clinical guidelines to effectively promote communication across levels of care and to continuously and concurrently monitor patient safety.

Because our health system is committed to promoting patient safety, maximizing the efficiency of care and the proper use of resources, and to financial responsibility, incorporating clinical practice guidelines and clinical pathways based on those guidelines has proved extremely productive for standardizing care and reducing variation across the system. These clinical pathways, called CareMaps, serve as powerful internal drivers of quality care.

National regulatory agencies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), recommend the use of clinical practice guidelines, either those promulgated by respected professional societies, such as the Agency for Healthcare Research and Quality, or those developed in-house, to improve quality, utilization, and patient education. Guidelines can also improve treatment protocols. Because individual physicians do not have access to large samples of patients or treatment protocols, they are forced to rely on their individual experience and their judgment, one case at a time. Guidelines make evidence from aggregated populations of patients available to the physician. However, the hospital has to overcome two cultural obstacles that lead to resentment: physicians’ perception that guidelines force them to do “cookbook” medicine and physicians’ and nurses’ feeling that documenting care on the medical record is meaningless paperwork that takes time and effort away from real patient care.

The original intent of the CareMaps was to define patient flow and to provide information for monitoring length of stay (LOS). Standardizing care results in appropriate LOS; unanticipated and unexplained variation from the standard of care increases LOS. CareMaps outline expected key interventions and outcomes along a time line for specific disease processes. When a patient is initially diagnosed, he or she is put on the appropriate CareMap (for heart failure or for hip replacement, for example), with the physician noting what should be accomplished in the patient’s daily plan of care (see Table 8.1). The CareMaps incorporate evidence-based guidelines as well as physician orders and clinical judgments. Therefore they are tailored to meet the needs of individual patients.

If a patient does not receive an expected intervention, the reason for the omission is documented on the CareMap. For example, if because of some contraindication or comorbid condition a patient with heart failure doesn’t receive an electrocardiogram (EKG) or a chest X-ray that is required by the evidence-based treatment guideline, that important information is recorded on the CareMap variance form and thus made available to all the caregivers on the caregiving team. Likewise, if an anticipated outcome (such as adequate oxygen saturation) does not result from a treatment, that is crucial information for the caregivers as well. At the same time, if the patient does not receive the EKG or X-ray, not due to any clinical reason but because of an organizational problem, such as poor communication among caregivers or inadequate documentation, that omission can be immediately rectified because variance from the expected treatment is also monitored and documented on an ongoing basis.

ENSURING THAT THE STANDARD OF CARE IS MET

The reason communication breakdowns occur is that in today’s complex health care environment, it not unusual for a patient to have multiple caregivers from various disciplines, caregivers with little coordination for moving through an episode of hospitalization. Oversight and communication are further complicated by the fact that each of the professionals involved in the caregiving process may have a unique style of interacting with other members of the professional staff, and an individual competency with language, communication skills, and information transfer. Without coordinated care at the bedside, and documentation of that care, both the patient and the organization are vulnerable to clinical and financial inefficiencies, with patient safety vulnerable as well. Without adequate communication, there is an increased risk for undesirable outcomes. The evidence-based clinical pathway serves as a methodology to coordinate and standardize the best quality care for a specific disease process and provides a permanent record of the multidisciplinary plan of care and the delivery of that care (see Figure 8.1).

Table 8.1. Heart Failure CareMap.

If hospitals are to improve the quality of care delivered to their patients, communication, discussion, data, and interdepartmental collaboration have to become entrenched in the culture. CareMaps are most useful in promoting interdisciplinary communication and accountability because they make documentation centralized and accessible. When working with clinical guidelines the entire caregiving team agrees on specific interventions, outcomes, and objectives—and the treatment is documented daily, as is the outcome of that treatment. In this way the CareMaps promote communication among care providers and the rest of the health care community. They detail specific treatments, actual outcomes, and ideal timing. They delineate the daily schedule of activities that affect the patient.

Everyone has to be on the same page in order for patient care to be continuous and effective. The physician orders the therapeutic interventions that should occur; the nurses monitor that these interventions are timely; other disciplines, such as physical therapy and respiratory therapy, can look at the CareMap and easily discern what treatments have already occurred and what remains to be accomplished; in other words, everyone can see where he or she fits into the overall process of care. Most important, during shift changes, where studies show communication gaps are frequent, the oncoming shift can see at a glance the daily progress of the patient.

CAREMAPS PROMOTE STANDARDIZED CARE

CareMaps are an extremely useful tool for helping the nurse improve the delivery of care because they provide a framework for treatment of a particular disease or condition. Generally, it is the nurse who documents the care services delivered daily to the patient. Because it is outlined on a pneumonia CareMap, for example, that unless contraindicated a pneumonia patient should change from IV antibiotics to oral antibiotics on Day 3 of hospitalization, the nurse can anticipate and plan, not only for one patient but for every pneumonia patient. If there are no unanticipated outcomes, changing medication to an oral antibiotic can signal to discharge planning that the patient will be ready to be discharged on Day 5.

Most important, the outcomes for patients treated according to guidelines are generally superior to the outcomes for those who aren’t. For example, data on heart failure patients has shown that the patients on clinical pathways that incorporated evidence-based medicine guidelines had a better record of nutrition consultations and timely medication delivery than the comparison group did. Consequently, those patients had more weight gain and were more compliant with dietary restrictions and medication administration. The patients on the CareMap recovered more quickly and were able to leave the hospital on time and with fewer complications. Clinicians who were made aware of these data recognized the effectiveness of following the guidelines.

Another advantage of incorporating CareMaps into clinical practice is that their use ensures standardization of care across different facilities. Providing a single consistent standard of care, to be applied whether a patient is treated in a tertiary care facility, a nursing home, an EMS ambulance, or a emergency department (ED), requires a deliberate and defined structure. In order to evaluate whether the care is standard or varies from the standard, it is crucial to carefully formulate uniform definitions regarding treatment. The CareMap provides the outline of the standard of care.

Guidelines establish treatment protocols on a proactive basis, improving safety for the patient. Rather than responding to an event with a retrospective analysis of what might have gone wrong with a single patient (as is done in a morbidity and mortality conference), guidelines can improve care for an entire class of patients—patients experiencing pressure injuries, alcohol withdrawal, or stroke, for example. In addition, in these litigious times physicians can protect themselves from lawsuits if they have documented that the standard of care has been met. This is especially useful when there is an adverse event and the mandatory investigation shows evidence that all processes and procedures were entirely appropriate and that best practices were followed along the treatment plan.

If guidelines are in use, establishing processes for optimal care, any deviation from that care can be noted and addressed promptly. With guidelines incorporated into the CareMap, quality management staff can pinpoint which units and physicians are complying with pathway documentation and which are not.

Research reveals that when patients become partners in their own care, results are improved. Each patient in our health care system who is on a CareMap receives a patient friendly version of the CareMap that outlines what will happen, when, and why. Being informed allows each patient to anticipate and understand his or her plan of care. The explanations that are provided for tests and medication help to reduce patient anxiety as well. Patients who understand the rationale behind monitoring their diet or their fluids, for example, have better results than those who have no information provided. In addition, patient education demystifies the medical process because an orderly plan of care is prepared. For example, patients with heart failure receive information about managing their condition that stresses and explains the importance of weight control and diet, and information about when to call the doctor (see Figure 8.2).

VARIANCE DATA HELP DRIVE QUALITY

Clinical pathways outline a treatment algorithm that works to benefit the patient, the physician, and the organization. Any deviation from the standard of care that may influence the quality of care or the patient’s outcomes, alter the expected discharge date, or affect the costs of the hospitalization is collected as variance data, with an explanation.

Variance data force the entire caregiving team to focus on expected interventions and outcomes, and patient-specific variance data allow the team to address causes for variation from the standard in a timely way. In our system, variance data from key interventions and outcomes are collected daily, generating immediate feedback about why the patient is not meeting the expected treatment goal.

A scannable variance form is completed by the primary registered nurse and sent to quality management analysts for concurrent review. Caregivers can be alerted to any variation from the standard of care, and if appropriate, corrective action can then be taken. Variance can also serve as a retrospective performance improvement tool. Reports can be aggregated and sorted by source of variance (patient, family, medical discipline, practitioner) and the resulting data can help to identify the effectiveness of treatment interventions and outcomes for a patient population, such as heart failure patients.

Constant feedback is an important element of improving the delivery of care. Retrospective analysis of variance data determines whether or not there are patterns and trends that require improvement efforts. Not only can potential managed care problems be identified through retrospective variance analysis, but payers are more amenable to negotiating favorable contracts when they are confident that a process is in place to quickly identify problems that might result in a prolonged LOS. Again, clinical and financial efficiency are interrelated.

When data reveal gaps in the delivery of care, action can be taken. For example, aggregated data regarding outcomes for pneumonia patients were analyzed for a one-year period and showed that discharge instructions, including smoking cessation counseling, were not being delivered effectively. Improvement efforts were then targeted toward a better process, and care was thus improved for this patient population.

Data are aggregated to identify trends. For example, if congestive heart failure (CHF) patients are not receiving ACE (angiotensin-converting enzyme) inhibitors on the first day, the variance data record why not and also where in the hospital this is happening. The database can analyze care from the system level down to the individual physician. Variance data help leadership prioritize improvement efforts and assist the clinicians with comparative data for education.

Measures, such as the number of days a patient is hospitalized, don’t explain why a patient had a comparatively short or long LOS. However, tracking information on a CareMap details the patient experience on a daily basis: what treatments were delivered and what outcomes resulted. Because any variation from the expected algorithm of care is documented on the CareMap, complications are quickly identified and can be treated. Variance data help identify problems during a patient’s stay, a result that is especially useful in understanding LOS and evaluating whether care was appropriate.

The use of CareMaps has been shown to have great value. Not only do they create order at the patient’s bedside by coordinating and documenting care but they also allow caregivers and administrators to monitor interventions and outcomes for quality as well as for cost and resource effectiveness. Because clinical pathways reinforce multidisciplinary communication, accountability is increased. Everyone involved in managing the patient is conscious of being part of an interdependent team. This patient-centered mind-set works to the advantage of the patient and the organization. The CareMap methodology has helped our system reduce day-to-day variation in resource and treatment patterns and at the same time has provided a framework for building a highly efficient, outcome-focused care delivery system.

DEALING WITH RESISTANCE TO CAREMAPS

Introducing change frequently meets with resistance, and learning to use CareMaps is no exception. Some nurses reject the CareMap as meaningless paperwork; some physicians reject the CareMap as cookie-cutter medicine. Providing education about CareMap value helps the organization at every level. Although some physicians may resist using CareMaps, either because they feel it overrides their autonomy or because they feel it is a nursing tool and does not concern them, others see the advantages. They realize that their individual knowledge coupled with the aggregated knowledge of evidence-based medicine will lead to the best results.

Nursing staff are generally less reluctant than physicians to implement CareMaps but still require education on CareMaps’ use and usefulness. To accomplish this in our system, quality management staff went to the different hospitals to establish train-the-trainer programs in individual units so that there would be on-site expertise in how to use the CareMap and fill in the variance form. By examining the CareMap the nurse can see at a glance what treatment or tests were accomplished on a specific day and what the next step in treatment should be, and with what expected outcome. Especially valuable during shift changes, when crucial information regarding individual care plans can be lost, this permanent record of information can help the nurse organize the patient’s care. Once a nurse realizes the advantage of CareMap documentation to patient care and to the organization of the unit, his or her reluctance to use it decreases.

IMPLEMENTING GUIDELINES TO DRIVE QUALITY CARE

Guideline development, implementation, and acceptance involve lengthy and complex processes. Multidisciplinary, disease-specific task forces, composed of potential clinical stakeholders from across the organization, should meet to evaluate and develop guidelines that are both based on the literature and individualized to meet the needs of the specific institution. Professional buy-in to guidelines helps to ensure their acceptance. When multidisciplinary teams develop the internal guidelines, research the expert literature, and champion guideline implementation to their peers, consensus for guideline use improves. Using multidisciplinary teams at this stage also increases accountability in treatment because the different disciplines have agreed on what is expected and how to coordinate services. Another advantage to asking the stakeholders to develop the guidelines is that they understand the limitations of the institution, the kinds of implementations that are realistic, and the resources that can be tapped. As with all improvement efforts, administrative leaders must support the task forces and their goals for the improvements to be effective.

In our system, after months of development, guidelines are presented to the appropriate performance improvement coordinating group for discussion and evaluation. Once finalized, the guidelines are reviewed by the department chair or director of the appropriate service, the medical board of the hospital, the nurse executive, and the multidisciplinary quality improvement committee before approval. With so much professional input and so many evaluative opportunities, clinicians feel less as though they have had something imposed on them from an external source and are more willing to use the guidelines.

Once approved, guidelines still have to be continuously monitored for ongoing effectiveness and updated as appropriate. As new information and technology influence medical treatment, guidelines have to be revised accordingly so that patients receive the most current standard of care. Educating the staff about such revisions can take many forms—system and hospital committee meetings, patient care rounds, in-service training programs, teleconferences, and train-the-trainer programs. Through education about the benefits of guideline implementation, administrators and managers help to create a climate where physicians are encouraged to standardize care.

EVERYONE BENEFITS FROM CAREMAPS

In developing disease-specific CareMaps, the goal is to outline appropriate care and the appropriate time frame for that care: what to do, in what order, and by whom. CareMaps allow caregivers to access the treatment plan of every patient and the results of that treatment each day. Also, because the CareMap is forward looking in that it outlines the following day’s treatment, organizational efficiency is improved because the nurses know what has been done, what the result was, and what is next in the treatment plan. All information is in one spot, not scattered in notes throughout the patient’s chart.

For the physician the CareMap becomes a database, documenting, for example, that aspirin was given on time. For administrators the CareMap provides a tool for understanding and improving patient flow. If all caregivers know what they are supposed to do every day, they can effectively prepare and plan and communicate. Because the measures recorded on the CareMap are also those required by the Centers for Medicare and Medicaid Services (CMS), completed CareMaps help the hospital meet CMS data collection and reporting expectations. The CareMap is also a useful tool for monitoring patient safety. The CareMap can be used as a research tool as well because isolated variables can be extracted from multiple CareMaps and analyzed in the aggregate.

CareMaps improve patient throughput because the outlines of the treatment per diagnosis are in place. Therefore, as soon as a patient is diagnosed in the ED and the appropriate CareMap put in the chart, everyone involved knows what to do and what to expect within a specified time frame. Expectations can be set and predictions can be made. For example, if a stroke is identified in the ambulance by the EMS staff, the ED can prepare the appropriate treatment, all outlined on the CareMap, such as a CT scan and administration of tPA (tissue plasminogen activator) if timely. Used properly, a CareMap produces best practices and promotes critical thinking, always a challenge to maintain in the face of so many routine tasks.

JCAHO has recently introduced tracer methodology into its accreditation surveys, because of its concern about gaps in communication and problems with moving the patient through an episode of hospitalization. JCAHO is looking to trace the patient’s care from the time of entry to discharge. Today, because multiple caregivers may be involved and different departments and disciplines interact with the patient, it is most important for a hospital to have coordinated communication and coherence in managing care. Nurses are expected to report the entire hospital experience when surveyors question them; the CareMap provides help here because it traces and documents the patient’s experience, from diagnosis to treatment to discharge. In addition, the CareMap helps clinicians verbalize the delivery of care to the JCAHO surveyors because it records what happened, which tests were administered, and what results or outcomes ensued. Furthermore, if there was variation from the standard, the explanation is noted directly on the CareMap.

As processes are improved with effective CareMap use, adverse events are also minimized. Research has shown that most serious medical errors are caused by a lack of communication among caregiving staff, a lack of proper assessment of the patient, or a lack of documentation. When caregivers don’t know what has occurred in the patient’s treatment, it is difficult to avoid mistakes. The CareMap outlines a coherent treatment plan and is useful for designing effective work strategies, maintaining appropriate LOS, improving interorganizational communication, especially shift to shift, and functioning as a diary of past care and a blueprint for future care. CareMaps provide an effective internal driver of quality care.

DOCUMENTING THE DELIVERY OF CARE

A CareMap is more than a checklist because it predicts what will occur each day in the normal course of treatment and provides a record of what has occurred previously. The checklist component of the CareMap reminds the caregiver of what should be accomplished: check the vital signs, administer medication, begin the discharge plan. Then the CareMap goes further by informing the caregiving staff about what should happen every day, and if an outcome does not happen as predicted, the explanation is recorded as variance data. When quality management analyzes the variance data, problems can be located and changes can be recommended based on objective information.

CareMaps, being concurrent documents of the care provided, enable staff to constantly update information. Therefore decisions can be made with a complete background of what was done and when and with what result. Because circumstances change constantly as the patient progresses through the episode of hospitalization, decisions are being made all the time. These decisions, when based on reliable information, such as the CareMap provides, are then grounded in evidence, not in a (perhaps biased) subjective experience.

CareMaps have a further advantage of placing the care in context. For example, before our system introduced CareMaps, the state department of health (DOH) would visit periodically and review the medical records. DOH reviewers usually found that patient weight was missing from a number of charts, and the hospital would receive deficiencies. Quality management staff attempted to educate the nurses on the importance of entering weight on the chart, and administrators even purchased new scales, but nothing improved. Weighing patients is important. Medication has to be calculated according to weight. In heart failure patients a weight gain can signal a serious problem; therefore a baseline weight is essential for effective treatment. When simply part of the normal routine, it is easy to neglect recording weight during the history and physical. Perhaps it doesn’t seem critical to the patient’s health and well-being. But when weight is part of a clinical context, as it is in the CareMap for heart failure, nurses respond and the weights get entered. Recording the weight stops being a mindless and meaningless chore and instead becomes integral to the treatment plan.

The CareMap provides a clinical background for why things are done the way they are done. It requires that the nurse record the medication so that the next caregiver knows what the patient received and with what outcome. In today’s health care system many specialists and consultants are involved in a single patient’s care, but no one has the time or patience to shuffle through a collection of everyone else’s disorganized progress notes. A tool like a CareMap, which allows everyone to see the daily treatment quickly and simply, eliminates errors.

The CareMap also encourages accountability; everything is oriented to the patient. If something is missing or has been overlooked, a reminder is right there on the CareMap. These reminders are quite useful. No one can remember everything. A busy nurse handles about eight patients; a busy doctor may be treating fifty patients. CareMaps provide useful reminders to the physician and nursing staff.

CASE EXAMPLE: DETOXIFICATION GUIDELINES

The following example illustrates the value of guideline development for improving patient safety and avoiding serious events. Aggregated data from our system’s quality management sentinel event database alerted leadership that there had been several incidences of patient suicide and attempted suicides. These events occurred not solely in the behavioral health setting but, surprisingly, in the acute care setting as well. Perhaps because these medical and surgical patients arrived at the hospital for medical rather than for psychological problems, their underlying behavioral health issues remained undiagnosed.

To address the problem of inpatient suicide, a multidisciplinary task force—with members drawn from the medical staff and nursing staff and from the environmental services, pharmacy, quality management, risk management, social services, and ancillary departments in the system’s community and tertiary hospitals—was formed to develop guidelines for assessing potential suicides. Over a period of several years, members of the task force interviewed staff, researched the relevant literature, and analyzed the medical record associated with each suicide incident.

The following case history is a composite of actual cases, and it illustrates some of the deficits in identifying and treating suicidal patients. Root cause analysis of cases such as this helped to target areas for improvement and the development of guidelines.

A fifty-four-year-old male was admitted to the ED with gastrointestinal bleeding. He was transferred from the ED to the medical intensive care unit (MICU), where he received transfusions and medication. A scan located the source of the bleeding, and after being stabilized he was discharged from the MICU and transferred to a medical patient care unit. Because the patient showed agitation and was wandering the halls, he was placed on one-to-one observation. Nonetheless, he entered the nursing station and demanded to use the phone and to smoke. Security was called to escort him back to his room. Once there, he became increasingly agitated, pulled out his IV lock, and was aggressive when the nurse attempted to take his vital signs and to give him medication. The patient was placed on wrist restraints which he quickly broke out of. He then shattered the window in his room with his roommate’s IV pole, jumped out of the window, and died.

In order to examine the factors that contributed to this suicide, members of the task force created a time line, reflecting what happened when, and developed a cause and effect diagram to identify processes and issues that might have influenced this tragic outcome. These specific issues and processes were categorized into larger groupings: patient assessment, the environment, interventions, staff, and policies and procedures. From this information and through meetings of relevant staff and experts over a period of weeks, risk points were identified, illustrating where the care had broken down.

In this example the patient was not adequately assessed, and therefore the caregiving staff missed the signs and symptoms of alcohol withdrawal, a syndrome known to be associated with increased risk of suicide. Adequate assessment would have alerted the staff to the significance of the heightened agitation, and then appropriate medical management might have prevented this tragedy. In addition, the nursing and resident staff had not communicated the patient’s escalating behavioral symptoms to the attending physician.

As a result of these findings, a multidisciplinary alcohol detoxification protocol development committee was convened to research and adopt an objective instrument to improve and standardize the identification of medical and surgical patients with alcohol problems and to enhance the medical management of patients undergoing alcohol withdrawal and at potential risk for suicide. The committee drew on the expertise of the medical, nursing, and psychiatric leadership throughout the system.

After nine months of research and planning, the alcohol detoxification protocol was designed, using evidence-based objective criteria, the CIWA-Ar (Clinical Institute Withdrawal Assessment-Alcohol, revised) scale, to evaluate the risk of alcohol withdrawal. The CIWA-Ar scale measures the extent of the anxiety, agitation, orientation, auditory, visual, and tactile disturbances typical of withdrawal symptoms. Interpretation of the scale objectifies withdrawal intensity, and on the basis of the evaluation medical management can be standardized. Clinical guidelines for patients assessed as at risk for alcohol withdrawal, with suggested physician order sets for treatment, were also developed from national guidelines and internal expertise. An alcohol detoxification treatment guideline in the form of a CareMap insert was incorporated into the primary CareMap of the acute care patient thought to be at risk.

The alcohol detoxification protocol, which included guidelines, education, and use of assessment tools, was reviewed and approved by the chairs of the departments of medicine and psychiatry, administration, and quality management, the associate chair for the Medical Intensive Care Unit, the multidisciplinary hospital performance improvement coordinating group, and chief residents. Although the approved policy was mandatory, its implementation required time and education. Recognizing that patients with this condition may be admitted to any service, the education and training program targeted nurses and physicians from surgery, maternity, and trauma as well as medicine.

Because these tools and protocols were new to the acute care medical and surgical units, educating the health care team about their use was necessary. Education was provided in a variety of medical and nursing forums to ensure appropriate patient assessment as well as initiation and maintenance of a medication regime upon the initial assessment or subsequent reassessment of a patient with actual or potential alcohol withdrawal. Classes for nursing staff included an overview of alcoholism, screening and assessment of patients at risk for withdrawal, use of the CIWA-Ar scale, and use of the CAGE questionnaire, a nonjudgmental tool to evaluate the patient’s use of alcohol. Several system hospitals incorporated the topic into medical staff grand rounds.

A suicide, attempted or completed, is such a harrowing experience for the professional staff that staff members were committed to learning whatever they could to prevent such an incident from occurring. Once the initial unfamiliarity was overcome, the new protocol was embraced, and there were many requests for on-site education at specific hospital units. Through clinicians’ greater awareness of the connection between alcohol withdrawal and the potential for suicide in the acute care setting and through increased communication between patient and caregiver, an improved therapeutic environment was created.

SUMMARY

To promote quality internally, the organization has to be committed to

• • Developing quality databases to monitor the delivery of care.
• • Adopting quality management methodologies to improve the delivery of care.
• • Educating staff about quality management methods.
• • Developing multidisciplinary teams to develop, promote, and implement clinical guidelines.
• • Using CareMaps, or clinical pathways, to standardize care across different levels of treatment and across different health care facilities.
• • Using CareMaps to improve documentation of treatment and outcomes.
• • Using CareMaps to improve communication among caregivers.
• • Reducing resource consumption and expenditure through CareMap methodology.
• • Educating patients about their treatment through information, such as provided on a patient friendly CareMap.
• • Documenting and analyzing variation from the outlined standard of care.

Things to Think About

You are in a leadership position in your hospital, and data reveal that the majority of physicians do not comply with evidence-based guidelines. Your job is to convince them to change. How would you do it?

• • How would you analyze the problem?
• • What data would you use to try and influence their behavior?
• • What consequences (financial and clinical) would you bring to their attention?
• • What would you do if the behavior did not change?