Health Affairs Committee Kristin Hahn-Cover, MD, Chief Quality - - PowerPoint PPT Presentation

Health Affairs Committee

Kristin Hahn-Cover, MD, Chief Quality Officer

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Vizient 2019 Quality & Accountability Study

• 38 out of 93 AMCs (PR 41)

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Mortality and Readmissions – Prior Year

• Performance in mortality index

in top one-third of academic medical centers in FY19

• Unplanned 30-day

readmissions: Rate for Q4 is 11%, compared to 11.7% in FY18 (annualized, this would equate to 150 fewer patients readmitted)

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Mortality – Current Year

• Stable performance
• Optimize clinical documentation improvement

(CDI) program for both financial and quality

• utcomes
• Improve capture of comorbid illnesses present
• n admission

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Mortality – PI Priorities Teams

• Annualized

lives saved: 16

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Mortality – Sepsis Team

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Mortality – Example

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Readmissions – CMS

NOTE: FY20 determination based on index discharges from July 1, 2015 to June 30, 2018

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Readmissions – Current Year

• Performance declined (July)
• Preliminary data for August demonstrates return

to recent range

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Readmissions Team

Intervention Process Measure Current Sparkline

% HR Patients with Pharmacy Med Review at Discharge1

(Baseline: 49.9% 2 | Goal: 75% )

% HR Patients with Meds in Hand at Discharge1

(Baseline: 17.3% 2 | Goal: 40%)

% of HR Patients with Need to Know Education Documented 80% of the Time in the Last 5 Days of Admission4

(Baseline: 0% | Goal: 75%)

% HR/DC Appointments Scheduled prior to Discharge1

(Baseline: 52% 2 | Goal: 75%)

% HR/DC Appointments Scheduled to Occur within Seven Days 1

(Baseline: 43% 2 | Goal: 75%)

 61.7%

(37 of 60)

 67.6%

(94 of 139)

 40.0%

(52 of 130)

Need to Know Patient Education Completed Every Shift

 78.9%

(206 of 261)

 70.4%

(69 of 98)

Designated Staff with DRG Targeted Worklists (Pharmacy) Pair DC Notification with Follow-Up, Default to Recommended Time Frame Standard Timeframe for High Risk Patients with Protocol Driven Follow- Up Appointments OPEN - HEALTH AFF - INFO 4-10

Readmissions – Example

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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!

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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

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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

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Hospital-acquired Infections – Current Year

• Performance improved

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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”…

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Daily Management

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Tiered Escalation Huddles – Do They Work?

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Tiered Escalation Huddles

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Tiered Escalation Huddles

• Daily management metrics, day 1 (8/5/19): hospital-

acquired pressure injuries

• Rolling out additional quality/safety metrics

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Tiered Escalation Huddles – Do They Work?

10 9 8 7 6 5 4 3 2

1

1

1 1 1 1 1 1 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

GEMBA RUN CHART Month

August

Metric

Hospital Acquired Pressure Injuries

Daily count

Day of the Month Event Occurred

10 9 8 7 6 5 4 3 2

1 1

1

1 1 1 1 1 1 1 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

GEMBA RUN CHART Month

September

Metric

Hospital Acquired Pressure Injuries

Daily count

Day of the Month Event Occurred

10 9 8 7 6 5 4 3 2 1

1 1 1 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

Daily count

Day of the Month Event Occurred

GEMBA RUN CHART Month

October

Metric

Hospital Acquired Pressure Injuries

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Questions?

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