Health Affairs Committee Kristin Hahn-Cover, MD, Chief Quality Officer OPEN - HEALTH AFF - INFO 4-1
Vizient 2019 Quality & Accountability Study • 38 out of 93 AMCs (PR 41) OPEN - HEALTH AFF - INFO 4-2
Mortality and Readmissions – Prior Year • Performance in mortality index in top one-third of academic medical centers in FY19 • Unplanned 30-day OPEN - HEALTH AFF - INFO 1-2 readmissions: Rate for Q4 is 11% , compared to 11.7% in FY18 (annualized, this would equate to 150 fewer patients readmitted) OPEN - HEALTH AFF - INFO 4-3
Mortality – Current Year • Stable performance • Optimize clinical documentation improvement (CDI) program for both financial and quality outcomes • Improve capture of comorbid illnesses present on admission OPEN - HEALTH AFF - INFO 4-4
Mortality – PI Priorities Teams • Annualized lives saved : 16 OPEN - HEALTH AFF - INFO 4-5
Mortality – Sepsis Team OPEN - HEALTH AFF - INFO 4-6
Mortality – Example OPEN - HEALTH AFF - INFO 4-7
Readmissions – CMS NOTE : FY20 determination based on index discharges from July 1, 2015 to June 30, 2018 OPEN - HEALTH AFF - INFO 4-8
Readmissions – Current Year • Performance declined (July) • Preliminary data for August demonstrates return to recent range OPEN - HEALTH AFF - INFO 4-9
Readmissions Team Intervention Process Measure Current Sparkline % HR Patients with Pharmacy Med Review 67.6% at Discharge 1 (94 of 139) (Baseline: 49.9% 2 | Goal: 75% ) Designated Staff with DRG Targeted Worklists (Pharmacy) % HR Patients with Meds in Hand at 40.0% Discharge 1 (52 of 130) (Baseline: 17.3% 2 | Goal: 40%) % of HR Patients with Need to Know Education Documented 80% of the Time in Need to Know Patient Education 78.9% the Last 5 Days of Admission 4 Completed Every Shift (206 of 261) (Baseline: 0% | Goal: 75%) Pair DC Notification with Follow-Up, % HR/DC Appointments Scheduled prior to 70.4% Default to Recommended Time Discharge 1 (69 of 98) (Baseline: 52% 2 | Goal: 75%) Frame Standard Timeframe for High Risk % HR/DC Appointments Scheduled to Occur 61.7% Patients with Protocol Driven Follow- within Seven Days 1 Up Appointments (37 of 60) (Baseline: 43% 2 | Goal: 75%) OPEN - HEALTH AFF - INFO 4-10
Readmissions – Example OPEN - HEALTH AFF - INFO 4-11
Patient Safety Indicators – Current Year • Composite score performance declined (August) • Performance remains dominated by hospital- acquired pressure injuries – 90 days with no hospital-acquired pressure injuries at Women’s and Children’s Hospital! OPEN - HEALTH AFF - INFO 4-12
Patient Safety Indicators – Example • Wound Scout thermal imaging – Avoided 8 reportable pressure injuries during two-month trial – Approved for adoption in ICU and by Skin Care Team consultant RNs OPEN - HEALTH AFF - INFO 4-13
Magnet – Nursing Sensitive Indicators • Hospital-acquired pressure injuries • Falls with injury • Hospital-acquired blood clots • Central line-associated blood stream infections • Catheter-associated urinary tract infections • Hospital-acquired C. difficile infection OPEN - HEALTH AFF - INFO 4-14
Hospital-acquired Infections – Current Year • Performance improved OPEN - HEALTH AFF - INFO 4-15
Hospital-acquired Infections – Example • Central-line associated bloodstream infection Hello to our Missouri friends! The SPS team is very excited to announce a SPS network centerline shift down in CLABSI from a rate of 1.424 to a rate of 1.264; a 11% decrease in harm. During this shift, it appears that your hospital also had a shift down in both your overall CLABSI rate and CLABSI MBI rate. We’re guessing you're not feeling "done" with your CLABSI work, but you have had a centerline reduction that we would like to learn more about! Trey Coffey, Associate Clinical Director of SPS, and Katie Staubach, SPS Quality Improvement Specialist, would love the opportunity to meet with your team in the next few weeks as a qualitative part of the special cause investigation. We are interested in what you think has been your “secret”… OPEN - HEALTH AFF - INFO 4-16
Daily Management OPEN - HEALTH AFF - INFO 4-17
Tiered Escalation Huddles – Do They Work? OPEN - HEALTH AFF - INFO 4-18
Tiered Escalation Huddles OPEN - HEALTH AFF - INFO 4-19
Tiered Escalation Huddles • Daily management metrics, day 1 (8/5/19): hospital- acquired pressure injuries • Rolling out additional quality/safety metrics OPEN - HEALTH AFF - INFO 4-20
Tiered Escalation Huddles – Do They Work? GEMBA RUN CHART Month Metric August Hospital Acquired Pressure Injuries GEMBA RUN CHART Month Metric September Hospital Acquired Pressure Injuries GEMBA RUN CHART Month Metric October Hospital Acquired Pressure Injuries Daily count 10 Daily count 9 8 10 7 Daily count 9 6 8 5 10 7 4 9 6 3 8 5 1 2 7 4 1 1 1 1 1 1 1 6 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 5 2 1 1 4 1 1 1 1 1 1 1 1 Day of the Month Event Occurred 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2 1 1 1 1 Day of the Month Event Occurred 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day of the Month Event Occurred OPEN - HEALTH AFF - INFO 4-21
Questions? OPEN - HEALTH AFF - INFO 4-22
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