https://doi.org/10.1177/1062860619839306

American Journal of Medical Quality2019, Vol. 34(2S) 3S –88S© The Author(s) 2019Article reuse guidelines: sagepub.com/journals-permissionsDOI: 10.1177/1062860619839306ajmq.sagepub.com

Dive Deep: Uncovering Bold Ideas to Improve Patient Care

Cindy White, MBA, RNVice President, Network Services, Vizient

Karen Latimer, MS, MSMI, LSSGB, RRT1

Senior Content Director, Network Services, Vizient

The 2018 Vizient Fall Connections Summit convened on October 2-4, 2018, in Las Vegas, Nevada, where nearly 3000 Vizient member organizations—including aca-demic medical centers, complex teaching medical cen-ters, community hospitals, pediatric facilities, and other specialty providers—gathered to discover, learn, and explore together.

Featuring a “Dive Deep” theme, the 2018 summit offered Vizient members, business partners, and staff educational offerings, networking opportunities, and col-laborative activities to help health care leaders from across the country learn how to achieve their clinical and operational goals. As the largest member-driven health care performance improvement company in the United States, Vizient works closely with its members to improve patient outcomes and lower costs.

Byron Jobe, president and chief executive officer of Vizient, commenced the proceedings with a fresh perspec-tive on the health care landscape. Jobe linked his video presentation—which focused on the mimic octopus and its ability to camouflage—with the disruptive changes experienced by today’s health care organizations and advised that members must adapt to achieve “best-in-class” quality and cost performance. The shift to beyond-the-walls care, system consolidation, blurred lines between payers and providers, and the digital disruption of consumerism are affecting all health care organizations. Leaders’ ability to succeed in this climate hinges on their ability to adapt and thrive. In turn, Vizient is responding by changing and adapting to meet members’ needs.

Intelligent Solutions Showcased in Huddles, Panels, and Posters

The summit provided attendees with a wide variety of knowledge-sharing opportunities, including power huddles, posters, and the Learning Lounge. Attendees had 63 thirty-minute power huddles and 45-minute power panels (for-merly known as rapid-fire sessions) from which to choose, during which peers presented, encouraged audience partici-pation, performed role plays, and stimulated interactive learning. These dynamic knowledge-sharing sessions focused on critical topics faced by members, including opi-oid stewardship, consumerism, empowered workforces, high reliability in service lines, responding to vulnerable patient populations, and new solutions grounded in evi-dence-based care. See the boxed text to learn about University of Minnesota Health’s efforts to improve patient access to spine surgeons and Nebraska Medicine’s efforts to make zero harm a reality.

Call Center Uses Evidence-Based Algorithm and Provider Network to Improve Access to Spine Surgeons

Using best-practice guidelines and input from a multidisciplinary team, the academic spine surgery clinic created an algorithm for nonclinicians in the call center to schedule new patients with the most appropriate provider type.

By building a provider network with a nurse prac-titioner clinic, academic sports medicine physicians, physical therapists, and primary care providers in

839306 AJMXXX10.1177/1062860619839306American Journal of Medical QualityA Report on the 2018 Vizient Fall Connections Summitresearch-article2019

1Vizient, Chicago, IL

Corresponding Author:Karen Latimer, MS, MSMI, LSSGB, RRT, Vizient, 155 North Wacker Drive, Chicago, IL 60606. Email: karen.latimer@vizientinc.com

Dive Deep: A Report on the 2018 Vizient Fall Connections Summit

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addition to academic spine surgeons, the University of Minnesota Health matched this complex patient population to the appropriate provider 99.4% of the time, a significant improvement from the 20% base-line. By the end of 45 weeks, 539 patients were matched accurately.

This project addressed the seemingly impossible task of coordinating complex patients without adding clinical staff or costly software by creating an evidence-based, patient intake algorithm and establishing a provider net-work beyond the walls of its academic multispecialty clinic.

A well-attended University of Kansas Health System session featured Bob Page, president and chief executive officer, and Tammy Peterman, executive vice president, chief operating officer, and chief nursing officer, both of whom spoke on the importance of culture in supporting the organization’s strategic mission and key improve-ments while engaging the hearts and minds of staff. The summit’s mobile app not only guided attendees to the ses-sions of their choice but also provided slides and other content that they could review and share with their teams.

Fifty-five posters were displayed throughout the event space and attracted great interest. Poster presenters—including physicians, nurses, other clinicians, and health care leaders—tackled diverse topics and showcased new

Making Zero Harm in Patient Safety a Reality

Nebraska Medicine underwent a focused redesign of its quality and patient safety structure in response to a renewed dedication to Vizient methodology. As part of this process, it created a unique multidisci-plinary committee structure to place Patient Safety Indicators and safety events directly into the hands of providers for evaluation and cause analysis.

Nebraska Medicine ranked 87 in the Vizient Patient Safety Domain in 2015, climbing to fifth in 2016, and fourth in 2017—a testimony to the success and sustainability of this project. An evaluation of performance using Agency for Healthcare Research and Quality 6.0 specifications in fiscal year 2017 compared to the same time period in fiscal year 2015 also identified a 73% reduction in the instances of patient harm.

Nebraska Medicine’s goal continues to be zero harm to patients.

tools, unique interventions, cost reducers, and helpful takeaways.

Members also visited the interactive Learning Lounge to engage with Vizient content experts and explore how key services can help them improve their clinical cost, quality, and strategic performance.

Embracing the Disruption of Innovation

Summit activities immersed attendees in the rapidly chang-ing world of clinical innovation. Members were encour-aged to explore new concepts and reimagine how emerging technology can improve their patients’ lives. Attendees also considered bold ideas to improve patient care and dis-cussed how to cultivate innovation at their facilities.

The Innovation Challenge competition pits innovators against each other as they pitch their solutions and win the audience’s vote. Moving Analytics, a digital rehabili-tation and prevention program for cardiac disease, was selected by attendees as the 2018 Innovation Challenge Award winner. The winner earned 65% of the final vote and $25 000 to expand its markets. This year the Innovation Challenge showcased a new format focused on 2 areas of great importance to members: a virtual care/remote monitoring domain and a care coordination/com-munication domain.

Members also visited the Innovative Technology Exchange to view more than 100 emerging health care technologies, products, and services. Visitors were invited to provide direct feedback using either an app with a QR scanner or tablets.

The clinical innovation theme was further explored by Roy Rosin, chief innovation officer, Penn Medicine, who presented ideas on leading transformative innovation to chief medical, nursing, and quality officers at the annual Joint Clinical Executives Network meeting. Rosin addressed how to shepherd innovation through hurdles and stressed the importance of leadership consensus and clear direction.

Making Lively Connections

Summit attendees participated in meetings of academic medical center and community hospital networks, user groups, and advisory councils, providing members with opportunities to share solutions with peers in similar dis-ciplines and roles, such as cardiovascular care, human resources, pharmacy, and operations. In addition, unique multidisciplinary sessions enabled leaders across the spectrum to gather together to learn from each other.

One of the most anticipated annual events hosted by Vizient—the 2018 Member Awards Celebration—recog-nized top performers according to the Vizient Quality and Accountability Study rankings. Winners were lauded for

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their pioneering work to improve quality, safety, and clin-ical innovation. Teams were encouraged to come on stage to accept their awards as a way of recognizing individuals throughout the organization who help make successes happen. See page 7S for a complete list of winners.

Through the Leadership Lens

During the closing session, Lt. General David D. Halverson (retired) spoke about leadership lessons within noble areas such as health care and the military. Drawing lessons from his 37 years of command experience, Halverson described the essential “4 Cs” of leadership: character, commitment, communication, and caring. He suggested a holistic approach to caring, including work-ing with staff on skill development.

He explained that the best leaders deliver simple mes-sages, referencing Abraham Lincoln’s Gettysburg Address, which was only 272 words. He urged health care leaders to consider the importance of face-to-face dialogue with staff and ensure that an organization’s com-mon vision is being executed.

A Shared Journey

The summit earned high marks from attendees, with sur-vey respondents rating the content as 9.21 out of 10. In particular, attendees valued the member-to-member interactions, which prepared them to advance their orga-nizations’ performance improvement strategies and expertise. Each organization’s team must define success in its own way, but benefits by collaborating with peers in markets across the country.

Members encouraged each other to dive deep into their ecosystems and explore new ideas. They returned to their organizations with new ideas, vetted solutions, and bold breakthroughs on how to drive performance and improve quality, cost, and growth.

Shared Solutions: Connections That Produce Results

Barbara Anason, MBASenior Vice President, Academic Medical Center Networks and Strategy, Vizient

Julie Cerese, PhD, MSN, RNGroup Senior Vice President, Performance Management and National Networks, Vizient

Scott DowningExecutive Vice President, Collaboration and Performance Improvement Networks, Vizient

Learning from other members remains the number one rea-son that the 2018 Vizient Fall Connections Summit and other networking events sponsored by Vizient are so suc-cessful. Members value the solutions that emerge from their peer-to-peer interactions, especially as they face an era marked by an incredible rate of change. Summit attendees encouraged each other to examine problems with fresh eyes and apply insights and innovations from other industries.

A Member-Driven Mission

The member experience is critical to Vizient and its revi-talized mission. When Byron Jobe assumed his role as Vizient president and chief executive officer in 2018, he spent months listening to leaders across the country and discussing their goals and needs. The result of these con-versations is a new mission statement that defines Vizient’s unique ability to address members’ cost, quality, and mar-ket performance needs in a value-based environment.

A Shared Sense of Giving

Even volunteering activities were infused with a spirit of collaboration. During the 3-day event, attendees gathered to pack pediatric hygiene kits and participate in a “Diaper Dash”—a race against the clock to pack 10 000 Huggies® diapers into easy-to-distribute packages, all of which were donated to the local Las Vegas Diaper Bank. Additionally, Huggies, the sponsor of the volunteer effort, donated a day’s worth of diapers for each attendee badge scanned. Members embraced this new way to contribute to the community.

Vizient Supports the American Fallen Soldiers Project

US Army Spc. Dane Balcon was killed by a roadside bomb in Iraq on September 5, 2007, at the age of 19. At the summit, his family was honored and received a touching portrait of Dane painted by artist Phil Taylor. The ceremony included an inspiring video on Balcon’s life, followed by stirring remarks from his mother.

Vizient supports the American Fallen Soldiers Project, formed in 2007 to help provide comfort and healing to the grieving families of fallen military. Vizient gives each family an original portrait of their loved one that captures his or her appearance and per-sonality. Artist Phil Taylor creates the portrait at no cost to the family.

Vizient Mission: Vizient strengthens members’ delivery of high-value care by aligning cost, quality, and market performance.

More than just a ranking system — awards grounded in evidence

Vizient® is proud to recognize the winners of the 2018 Vizient Excellence Awards for Clinical and Operational Performance and the 2018 Vizient Excellence Awards for Supply Chain Management and Sustainability, identifying the top-performing hospitals in the country. Many groups announce “rankings” of health care organizations, but the Vizient Excellence Awards are grounded in evidence.

2018 award winners

Bernard A. Birnbaum, MD, Quality Leadership Award Given to academic medical center (AMC), complex teaching medical center and community hospital members that demonstrate excellence in delivering high quality care based on mortality, safety, efficiency, effectiveness, patient centeredness and equity. These top organizations consistently demonstrate a shared sense of purpose, hands-on leadership style, vertical and horizontal accountability, a focus on results and interdisciplinary collaboration.

Academic medical centers

• Mayo Clinic Hospital – Rochester

• Rush University Medical Center

• NYU Langone Medical Center

• University of Texas Medical Branch at Galveston

• The University of Kansas Health System

• University of Pennsylvania Health System

• University of Utah Health

• Houston Methodist Hospital

• Memorial Hermann – Texas Medical Center

• Tufts Medical Center

• Morristown Medical Center

Complex teaching medical centers

• Froedtert & the Medical College of Wisconsin Community Memorial Hospital

• The Chester County Hospital and Health System

• Mayo Clinic in Florida

• Beaumont Hospital – Grosse Point

• Houston Methodist West Hospital

• Mayo Clinic in Arizona

• Memorial Hermann Memorial City Medical Center

• Mayo Clinic Health System in Eau Claire

• Beaumont Hospital – Trenton

Community hospitals

• Cleveland Clinic Lutheran Hospital

• Mayo Clinic Health System in Red Wing

• Barnes-Jewish West County Hospital

• Sanford Worthington Medical Center

• Saint Luke’s South Hospital (Overland Park, Kan.)

The Vizient Ambulatory Care Quality and Accountability AwardThe award measures the quality of outpatient care in the five domains: access to care, capacity and throughput, quality and efficiency, continuum of care, and equity.

• UCHealth University of Colorado Hospital - University of Colorado Medicine

• UW Health (Madison, Wis.)

• NYU Langone Health

• Emory Healthcare Physician Group Practices

• University of Utah Health

Clinical Innovation AwardThis award recognizes member health care organizations that implemented digital health technology solutions that improved clinical efficiency or care delivery resulting in improved patient experience.

• Penn Medicine

Quality Leadership Rising Star AwardThe award recognizes AMCs that have made significant improvements in their year-over-year rankings and perform in the top quartile in the annual Vizient Quality and Accountability Study.

• Stanford Health Care

• Saint Luke’s Hospital (Kansas City, Mo.)

• UT Southwestern Medical Center William P. Clements Jr. University Hospital

• UK HealthCare (Lexington, Ky.)

Serving the nation’s leading health care systems Vizient serves the nation’s best health care systems — AMCs, integrated delivery networks, independent community hospitals, safety net organizations, pediatric facilities and non-acute providers. They all work diligently every day to provide the highest quality care to their patients and communities.

We are humbled and inspired by these award winners.

To learn more about us, visit vizientinc.com.

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Members want to flourish in their markets while con-tinuing to provide exceptional patient care. This year, interest in clinical data reached an all-time high. Although leaders are inundated with a vast choice of data tools, the Vizient Clinical Data Base is prized by organizations that participate and share their data. As teams aim to reduce clinical variation and control costs, they rely on Vizient data to help them meaningfully benchmark against other organizations and track improvements over time. They value their interactions with peers as they strive to achieve best-in-class performance.

“Do It Yourself “Disruption

A rapidly changing health care landscape demands that organizations think and innovate in new ways. Despite a plethora of external innovations, members are refusing to passively accept market changes and are instead choosing to disrupt themselves to find the best way to deliver care. For example, organizations are implementing teams and structures that encourage innovation from the inside out. Innovative practice units help teams test ideas, processes, technologies, and products. They are exploring paths that achieve value-based care, sometimes ignoring theoretical constructs like population health and asking the incisive question: What do we need to do now to achieve the right outcome?

As they work together to answer this question, mem-bers support the Vizient strategy to become a perfor-mance improvement (PI) company. Their thirst for practical ideas was evident at the summit, as chief medi-cal officers, nursing officers, and quality officers from academic medical centers (AMCs) gathered for a presen-tation by experts from the Penn Medicine Center for Health Innovation that focused on accelerating innova-tive practices. The Penn Medicine team shared an innova-tion framework comprising 4 stages: gain insight, define problem, explore solutions, and rapidly validate. Attendees were encouraged to view health care as a behavior change business while exploring innovative solutions for 2 common issues in health care: reducing hospital readmission rates among pregnant women with high blood pressure and increasing participation in car-diac rehabilitation programs among patients at high risk for cardiovascular disease. The interactive session helped attendees learn how to test hypotheses and design experi-ments to rapidly validate assumptions.

The share of outpatient hospital revenue grew from 21% in 2010 to 60% in 2015,1 a shift that will continue to grow and fundamentally change care delivery in the United States. As ambulatory care evolves to address continuum-of-care needs, members are keeping pace. More than half of the Vizient PI collaboratives address some dimension of ambulatory care, such as clinical uti-

lization, behavioral health, care coordination, and alter-native care delivery sites.

Pressure on the Safety Net

Vulnerable patient populations (VPPs) present unique challenges to providers. All Vizient members seek more information in this arena because there are a number of groups who are considered vulnerable, such as veterans, LGBTQ individuals, elderly people without caregivers, minorities, and others who face health care disparities. When establishing care plans, providers must consider issues such as nutrition in the midst of food deserts, inad-equate access to transportation, and household poverty. National work is underway to improve measuring social determinants of health to better understand how to deliver care to those at risk.

In response to this challenge, Vizient launched an AMC VPP Network to develop and share strategies to improve the care provided to the vulnerable. This new network has chosen to focus on 3 strategic areas: creative partnerships, financing solutions to demonstrate that investing in health equity generates returns on investment, and organizational and strategic alignment within members and with other organizations. Vizient has worked extensively with mem-bers to identify their VPPs by evaluating gender, race, eth-nicity, and language data. This data mining has helped members build strategies to improve VPP care within selected populations; member-driven improvement collab-oratives in 2019 will deepen the focus on VPP needs.

The summit featured multiple VPP power huddles and posters, with presenters inviting attendees to examine how to decrease readmissions, understand social determi-nants of health status, identify health care disparities, address malnutrition and reimbursement, create screen-ings for high-risk patients, leverage community partner-ships, and other issues.

Adapting Within a Tumultuous Market

In a tight labor market, members vie with other organiza-tions to populate their talent pipeline with the appropriate mix of employees. As staffs grow, it is crucial that people understand how to interface and work together. With organizations adding layers of staff—such as advanced practice practitioners, hospitalists, navigators, and case managers—each function must be delineated and its impact on existing roles considered. A continual appraisal of organizational roles includes the development of lead-ers as well as staff for efficient operations.

System integration within health care continues to be a driving factor as value-based care takes center stage. Members struggle with the myriad challenges associated with strategic acquisitions and mergers, but are making

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progress as they continue to evaluate and refine struc-tures, governance, and leadership roles. For instance, does every hospital within a system require its own chief executive officer or, alternatively, a general manager? As they aim to eliminate redundancy and create intelligent decision-making bodies, members created an AMC System Executives Network to help them resolve integra-tion challenges and focus on their systems’ quality, cost, and market strength.

The rising cost of health care continues to challenge the traditional roles of market players. Payers are enlarg-ing their presence and controlling costs by employing physicians. For example, a payer joined together with major health systems in California to create a health maintenance organization that promises affordability to employers and high-quality care to employees. In turn, hospitals are responding by contracting directly with large employers.

This blurring of roles is occurring as consumers now control $330 billion in annual out-of-pocket health care expenses.2 Consumers’ health care spend will only increase as employers shift more care costs to employees and younger patients demand that services be delivered via apps and telehealth. These dynamic forces spur tech-nological advances and further disrupt traditional health care models. In fact, millennials may prove to be the ulti-mate disruptive generation in their quest for affordable, on-demand care.

At the other end of the age spectrum, roughly 10 000 baby boomers are retiring every day,3 and per-capita Medicare spending is projected to grow at an average annual rate of 4.6% over the next decade.4 This growth will occur as the ratio of workers per beneficiary making payroll tax contributions declines. On the other hand, patient satisfaction with Medicare has whet some appe-tites for a single-payer system for all Americans, which promises consumer affordability and simplicity. Members must remain vigilant about these macro market dynamics to ensure that their services align with often divergent generational needs and preferences.

Achieving High-Value Care Together

In the complex work of patient care, PI teams rarely have time to celebrate their successes. At the summit, however, peer acknowledgement is a vital ingredient of shared progress. Multidisciplinary teams took the stage to accept Vizient’s prestigious annual awards recognizing top clini-cal and operational performance in inpatient and ambula-tory settings. From winners standing together to accept their awards to a presenter receiving hearty applause for a provocative insight, members appreciate achieving suc-cess through collaboration.

Whether building an evidence-based clinical path-way or exploring a game-changing business model, members are encouraged to be fearless in their pursuit of exceptional, value-based care. Behind the scenes, Vizient content experts serve as trusted partners, con-necting organizations to help them learn, improve, and build together.

Regardless of the scale of the work, members depend on Vizient’s 3 cultural cornerstones—collaborative, adap-tive, and resourceful—to support their initiatives to deliver high-value care every day.

1. Gooch K. Hospital outpatient revenue grew about 40% over 5 years. https://www.beckershospitalre-view.com/finance/hospital-outpatient-revenue-grew-about-40-over-five-years.html. Published May 23, 2018. Accessed February 1, 2019.

2. Cordina J, Kumar R, Olson E. Payor insights: enabling healthcare consumerism. https://health-care.mckinsey.com/enabling-healthcare-consum-erism. Published May 2017. Accessed September 2018.

3. Landau J. Health-care dilemma: 10,000 boomers retiring each day. https://www.cnbc.com/2017/10/03/health-care-dilemma-10000-boomers-retiring-each-day.html. Updated October 3, 2017. Accessed October 2018.

4. Cubanski J, Neuman T. The facts on Medicare spending and financing. https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/. Published June 22, 2018. Accessed February 1, 2019.

Harnessing Research Insights to Guide Success

Julie Cerese, PhD, MSN, RNGroup Senior Vice President, Performance Management and National Networks, Vizient

Tom RobertsonExecutive Director, Vizient Research Institute

Chief medical, nursing, and quality officers gathered dur-ing the 2018 Vizient Fall Connections Summit to attend the Joint Clinical Executives Network meeting, which provided participants with the opportunity for integrated, collaborative engagement. The meeting environment was relaxed and open, with leaders from community-based hospitals and academic medical centers (AMCs) learning from each other, embracing the concept of shared leader-ship, conversing with their peers about the challenges of interpersonal learning, and engaging in “blue-sky”

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thinking about how they can build stronger, more effec-tive clinical teams.

This heightened engagement reflects the revolution occurring within health systems, where leaders avidly seek to achieve stronger teamwork and promote joint decision making. Although an integrated model of shared clinical leadership has permeated hospitals throughout the United States, many teams still struggle to operation-alize the concept throughout all staff levels, including nurses and residents. Although they want to improve teamwork, they are still identifying and refining best practices to achieve it.

Exciting Approaches to Shared Decision Making

At the meeting, the benefits of an orchestrated learning environment were presented by Kevin Weiss, MD, MPH, senior vice president of the Accreditation Council for Graduate Medical Education (ACGME). Weiss laid the groundwork for the interactive session by identifying an ACGME learning environment imperative: enhancing the interprofessional (IP) team-based orientation to care, with an emphasis on the concept of “teaming.” In pursuit of sustainable improvements, the ACGME Clinical Learning Environment Review teaming focus includes

•• IP collaborative practice•• IP collaborative learning•• The patient as a member of the IP care team•• Resources to support teaming

After this discussion, 2 member organizations—the University of Chicago Medicine and Our Lady of the Lake Regional Medical Center—described their journeys to build learning organizations and team-based care models.

The University of Chicago Medicine’s team provided insights on IP collaboration and described the results

they achieved using the Improving GME Nursing Interprofessional Team Experiences (IGNITE) model of a shared vision, effective communication, clear roles, and monitoring and feedback. IGNITE encourages pro-viders to practice in well-functioning teams to improve care and patient and staff satisfaction (Figure 1). The model creates learning experiences between nurses and residents to rapidly identify problems and improve pro-cesses. One participant noted, “My first kaizen event showed how much a team can accomplish in four days.”

Joint IGNITE rounds with nurses and residents are an important component of IP collaboration. During rounds, nurses use the CALM model (Clarify the issue, Address the problem, Listen to the other side, Manage your way to resolution) to address concerns and assess changes, lines, and monitors; this is then followed by the medical team’s input.

A pre- and post-IGNITE survey of pediatric nurses and residents showed improvements in

•• Satisfaction with physician and nurse communica-tion regarding the plan of care

•• Nurses’ willingness to express concerns with phy-sicians during IGNITE rounds

•• Physicians’ acknowledgement of nurses’ knowl-edge during rounds

Similarly, Our Lady of the Lake Regional Medical Center, a Louisiana community hospital, transformed itself into a learning environment in the midst of disrup-tive change following Hurricane Katrina in 2005. As a result of the hurricane, the hospital welcomed displaced medical residents from Louisiana State University (LSU) and Tulane University. In 2010, the hospital focused on becoming an AMC, and its Pediatric Residency Program became accredited. By 2014, the Earl K. Long Medical Center, an LSU safety net teaching hospital, had closed, and LSU’s medical education programs transitioned to Our Lady of the Lake. As a result, the organization

Figure 1. The value of interprofessional collaboration.Source. University of Chicago Medicine. IGNITE: Improving GME nursing interprofessional team experiences. Presented at: 2018 Vizient Fall Connections Summit; October 2008; Las Vegas, Nevada.

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experienced a 147% increase in the number of residents in the first year, with a 400% increase in residents within 6 years. The added residency program requirements actu-ally enhanced quality improvement within the AMC and created a shared vision for the transformation of medical education. In addition, a singular focus on patient safety and quality improvement helped establish a shared culture as IP education and teaching teamwork became top priori-ties. A cross-disciplinary focus was brought to huddles, rounds, work groups, and faculty development to build a sustainable platform.

During the second half of the meeting, the featured presenters shared their wisdom about how to achieve the ideal state: an integrated collaborative team.

An Evolving Understanding of Team Dynamics

As members dive deeper into interdisciplinary perfor-mance improvement, legacy models are not always use-ful. One long-standing concept—see one, do one, teach one—may not be effective in diffusing knowledge and nurturing teamwork throughout an organization because its proposed linear behaviors do not always match a clini-cian’s reality.

New research1 suggests a different maturation process involving 3 stages:

1. In the beginning, the inexperienced clinician has sound knowledge but may be nervous or intimi-dated about how to effectively share it.

2. The second stage sees an increased confidence, as the clinician realizes the importance of learnings based on education and experience.

3. The third stage delivers a complete sense of col-laboration, in which all parties are confident to explore, debate, and make decisions together.

The process may unfold in a matter of months, but cli-nicians need encouragement from top leadership to real-ize their full potential. With appropriate support, clinicians can fully develop not only their knowledge and skills but also the right attitude—all of which are necessary to make care decisions that are in the best interests of patients. This maturation approach is organic and cannot be confined to an academic course or short-term onboard-ing experience. It must be embraced by top leaders as a cultural imperative to produce the most effective shared leadership teams.

Shared leadership is not unique to top performers; it is seen in all types of member organizations. However, top performers’ distinguishing characteristic is the commit-ment to execute: What do you implement to ensure the right thing happens every day?

At its core, effective and successful teamwork involves the ability to ask questions and explore solutions. This collaborative behavior needs to be modeled at all levels, from executives to junior staff. Senior leaders must give their teams permission to strive toward IP learning and recognize those who contribute to its success.

Positioning Your Organization for the Long Term

While health care leaders continue to grapple with today’s challenges, they also must take a longer view of the changing market and its impact on their organizations and competitors.

For more than 2 decades, the Vizient Research Institute has worked closely with members and their boards to understand these dynamics and prepare for future trans-formations. As trusted partners, Vizient Research Institute staff are encouraged to ask difficult and sometimes uncomfortable questions to help members shift their per-spectives. As one chief executive officer succinctly summed up, the Research Institute studies provide answers that prevent his organization from spending mil-lions of dollars on the wrong ideas.

Findings from the Research Institute’s 2017 strategic economic research study, Health Care’s Tipping Point: The Risk of Unchecked Spending in a Global Economy, were featured at the 2018 summit. The startling trajectory of health care spending and its diminishing affordability for the middle class were examined in this provocative analysis, which concluded that price—not utilization—needs to change.

The study dissected the effects of the growing Medicare population, as each day 10 000 baby boomers turn age 65—a trend that is forecast to continue through 2030. Annual health care spending by the working popu-lation has tripled in the last 15 years and will double again over the next 15 years unless interventions slow the rate of increase. If unchecked, health care spending will reach $50 000 per working household by 2030, an amount that middle-income families simply cannot afford (Figure 2).

For health care spending to increase at the same rate as wage growth—thereby preventing further erosion of middle-class purchasing power—a reduction of more than 30% in projected health care spending must be achieved. Cutting costs through reduced utilization solves only part of the problem. Price compression, through an efficient private sector market or externally imposed price controls, appears to be the only path to sustainabil-ity for the American working class.

Building on its 2017 findings, the Research Institute’s latest study tests the assumption that higher insurance deductibles and price transparency trigger changes in

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consumer behavior, and assesses the likelihood that mar-ket-based forces will have a material impact on health care spending. Results of the study will be shared with members in 2019.

Pooled Knowledge Produces Success

Members are curious, open-minded, and ready to grapple with thorny questions. They understand that lessons learned during the last decade will not necessarily be rel-evant or applicable in the future. Despite this, they remain committed to working together and selflessly sharing their ideas and failures with each other to improve perfor-mance and patient care. From peer presentations at the summit to a glimpse of the future through the Research Institute’s quantitative and rigorous insights, members are setting a new course for their organizations and the market overall.

1. Cerese J. Getting on the Same Page: A Grounded Theory Research Study of Nurse and Physician Development. Chicago, IL: Loyola University Press; 2019.

A Clearer Picture: Actionable Data to Make Better Decisions

Julie Cerese, PhD, MSN, RNGroup Senior Vice President, Performance Management and National Networks, Vizient

David Levine, MD, FACEPGroup Senior Vice President, Advanced Analytics and Product Management, Vizient

Steve Meurer, PhD, MBA, MHSExecutive Principal, Data Science and Member Insights, Vizient

Achieving quality and safety goals is vitally important work for our members, and peer recognition of those sig-nificant achievements is especially gratifying. The Member Awards Celebration, held during the 2018 Vizient Fall Connections Summit, awarded highest hon-ors to members in 4 categories: quality leadership, ambu-latory care quality and accountability, rising stars in quality leadership, and clinical innovation.

The annual awards program has become a signature moment in performance improvement for Vizient mem-bers. The award winners are listed on page 7S. A desire for improvement and friendly competition among peers make for a lively event. Most important, the awards pro-vide an opportunity for collective learning—not only are the winners heartily congratulated, they also can openly share their successes. The members’ positive competitive spirit spurs them to improve together.

Behind these awards are successful leaders who exhibit a rigorous commitment to define and redefine their organizations. They provide daily “North Star” guidance about what they and their teams must do to excel and sustain that excellence. Among Vizient mem-bers, sometimes only slight differences exist between the 5-star award winners and the 4-star runners-up. Vizient’s

Figure 2. How much can middle America afford for health care?Proprietary Information: Vizient 2018.Source. Girod CS, Weltz SA, Hart SK. Milliman Medical Index, 2016. http://www.milliman.com/uploadedfiles/insight/periodicals/mmi/2016-milliman-medical-index.pdf.Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group; US Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2016.

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goal is to prepare all members for the future by helping them to meet and exceed performance goals.

A Deeper Data Dive for 2018

Each year the Vizient awards criteria are fine-tuned to more accurately reflect members’ needs as well as the dynamics of the larger health care landscape. For exam-ple, in 2016 community hospitals began receiving the Bernard A. Birnbaum, MD, Quality Leadership Award in recognition of their achievements. In 2018, complex teaching medical centers were identified as a separate cohort of this award. Analyzing top performance by the type of institution ensures that mission, size, market posi-tion, and benchmarking are comparable within groups.

A member steering committee composed of physi-cians and statisticians helps Vizient with its data and ana-lytics improvements. For example, the committee recently urged Vizient to use more clinical data, leading to the addition of laboratory values in safety measures. The committee also challenges Vizient to identify mean-ingful metrics, leading the way by deconstructing more generalized measures into main drivers. For example, the traditional readmission metrics used for inpatient stays remain useful, but will require expansion to a revisit met-ric that can be used throughout ambulatory care. Vizient data also aligns well with Centers for Medicare & Medicaid Services measures, as well as success measures published by U.S. News & World Report and the Leapfrog Group’s annual hospital survey.

Actionable and Transparent Data

As opportunities for data capture increase and become more complex, it is important to deliver meaningful metrics to health care teams. They require more action-able data to actually solve problems and meet their goals.

Transparency in metrics is essential to guide quality improvement initiatives. For example, composite metrics combine several weighted metrics to produce one simple score, but the score is not always helpful because it does not identify which component of the composite is driving performance. With data transparency, specific condi-tions—such as hospital-acquired postoperative deep vein thrombosis or catheter-associated urinary tract infec-tions—can be isolated and remedied.

Work is underway to bundle and curate inpatient and outpatient data to provide an across-the-continuum view of patient experiences and outcomes. Members also are evaluating how to effectively incorporate data from patients’ wearable biosensor devices and machine learn-ing to augment their data picture.

Members look to Vizient to help prioritize their data needs against their strategic goals. For example, a mem-ber aiming to become a regional center for organ trans-plants would want to develop robust metrics around demand, capacity, length of stay ranges, and other indica-tors to assess its progress toward this goal. The right met-rics help define opportunities, highlight a lack of compliance with leading practices, and identify areas in which patient safety can be enhanced.

Seeking Data Scientists With Curiosity

Because of the abundance and complexity of current data, teams require assistance to understand the numbers and obtain agreement on needed process improvements. Data analysis is no longer confined to Excel spreadsheets; it has evolved into sophisticated dashboards grounded in data science.

Although tools are useful instruments, what also is needed are skilled data scientists who can drill down into the information before leaders ever see the data; assess it; and explain the meaning behind the dashboard’s red, yel-low, and green dots to stakeholders. After all, it is the story built from the dashboard—not the dashboard itself—that actually stimulates valuable and impactful changes.

Intensive analyses conducted by data scientists have proven successful in finance and other industries and are now emerging in health care. The data scientist must have permission from leadership to ask questions, query data, and be relentlessly curious about why and how the status quo works—or does not. This expertise helps glean real answers from mountains of data and reports; actionable insights are revealed that help quality improvement teams listen, learn, and lead.

An Expanding Team of Data Users

The number of data users within a health system or hos-pital has increased during recent years. Objections to data still exist but appear to be diminishing, and claims such as “my patients are sicker or different” have been slowly debunked by more transparent data. Electronic health record data can now be integrated with database data, enabling electronic quality measures and historical coded data to be applied more quickly.

Nursing now plays a larger role in quality metrics, and more physicians are involved and becoming data champi-ons. The chief medical officer role, historically focused on operations, is now immersed in data and analytics for performance improvement. Department chairpersons and C-suite officers also have become data advocates. In top-performing organizations, the quality team supports all

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improvement activities; however, nursing and physician leaders are held accountable by leadership for measurable advancements. Notably, organizations with integrated teams that use data to drive improvements are actually seeing improvements in their focus areas.

The alignment between neurologist and data scientist was seen at the summit during a power huddle, during which a neurologist led an engaging conversation about improvements in the organization’s observed versus expected mortality. A skilled drill-down analysis identi-fied an unusually high patient transfer rate, in which deaths were occurring within 1 to 2 days of transfer. This insight led to an increased focus on the use of telehealth, family conversations about transfers, patient safety, and end-of-life comfort.

The power huddle displayed a convergence of inter-ests, analysis, and solutions that resolved a troubling issue for the organization as well as patients’ families. In situations in which separate data reports are created and fragmented quality improvement is executed, progress can be elusive or can stall altogether.

System Connectors Strengthen Performance

As systems grow and diversify, data and analytics become key connectors within the infrastructure. The right data help link and unify clinical practice among sites. Some system teams are experimenting with the use of different sites to apply and learn from different processes, where real-time data capture can prompt rapid change. For example, a system-wide evaluation of total knee replace-ment procedures may lead to a greater emphasis on com-munity hospital settings based on outcomes, patient satisfaction, and post-surgical compliance; academic medical center resources can then be more strategically applied to other procedures requiring tertiary care.

Teams are applying data and analytics to service lines to help evaluate and strengthen performance within car-diovascular, oncology, neurosurgical, and orthopedic ser-vices. By selecting key service lines and integrating inpatient and outpatient data into a unified service-spe-cific dashboard, leaders develop a clearer view of their performance. In the future, this integrated methodology may be used to identify population health needs within specific markets.

New Innovations on the Horizon

Innovations in telehealth and the escalating demand for home care services greatly impact data capture and anal-ysis. As care sites diversify, they represent new horizons in terms of evaluating performance and the patient experience.

Yet, as data use expands and becomes increasingly refined, Vizient’s attention remains focused on collecting and analyzing the right data to help members make better decisions and achieve their goals. Whether the solution is simple or requires a more sophisticated project driven by a data scientist, members are single-minded in their focus to achieve quality and safety across the continuum of care.

The Journey Toward Accelerating Innovation

Crystal Mullis, RN, MBA, MHAVice President, Innovation Development, Vizient

Each year, during the Vizient Fall Connections Summit, Vizient hosts its Innovative Challenge—inviting mem-bers to listen to, contemplate, evaluate, and ultimately select the winning health care innovation from among a select team of competitors.

This year’s unique format featured competitors arranged in 2 cohorts: a virtual care/remote monitoring domain and a care coordination/communication domain. These domains were selected by the Vizient Innovation Practice Network, an invitation-only cohort of member chief innovation officers whose expert insights helped identify the domains of greatest interest to members cur-rently. Network participants hail from member organiza-tions that have created a strategy around innovation and have committed to that strategy by hiring an innovation executive. The Innovation Practices Network worked with Vizient content experts to select 4 start-ups to com-pete as finalists in the 2018 Innovative Challenge.

Exciting Concepts Aimed at Patient Engagement, Improved Care

Each contestant was allotted 13 minutes: 8-minute pitches were followed by 5-minute Q&As conducted by panelists Byron Jobe, president and chief executive officer of Vizient; Tim Babineau, MD, president and chief execu-tive officer, Lifespan; Cathy Jacobson, president and chief executive officer, Froedtert Health; and Vic Katz, managing director of Ascension Ventures and a represen-tative of the investor community.

The new format pitted 2 competitors against each other in each domain (Figure 1). In the virtual care/remote monitoring domain, the contestants included

•• Moving Analytics, a digital cardiac rehabilitation program

•• Vital Connect, a wireless, wearable biosensor that provides continuous monitoring and helps prevent unnecessary readmissions

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In the care coordination/communication domain, the contestants included

•• CoHealth, a personal health manager designed to assist discharged patients with organizing dis-charge instructions, appointments, medications, education, surveys, and other tasks required for a successful recovery

•• PreparedHealth introducing enTouch, the world’s first digital Health Insurance Portability and Accountability Act (HIPAA)–compliant commu-nity of caregivers

The 2018 winner was Moving Analytics, a digital cardiac rehabilitation program that earned 65% of the audience’s vote and a $25 000 prize. Harsh Vathsangam, chief executive officer, announced he will use the award money to conduct a study with a prominent payer to validate his program’s cost-effectiveness in a value-based environment.

During his pitch, Vathsangam touted the many bene-fits of cardiac rehabilitation: it extends life expectancy, reduces the chances of another heart attack, and cuts readmissions by 40%. Yet less than 15% of those eligible for cardiac rehabilitation actually participate because of problems with access and compliance. Moving Analytics’ digital product permits cardiac rehabilitation progress to be tracked from home, creating zero footprint for the hos-pital while cost-effectively caring for thousands of patients. The organization’s studies demonstrate an 80% completion rate at one quarter of the implementation cost of traditional programs. This unique service delivers on its promise of patient convenience and compliance bal-anced by a low cost in the face of tight reimbursement.

One hallmark of the Innovation Challenge winner and other successful start-ups is the absolute clarity of their message: they succinctly demonstrate the value of shifting away from how things have always been done. Helping health care leaders understand how the new concept is superior to a traditional process—buoyed by performance metrics and established user sites—is vital to springboard-ing the concept into market and gaining acceptance.

All 4 contestants also participated in the Innovative Technology Exchange, a meet-and-greet forum showcas-ing the latest in health technology advancements, where they engaged with members about future partnership ideas. Visitors had hands-on access to more than 100 new and innovative products. Members asked questions and offered immediate feedback on ways that the products might improve patient outcomes and safety for their organizations.

Growing Urgency in a Hectic Market

Entrepreneurs are finding that members are increasingly receptive to innovations and even feel a sense of urgency about preparing for market disruptors. Vizient conducts member polls that track attitudinal changes about techno-logical disruption and readiness to innovate. In 2018, C-suite leaders rated their sense of urgency to respond to disruptive innovation higher than in previous discussions and polls, indicating that leaders are embracing innova-tion strategies in a quickly moving market.

This uptick in readiness matches a hyperactive mar-ketplace, with high-tech behemoths and other giants moving into health care spaces. From Amazon’s supply chain and prescription drug fulfillment to Apple’s activity

Figure 1. Contestants and format for the 2018 Innovation Challenge.

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with wearable devices and even clinical trials, traditional boundaries between providers, payers, and suppliers are rapidly becoming blurred.

A New Breed Emerges

Members are eager to stay abreast of these seismic changes and create intelligent strategies for success. In response, more hospitals have appointed chief innovation officers to help them understand the health care landscape and make valuable connections with inventors and inves-tors. The most effective innovation executives tend to be successful serial entrepreneurs who are well connected to the innovation community and have corporate innovation experience. This new breed has unique talents and does not necessarily fit into the traditional strategy/business role. Although many of them join member organizations without deep health care experience, they bring fresh per-spectives and the ability to help the C-suite understand and capitalize on market trends.

As innovation executives work within members’ organizations, they help promote a digital mind-set among leaders and staff. As evidenced by the Innovation Challenge’s contestants, emerging solutions are typi-cally digitally based and often do not require much labor intensity. When interesting concepts emerge, innovation executives work with teams to create “clinical

sandboxes” in which hospital staff can experiment with early-stage products before making longer term scale-up decisions. Some members have dedicated innovative nursing units to test monitors, wearable sensors, and other products.

Finding the Right Path

As members advance along the innovation curve, one major hurdle is how to best position their organization. Understanding market disruption (Stage 1) is important, but not sufficient if the leadership team wants to benefit from it directly. In addition, most health care organiza-tions are not prepared to implement and operate Innovation Development Labs (Stage 3) where teams develop, test, iterate, and commercialize innovations. The appropriate adoption path for many members is Stage 2, where they work closely with external incubators, accel-erators, and investors to identify and co-develop worth-while solutions to bring to market.

Currently, members have considerable expertise in 3 areas of tremendous interest to market disruptors: data, provider relationships, and asset infrastructure. Disruptors have deep pockets and are willing to assume risk to rap-idly bring innovations to market. Productive partnerships with disruptors can be forged whereby all parties in the value chain—including patients—win.

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Power Panel Session Abstracts

Practical Solutions to Managing Aggressive and Violent Patients

Neel B. Shah, MD, Jacqueline J. Johnson-Howell, MA, RN, Tera L. Gross, DNP, RN, Danielle D. Crawley, MA, Ann K. McKay, MS, RN, Bernard A. Theobald, MAN, RN, and Robert J. Morgan III, MD, PhDMayo Clinic

Background. Health care violence is a growing issue across the country that can result in injury, medical errors, decreased patient satisfaction, increased adverse out-comes, and an increase in cost and staff turnover. Many institutions have taken steps to mitigate risk and train staff. Minnesota passed legislation requiring all hospitals to design a program to reduce violence. Mayo Clinic developed a comprehensive violent patient program using a triad approach involving nursing, safety, and security. The key program components include leader-ship engagement and communication, robust data, educa-tion, security partnership, culture change, and eventually a designated clinical unit. Intervention Detail. We tiered our staff educational programs based on the risk assess-ment for a given unit and simulation drills are used for direct care staff in the units with highest risk. Security began to round more intentionally within high-risk areas, supported staff filing criminal charges, and supported staff training programs. We established door alert cards, electronic health record flags, a violent patient handoff tool, behavioral safety plans, emergency medication tool kits, centralized online resources, and a leadership response guide to support staff. As awareness of health care violence increased, Mayo Clinic developed an inno-vative care model starting with a pilot “co-location” unit in a dedicated wing of a medical unit. Rooms were modi-fied and security was always present. This ultimately led to the purpose-built Complex Intervention Unit (CIU), with novel protocols and processes and a dedicated team of internal medicine and psychiatry physicians, nursing, social work, pharmacy, and security. CIU is a locked medical unit built to psychiatry specifications with uni-versal video monitoring, seclusion rooms, secure nurses’ station, sally ports, and interview room with the ability to attend court remotely. It also has electrocardiogram mon-itoring available for all beds, bariatric rooms, and rooms able to accommodate hemodialysis. All staff have advanced de-escalation skills. Outcomes and Impact. This program has been effective in reducing violent events, staff assaults, attrition, behavioral emergency response calls, and property damage across the entire hospital. We have seen a 96% reduction in lost/restricted

work days. CIU has received patients from across the hospital, and has reduced length of stay for this popula-tion, as well as improved ED (emergency department) throughput. By integrating with the existing hospital eco-system and coordinating support to other inpatient units with the behavioral emergency response team, CIU has become the apex unit for patients with behavioral needs at our institution. Risk stratification is necessary for effective triage of patients, and we have developed tools to differentiate disruptive from aggressive patients. In conclusion, a comprehensive violent patient program requires senior leadership engagement and support, safety training for all staff, positive unit culture, and strong local leadership. For the designated clinical unit, the multidisciplinary team is key to development and implementation; however, both unit design and staff pre-paredness through proactive communication and educa-tion are vital to success.

Population Health: Collaboration to Achieve High-Reliability Team-Based Care

Carla Braxton, MD, MBA, FACS, and Alice Pollard, MPH, BSN, RNHouston Methodist West Hospital

Background. Hospitals are in continual pursuit of high reliability and seek methods to achieve the safest care with the best possible outcomes. Quality and infection control team collaboration with the case management and bedside clinical teams can support high reliability with positive impact on patient care. We have developed a pro-cess whereby quality and infection control staff members participate in person during multidisciplinary care coor-dination rounds to support risk-based thinking and align-ment with best practices. The discipline of hospital quality/safety/performance improvement (QPI) has evolved beyond the solo nurse auditor or compliance offi-cer to a collaborative model with a focus on teamwork, shared knowledge, and best practices. QPI is the corner-stone of high reliability whereby potential problems are anticipated, prevented, detected early, and responded to quickly. In order to achieve these goals, hospitals rely on QPIs to communicate with members of the care team about medical risks, potential regulatory exposure, and threats to positive clinical outcomes. Multiple modes of communication are needed to support activity around the current plan of care and effective discharge planning. Since the opening of our complex teaching medical cen-ter in 2010, we have conducted daily multidisciplinary care coordination rounds on the medical/surgical units and intensive care unit, with QPI staff and infection con-trol practitioners (ICPs) as founding members.

18S American Journal of Medical Quality 34(2S)

Purposefully embedding QPIs and ICPs into daily patient rounds supports real-time communication and is superior to telephone calls or secure email for addressing patient issues. Participants in daily care coordination rounds include representatives from quality/safety, infection control, case management, social work, clinical phar-macy, respiratory therapy, physical therapy, and the charge nurse from each clinical unit. The rounds occur in a private, visitor-free area on the unit. First, the bedside nurse delivers a short summary of the patient’s course, and then each discipline takes a turn contributing infor-mation relevant to the clinical course and/or discharge planning. Each unit spends approximately 30 minutes for review of 32 patients per unit. QPI/ICPs often remain on the units for additional support for the nursing staff at the conclusion of rounds. Intervention Detail. QPIs and ICPs address specific clinical issues that can impact outcomes or reportable safety metrics. Areas of focus for the QPI team during rounds include accurate sepsis and fall risk scoring and interventions, stroke and acute myocardial infarction metrics, venous thromboembolism prevention, Centers for Medicare & Medicaid Services core mea-sures, and restraints documentation. ICPs assess neces-sity of central venous access and urinary catheters, assist with appropriate use of medical isolation, review risks for ventilator-associated events, and evaluate compliance with our Clostridium difficile prevention program. In addition, QPI and ICP staff survey for potential risk issues and for alignment with accreditation standards. Multiple communication modalities are used by QPI/ICP staff. A system exists whereby QPI coordinators or ICPs can send messages to the medical staff in the electronic health record by nonpermanent electronic “sticky notes.” Clinical information about benchmarks also is provided by centralized electronic “best practice advisories” through the computerized practitioner order entry system. Each of the communication modalities adds a different benefit to the recipient and helps avoid missed opportuni-ties. Examples of the positive impact of daily quality and infection control involvement in rounds can be seen in our sepsis mortality initiative—mortality has decreased from approximately 29% in 2014 to less than 5% in 2017. The hospital’s overall risk-adjusted mortality index has improved from 0.65 in 2015 to 0.47 in 2017, the hand hygiene compliance rate has improved from 97.7 in 2015 to 99.2 in 2017, and the Agency for Healthcare Research and Quality Patient Safety Indicator compliance rate has improved from 0.65 in 2015 to 0.47 in 2017. Outcomes and Impact. QPI and ICP staff participation in care coor-dination rounds is part of a structured, daily effort for pre-vention of hospital-acquired conditions. Embedding QPI and ICP staff members within the care coordination team is an example of systems thinking, which streamlines communication between multiple disciplines and

compresses the time needed for decision making. QPI and ICP collaboration in care coordination rounds keeps a focus on safety and acknowledges that the patient’s clinical condition is continually evolving. These elements of high reliability, wherein the conditions are dynamic and require frequent reevaluation, support mindfulness in patient care. In our experience, direct discussion about quality or infection control issues is complementary to other modes of communicating patient information. Even the most abbreviated dialogue during rounds can decrease the likelihood of misinterpretation of information and allows for clarification of goals when needed. Face-to-face interaction has helped develop years of trust and col-laboration between bedside clinical staff and the QPI/ICP staff. It also offers opportunities for just-in-time educa-tion about the latest regulatory changes, medical bench-marks, or safety alerts. QPI and ICP direct involvement in care coordination also supports the goal to achieve high overall employee engagement in key safety areas such as error prevention, ability to speak up, and collaboration to ensure safe working conditions.

Note: The Population Health: Collaboration to Achieve High-Reliability Team-based Care panel presentation was presented in collaboration with Sanford Health.

Quality Diabetes Care: Stacking the Deck Through Innovation

Joshua D. Miller, MD, MPH, Paul F. Murphy, BS, CSSBB, Sandra E. Martich, MS, Anthony D’Aulerio, BA, Robert Rocconi, and Lawrence E. BenderStony Brook University Hospital

Background. Stony Brook University Hospital cares for more than 6000 patients with diabetes annually, crossing the spectrum of inpatient clinical care by both disease state and geographic location. We underwent a dramatic transformation to align the institution with standards of care in the management of patients with diabetes. In 2015, a Diabetes Advisory Committee (DAC) was formed under the purview of a new hospital quality vector focusing on clinical outcomes. This group was charged with spear-heading the transformation and driving the innovations needed to establish Stony Brook as the region’s leader in diabetes care and a recognized diabetes center of excel-lence. As a chronic “secondary diagnosis,” the clinical impact of diabetes care is far-ranging and influences many familiar hospital outcome measures, including readmis-sion rates, hospital length of stay (LOS), surgical compli-cations, and surgical site infections. Other indicators provide a barometer for clinical process measures of

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diabetes care with national benchmarks outlined by the American Diabetes Association (ADA), including hemo-globin A1c (HbA1c) testing, rates of hyper- and hypogly-cemia, dietary considerations, and tracking of diabetes “never events.” The evolution of diabetes care at Stony Brook has included each of these “glucometric” measures that are defined, tracked, and analyzed through a series of real-time and historic automated dashboard monitors. Through improvement cycles and amendments within the electronic medical record (EMR), Stony Brook standard-ized safe and protocolized insulin ordering and adminis-tration while using a glucometric flag system to ensure safe and outcomes-driven progression. These efforts were paired with a dynamic educational initiative through teaching sessions and an online learning management sys-tem for all hospital staff. Recent expansion of the program has included preoperative glucose management and care for patients using insulin pump therapy. Intervention Detail. Diabetes care and associated metrics are well defined by the ADA and include further program and quality measures as outlined by The Joint Commission’s Disease-Specific Certification for Inpatient Diabetes. Stony Brook began by establishing baseline reports from coded data, obtained through the Vizient Clinical Data Base (CDB). These measures used a series of diabetes International Classification of Diseases (ICD)-9/10 codes for all diabetes diagnoses and included rate of HbA1c within 90 days of inpatient admission, readmission within 7/14/30 days, population case mix index (CMI), LOS, and LOS index. On a patient level, further process measures included appropriate carbohydrate-consistent diets, instances of hypo- or severe hypoglycemic events, and the presence of an insulin pump. Each of these process and outcome measures was then incorporated into a Tableau reporting program in conjunction with our Cerner EMR platform. Working with our information technology and visualizations department, the diabetes team was able to design, build, and review a real-time diabetes dashboard with access through an online portal. Pulling directly from the EMR based on these diabetes ICD-9/10 codes and associated clinical flags, all patient histories and select clinical criteria were available within 1 hour of entry into the EMR. A secondary historic dashboard was then designed to monitor these same flags on a trended basis retrospectively. Stony Brook has thus developed the abil-ity to determine all inpatients with a history of or new risk for diabetes while simultaneously tracking their outcomes each hour, month, and year of their care. The implementa-tion of standardized insulin ordering based on insulin sen-sitivity has influenced each of these metrics, as well as provided tracking within these dashboards for the appro-priate regimen throughout a patient’s stay. Outcomes and Impact. Current data analyses report significant improve-ments from a 2014 baseline period. HbA1c compliance

within 90 days of admission has increased from 50% at baseline to 88% in the second quarter of 2018, and is closely tied to select order inclusions within the new stan-dardized insulin order sets. Thirty-day readmission rates have decreased from 16.82 to 12.99 over the same time period. Using the Vizient CDB, Stony Brook was able to benchmark against institutions of similar size and CMI and establish appropriate goals regarding readmission rates. The LOS index has decreased from 1.20 to below 1.06 for 2018. Implementation of the insulin EMR PowerPlans has standardized administration schedules and decreased our point-of-care fingerstick glucose checks by more than 5000 tests per quarter. In accordance with ADA guidelines, Stony Brook has worked with our labo-ratory department to align thresholds of hypoglycemia and critical value reporting. The development of the Tableau dashboard reporting has included utilization of new insulin PowerPlans, appropriate carb-consistent diets, presence of an insulin pump, and rates of hyper- and hypo-glycemia. This dashboard innovation allows for real-time filtering by ordering physician, patient unit location, and patient-level glucose history, allowing immediate feed-back and intervention. As an online portal, the dashboard is accessible by our nursing and physician staff, as well as our diabetes educators and clinical nutritionists. Patients are actively identified, managed, evaluated, and flagged throughout their stay. DAC continues to review policy and practice while monitoring the historic, automated Tableau dashboard to enhance diabetes care at Stony Brook, with each implementation and effect immediately present in the bedside care a patient receives. Further management of these glucometrics and associated EMR guardrails and flags in the management of patients with diabetes will help maintain and exceed ADA benchmarks and Vizient comparative data.

Note: The Quality Diabetes Care: Stacking the Deck Through Innovation panel presentation was presented in collaboration with Froedtert & The Medical College of Wisconsin.

Quality Diabetes Care: Stacking the Deck Through Innovation

Erika E. Smith, PharmD, FACHE, and Bradley H. Crotty, MD, MPH, FACPFroedtert & The Medical College of Wisconsin

Background. As Froedtert & The Medical College of Wisconsin (F&MCW) sought to improve performance in clinical effectiveness and patient-centered care, espe-cially for high-risk patients, we identified a need to cre-ate care processes to assist patients in reaching their

20S American Journal of Medical Quality 34(2S)

desired health goals and outcomes using a multidisci-plinary approach with touch points between visits. Consumer informatics tools, or “digiceuticals,” increas-ingly offer opportunities to assist the traditional care team from an efficiency perspective, as well as increas-ing patient activation and engagement. The Ambulatory Diabetes Outreach Program (ADOP) was implemented at the F&MCW primary care clinics in 2016. The goal of this program was to use a broader care team in patient-centered ways to improve diabetes control, mainly measured by hemoglobin A1c (HbA1c) control. In collaboration with primary care providers, the multi-disciplinary team, composed of pharmacists, care coor-dination nurses, a certified diabetes educator, and a social worker, manages pharmacotherapy, identifies and addresses barriers, increases access to care, and coaches patients on lifestyle modifications. Team members work under a system-wide collaborative practice agreement or protocol whereby they can prescribe and adjust medi-cations related to diabetes and associated comorbid con-ditions. The team leveraged Glooko for the work, a diabetes management platform that supports the down-loading of data from more than 95% of blood glucome-ters and continuous glucose monitors to its platform. The data can be viewed by patients and their care teams, which allows for more efficient, real-time assessment of individual patients’ diabetes control and enables the ADOP team to make medication and treatment plan adjustments quickly between a patient’s provider visits. Glooko also provides the opportunity for patients to become more engaged in their care by allowing them to track more specific data, including preprandial and postprandial blood sugars; identify when medication doses were missed or taken; record eating habits and exercise; and visualize their results. Intervention Detail. We used multiple data sources to identify and track patients in the process, including registries created within our electronic health record. We benchmarked data against our local quality collaborative, the Wisconsin Collaborative for Health Care Quality, which identifies the goal of HbA1c <8% in patients with type 2 diabetes. We used registry functionality to identify eli-gible patients and sent them a letter inviting them to the program. We followed up letters with telephone invita-tions on behalf of their primary care provider and tracked acceptance of the program. We assessed the pro-gram’s performance against the Centers for Medicare & Medicaid Services’ programs through the Medicare Access and CHIP Reauthorization Act of 2015/Merit-Based Incentive Payments System, and more broadly looked at the impact of the program on other cardio-metabolic parameters such as blood pressure control. To evaluate the program, we tracked the number of patients enrolled and participating in the program, as well as

program engagement and completion. We tracked changes in HbA1c over time, and also assessed for improvements in blood pressure. As part of our evalua-tion, we looked to assess the incremental value provided through use of the Glooko platform. Glooko was offered to all patients engaging in the ADOP program. We tracked enrollment in the technology and refined out-reach strategies to improve adoption of the tool. As Glooko was being implemented, we assessed enroll-ment in the technology platform and tracked feedback from pharmacists and patients about onboarding and usage of the tool. In addition to these measures, we tracked patient goals, including lifestyle goals and tar-gets. Outcomes and Impact. Through the first quarter of calendar year 2018, 1330 patients enrolled in the pro-gram, 802 (60%) of which had an HbA1c >9% at enrollment. One out of 4 patients invited to participate in the program accepted. Of the enrolled patients, 188 (14%) used Glooko to manage their diabetes in conjunc-tion with the multidisciplinary team. There was an aver-age of 3 telephone contacts per patient per month. Among enrolled patients, 213 (16%) accepted but had minimal engagement in the program, with patients not answering calls or engaging with the clinical staff, lead-ing to program closure within 6 weeks of enrollment. During an interim analysis conducted after the first 9 months of the program (April 2017), we assessed out-comes for the first 82 patients with a more in-depth analysis that included chart review. The average base-line HbA1c was 9.6%, improving to 8.2% at 3 months. Our analysis at this time showed early signs of success, including achievement of personal HbA1c goals, blood pressure control, and associated gaps in care, that led to continuation and expansion of the program. Overall pro-gram success in glycemic control demonstrates a 1.45% decrease in HbA1c over an average of 107 days of man-agement. HbA1c appeared to be sustained after program completion, with an average increase in A1c of 0.14% (standard deviation 0.5). In initial analyses, those patients enrolled in Glooko demonstrated an additional 0.3% further decrease over those who were not using the tool, with better sustained HbA1c improvement. Building on early success, we have integrated Glooko into our electronic health record, enabling clinicians to engage with their patients using the technology. Patients with HbA1c >9% also received support from our ADOP team. Cost of care analysis demonstrated reduction in utilization across all environments of care including inpatient, hospital outpatient, specialist, and primary care group practices.

Note: The Quality Diabetes Care: Stacking the Deck Through Innovation panel presentation was presented in collaboration with Stony Brook University Hospital.

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Power Huddle Session Abstracts

An Ounce of Prevention: Opioid Stewardship at an Academic Health System

Kristy S. Deep, MD, MA, FACP, Doug Oyler, PharmD, and Phil Chang, MD, FACSUK Healthcare

Background. Drug overdose kills 1 American every 12.5 minutes. Opioid overprescribing contributes to wide-spread drug availability and exposes people at risk for substance use disorders. Nearly 75% of individuals who abuse opioids began with a legitimate medical prescrip-tion. It is imperative that health systems and prescribers develop strategies to reduce opioid exposure. UK Healthcare implemented a multidisciplinary opioid stew-ardship program that addresses care processes across the continuum—from nurse at the bedside to ordering pro-vider, and from admission to discharge. This program aimed at minimizing unnecessary exposure to opioids from the health care system without sacrificing pain man-agement. The primary goal of the program has been to equip providers with the tools, knowledge, skills, and atti-tudes to maximize nonopioid analgesia and safely pre-scribe opioids when required. Our opioid stewardship program has the following operational aims: (1) reduce unnecessary opioid use by employing evidence-based nonopioid analgesic strategies; (2) safely prescribe opi-oids at minimal dose and duration; (3) engage patients via education and improved pain assessment; and (4) monitor opioid utilization and patient outcome data. The team includes prescribers (physicians, advanced practice regis-tered nurses, and physician assistants), pharmacists, nurses and nursing leadership, patient education staff, and clinical informaticists. The scope of work now encom-passes 6 subgroups addressing prescriber education; nurse and patient education; formulary, informatics, and data; ambulatory initiatives; nonpharmacologic therapy; and pediatric pain management. Intervention Detail. Our pro-gram began by surveying practitioners (prescribers and pharmacists, N = 363) across our institution to assess readiness for change and identify the highest-yielding opportunities for improvement regarding opioid prescrib-ing. Most providers (61.7%) believed opioids were over-used despite similar efficacy to nonopioid analgesics and higher risk. Nearly two thirds of respondents felt that patients would not be accepting of nonopioid treatment modalities. Furthermore, 63.9% of respondents felt pres-sured by patients to prescribe opioids, both while inpatient and at hospital discharge. Providers’ highest-ranked needs included guidelines for using nonopioid analgesics and managing pain in patients with substance use disorders. Using these results to prioritize interventions, the opioid

stewardship program developed or championed the fol-lowing initiatives:

•• Development of pain management practice guide-lines applicable to service lines

•• Creation of an inpatient order set that prioritizes nonopioid analgesics

•• Revision of patient education materials regarding inpatient pain and analgesia

•• Implementation of a new pain assessment scale•• Expansion of nonpharmacologic measures to man-

age pain

Using our enterprise data warehouse, we developed a real-time dashboard that displays opioid utilization and balancing measures by both clinical service and nursing unit location. Measures include

•• Opioid use: median inpatient daily morphine mil-ligram equivalents (MMEs), number of opioid dis-charge prescriptions per day

•• High-risk use: percentage of patients receiving a total daily opioid dose >90 MME, co-prescribing of opioids and benzodiazepines

•• Safety: use of opioid sedation scale for patients receiving opioids, naloxone use for inpatients receiving opioids

•• Balancing measure: percentage of patients with moderate (4-6) or severe (7-10) pain as highest daily pain rating

Outcomes and Impact. Hospital-wide daily opioid use decreased from 32 MMEs per patient per day to 28 MMEs per patient per day, leading to a reduction of 1 890 000 MME per year. Among previously high-utilizing service lines (eg, orthopedics, trauma), the reduction has been even more substantial (51 MMEs per day to 39 MMEs per day). Similarly, the number of patients on high-risk regimens (>90 MMEs per day) has decreased by approx-imately half (~5% in July 2016 to ~2.5% in July 2018). Some service lines have seen even greater reduction. For example, more than 30% of patients on inpatient orthope-dic services received >90 MMEs per day in July 2016; in February 2018 this had decreased to less than 10%. For adult inpatients, the number of patients discharged with a prescription for opioids has decreased from 51.2% in July 2016 to 44.5% in February 2018. That equates to 211 fewer opioid prescriptions entering the community each month. Despite dramatic reductions in opioid utilization, inpatient pain ratings have remained fairly constant or shown a trend toward improvement. In the third quarter of 2016, the percentage of patients with any daily pain score >7 ranged between 25.8% and 26.9%. In the sec-ond quarter of 2018, the range was 22% and 24.5%. The

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range of patients with highest daily pain rating of 4 to 6 has been stable, with a range of 16.5% to 18% through-out. Our experience shows that health systems can imple-ment strategies to reduce opioid prescribing both during admission and at discharge. These initiatives should include patients, bedside staff, and prescribers to truly change the culture of opioid utilization.

A Self-Service Analytical Tool to Cultivate a Data-Driven Quality Improvement Culture

Meng Wei, BSN, MBA, and Pin-Chieh Wang, PhDUCLA Health

Background. Improving quality and safety has been a top priority for UCLA Health System; therefore, a strategic quality vision called MOVERS was developed by the leadership. MOVERS integrates 5 priorities: reducing risk-adjusted Mortality, improving process and Outcome measures, implementing Value-based redesign, enhanc-ing the patient Experience, reducing preventable Readmission, and Strengthening patient safety. However, there was no centralized platform for the institution to track these performance measurements; tracking of such data was not user friendly and the data were not readily available to users. To achieve an integrated and coordi-nated approach to improve quality and safety, and to ensure the system quality goals align with individual quality improvement projects, the quality informatics and analytics team built and shared the MOVERS online tool, which serves as a centralized platform for performance data sharing across the whole institution, and provides easy-to-use self-analytics functions for end users. The MOVERS online tool has drill-down capabilities and is available to the whole institution via the intranet. It uti-lizes Vizient output data files, institutional clinical data-bases, and external public reporting information for ongoing performance monitoring and health care quality metrics tracking. With data readily available at the user’s fingertips, this online tool promotes information transpar-ency and enables end users to access quality metrics any-where on campus, allowing users to perform data analysis without help from professional analysts, and also allow-ing users to communicate insights with others in much more convenient ways. This interactive tool attracts users to perform more data-related activities such as data vali-dation and analysis. Users are able to identify multilevel issues related to quality performance improvement through project prioritization, implementation, real-time data monitoring, and self-service analysis. A data-driven quality improvement culture was formed as a result of the implementation of this tool. Intervention Detail. This

online self-service analytical system contains 3 sections: the MOVERS section contains system-wide annual goals for the high-priority quality measures; the PROCESS MEASURES section contains drill-down dashboards supporting quality projects from system level to opera-tion level; and the PUBLIC RANKING section offers various benchmarking capabilities. The web-based ana-lytic tool was implemented in April 2017, starting with 1 dashboard section with 4 drill-down dashboards, ulti-mately extending to 3 major dashboard sections connect-ing to 77 drill-down dashboards presenting hundreds of health care quality metrics with an average of 500 daily usages. By March 2018, 80 000 encounters had been gathered and stored in this system. The database consis-tently expands to include retrospective and prospective data. The data have been monitored continually for com-pletion and accuracy; the accuracy rate is higher than 98%. The quality informatics and analytical team has conducted training sessions for various departments and units to promote utilization of the tool. The tool was dem-onstrated at virtually all quality and safety conferences and meetings within the health system. Initially, more than 500 users had been granted access to the tool. Starting July 2017, with approval from top leadership, the tool was moved from a password-protected environment to the institution intranet with no password requirement to promote information transparency within the institu-tion. Now employees at UCLA Health can access the quality metrics data (without protected health informa-tion) anywhere on the UCLA campus. By March 2018, the MOVERS tool had a total of 23 000 views and grow-ing. Outcomes and Impact. The Tableau-based tool has dramatically improved the way users monitor perfor-mance, identify actionable approaches, and benchmark with other institutions. With the implementation of this self-service tool, the institution is able to concentrate its resources and efforts to support system-wide quality ini-tiatives. With highly accurate data and high utilization of the MOVERS tool, this self-service system becomes the most preferred method for health system employees to identify institutional quality goals and to monitor health care quality metrics and the progress of quality improve-ment activities. One year after implementation of this tool, significant performance improvements were observed in several quality metrics. A consistent reduc-tion trend (P = .02) was observed for mortality index between April 2017 to March 2018 in contrast to the increasing trend in the previous 12 months. We observed a 13.3% reduction in the mortality index (from 0.83 at 1 year pre implementation of the MOVERS tool to 0.72 at 1 year post implementation of the MOVERS tool). For the length of stay index, the time trend also changed from a positive to a negative direction showing strong improve-ment. We observed a 6% reduction in the length of stay

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index (from 1.09 at 1 year pre implementation of the MOVERS tool to 1.03 at 1 year post implementation of the MOVERS tool). For 30-day readmission, the reduc-tion time trend increased 2-fold: the readmission rate changed from 11.5% at 1 year pre implementation of the MOVERS tool to 11.2% at 1 year post implementation of the MOVERS tool. The web-based self-analytic tool dic-tated the quality (completion and accuracy) of the data. The high data accuracy rate and high usage traffic are encouraging, and confirmed the feasibility of our designed system.

Call Center Uses Evidence-Based Algorithm and Provider Network to Improve Access to Spine Surgeons

Emily K. Karlen, MBA, MPT, and Jane K. Anderson, DNP, APRN, CNPUniversity of Minnesota Health

Background. When in pain, patients often seek a spine surgeon, thinking the specialist is best suited to reduce their symptoms. Research reports that surgery is an appropriate treatment for less than 2% of these patients. Many are most appropriately treated with conservative care through primary care providers or nonsurgical spe-cialists. When nonsurgical patients fill surgeon sched-ules, appropriate patients struggle to access surgeons and nonsurgical patients wait months only to hear that the surgeon cannot help them, delaying more appropriate conservative care. Prior to this project, patients waited at least 3.5 months for an initial evaluation from a spine surgeon, and many waited more than 5 months. Using best-practice guidelines and input from a multidisci-plinary team, the academic spine surgery clinic created an algorithm for nonclinicians in the call center to sched-ule new patients with the most appropriate provider type. In order to best meet patients’ needs, the clinic looked beyond their partnership with sports medicine physi-cians, building a provider network that included a nurse practitioner primary care clinic and physical therapists. Intervention Detail. Spine care is known to be costly and complex, being second only to the management cost of cardiovascular disease, and with more than 12 provider types that offer 200 treatment options.1,2 Before using the algorithm, only 20% of new patients calling the University of Minnesota Health spine surgery clinic were appropriate for a surgical consult. When patients see surgeons early, high costs and inappropriate care often follow. Many surgeons, including those at the University of Minnesota, require new patients to have a magnetic resonance imaging (MRI) prior to their visit. Imaging early in back pain increases the probability of

surgery by 8-fold and medical costs by 5-fold.3 In one study, patients referred to a spine surgeon first saw a nonsurgical provider. Spine surgery decreased 25%, and 74% of patients were highly satisfied seeing the nonsur-gical provider.4 Additionally, when nonsurgical patients delay care, they have a higher overall cost of care and worse clinical outcomes than if had they received con-servative care sooner.5,6 Quantitatively, the team col-lected the intake algorithm for each patient. Data tracked included referral and symptom information, patient treatment preferences, and with which provider the patients scheduled. The project manager tracked whether the algorithm was followed correctly and if the result was appropriate. The team measured access to spine sur-geons and the number of new patients per week, making sure patients were not going to competitors when not assured a visit with a surgeon. Qualitatively, clinicians collected patient satisfaction data from patients placed with nonsurgical providers, provider perception of over-all new patient appropriateness, and job satisfaction among the call center representatives, where high turn-over is a common concern. These data helped the team understand the broader impact of our work. Outcomes and Impact. By building a provider network with a nurse practitioner clinic, academic sports medicine physicians, physical therapists, and primary care providers in addi-tion to academic spine surgeons, the University of Minnesota Health matched this complex patient popula-tion to the appropriate provider 99.4% of the time, a sig-nificant improvement from the 20% baseline. By the end of 45 weeks, 539 patients were matched accurately. Average access for the 307 surgical patients went from 4 months to 52 days, and from 4 months to 1 day for the 232 nonsurgical patients. Collectively, more than 124 years of patient wait time were eliminated. In spine care, delaying care just 10 days increases cost and reduces the clinical outcome.5 During the project, when patients were scheduled with a more appropriate provider type, costs to the patients decreased while clinic revenue increased. Of the 539 patients, 232 did not begin with a surgeon visit and therefore did not require an MRI to begin their care, saving as much as $260 000 to $1 230 000 for a population of 539. Patients reported satisfaction with their evaluation and care by nonsurgeons. Additionally, the average number of new patients each week increased from 11.3 to 13.2. Frontline staff also expressed increased job satisfaction. Call center employ-ees scheduled patient visits sooner, nurse practitioners and physical therapists evaluated patients earlier in their condition, and surgeons evaluated patients who were more likely to benefit from surgical interventions. This project addressed the seemingly impossible task of coor-dinating complex patients without adding clinical staff or costly software by creating an evidence-based patient

24S American Journal of Medical Quality 34(2S)

intake algorithm and by establishing a provider network beyond the walls of its academic multispecialty clinic.

1. Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656-664. (Erratum in: JAMA. 2008;299:2630.)

2. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. Spine J. 2008;8:1-7.

3. Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41:838-846.

4. Fox J, Haig AJ, Todey B, Challa S. The effect of required physiatrist consultation on surgery rates for back pain. Spine (Phila Pa 1976). 2013;38(3):E178-E184.

5. Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976). 2012;37:2114-2121.

6. Fritz JM, Magel JS, McFadden M, et al. Early physical therapy vs usual care in patients with recent-onset low back pain: a randomized clinical trial. JAMA. 2015;314:1459-1467.

Advancing Your Culture of Safety by Supporting Second Victims

Jennifer A. Call, RN, MSN, CPHQ, and Nicole R. Silva, MSW, LICSWLifespan

Background. The process of reporting patient safety events focuses predominantly on the impact of the event on the patient. At Lifespan, we identified opportunities to ensure that the impact of the patient safety event on staff and providers—second victims—is not forgotten. In response, a new program was developed to proactively offer a guided support network for employees and man-agers who reported in the Vizient Safety Intelligence pro-gram (branded at Lifespan as SafetyNet) and/or were involved in significant patient safety events. Intervention Detail. Patient safety culture can be measured by deter-mining what is rewarded, supported, expected, and accepted in an organization as it relates to patient safety. Lifespan last administered the Agency for Healthcare Research and Quality (AHRQ) Hospital Culture of Safety Survey in 2017 and identified patient safety as an organi-zational priority that was most closely aligned with

employee engagement, targeted improvement efforts focused on the composite scores for supervisor/manager expectations, and actions promoting patient safety. A key strategy for improvement included a new program devel-oped by the departments of patient safety and clinical social work to proactively offer a guided support network for employees and managers who reported in the Safety Intelligence program and/or were involved in significant patient safety events. When a potentially significant (harm score of 6 or greater) patient safety event is entered by a staff member or provider, a patient safety specialist and social worker reach out to the reporter and his or her manager to offer counseling and/or emotional support. Additionally, feedback mechanisms were incorporated into our processes to acknowledge the reporter’s partici-pation in our patient safety program. If the event warrants a larger response, Lifespan’s staff crisis response team will organize a structured debriefing event using the con-cepts of Critical Incident Stress Debriefing, in which all members of the team have been trained. The team com-prises members from social work, psychiatry, spiritual care, and nursing. Staff involved in the safety event can process the event in a structured, safe environment and learn skills to manage stress. For staff who experience ongoing stress related to the safety event, referrals to the Lifespan Employee Assistance Program (EAP) or other providers are made to connect staff with needed resources to cope effectively with the event. Outcomes and Impact, Modifications were made to the SafetyNet Event Reporting module so that social work department leader-ship could track the number of outreach efforts made to the manager of the department in which the safety inci-dent occurred. The number of debriefings is also tracked through SafetyNet. So far, in calendar year 2018, six structured debriefings have been held in relation to patient safety events. Responses from the 2018 Burnout and Resiliency and AHRQ Hospital Culture of Safety Surveys have further guided program development. Feedback from 6 structured debriefings to date has been extremely positive. Staff have voiced feeling supported, and manag-ers appreciate the collaboration and support from social work in helping their impacted employee(s), which addresses many of the comments that we received in the survey responses. Among comments received, one included, “If the hospital is concerned with patient safety, they need to make employees happy first.” This was a common theme from employees, and this supportive net-work helps address this cultural element. Results from surveys conducted in 2018 demonstrate that both employ-ees and managers have high action planning readiness scores, leading to employee engagement and a culture of safety. Though the guided support interventions began before the clinician burnout survey, we aim to reduce cli-nician burnout by providing on-site support to staff

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immediately following a safety event as well as referring them to EAP or other providers for ongoing support and intervention as needed. This new process and use of the supportive network ensures that all staff involved in patient safety events are offered and provided with the help they need, with no employee feeling unsupported.

Establishing a High-Reliability Infrastructure: The Vizient Sepsis Lactate Lab Measure

Russell Kerbel, MD, MBA, Summer Gupta, RN, MSN, and Phanindra Yadlapalli, MCSUCLA Health

Background. UCLA Health (UCLA) has implemented high reliability principles as a framework to address the new Vizient Sepsis Lactate Lab Measure by defining a shared “true north” vision for the early recognition of and response to sepsis and establishing a multidisciplinary team infrastructure guided by transparent data visual dashboards. Sepsis is defined as an infection-inducing pathophysiological syndrome associated with high mor-bidity and mortality. Treatment in intensive care units is associated with high fixed costs, and thus once a patient progresses into septic shock, cost savings are limited.1 Venous lactate levels have been shown to risk stratify in-hospital mortality within 3 days.2 In 2017, Vizient intro-duced the Sepsis Lactate Lab Measure, defined as the “percentage of cases that do not have a lactate level within 12 hours of admit labs that have severe sepsis or septic shock which is present on admission,” and placed the measure within its “effectiveness” metric for aca-demic medical centers (AMCs). Vizient lab measures were developed to “provide extended insights into a patient’s status throughout his or her course of care and mirrors the information clinicians evaluate when making treatment decisions.” This year the Sepsis Lactate Lab Measure is weighted at 3.23% of the “effectiveness domain” (20% of the AMC Vizient score), thus making up an overall metric weight of 0.65%. Intervention Detail. UCLA created the International Classification of Diseases, Tenth Revision (ICD-10) Coded Sepsis Lactate Dashboard through a collaboration between departments within the UCLA High Reliability Sepsis Initiative: sep-sis physician champions, sepsis nursing champions, the quality department, and the quality informatics and ana-lytics department. An automated monthly run chart was built to filter cases by ICD-10 code, present on admission (POA) versus non-POA, admission floor, and discharge date. The dashboard included a 12-hour lactate flag to identify pertinent cases. The denominator was composed of a population of greater than 5000 discharged patients.

Outcomes and Impact. Over the past 3 years, the UCLA High Reliability Sepsis Initiative has implemented numerous measures to both identify septic patients early as well as implement the SEP-1 Sepsis Bundle (which includes a lactate level). These interventions include an emergency department sepsis triage code, nursing severe sepsis screening tools, a nurse sepsis screening policy to allow lactate level draws as a standing order for patients who screen positive, and a sepsis best practice. Specifically, UCLA Ronald Reagan has established a high-reliability infrastructure to address the Vizient Sepsis Lab Measure. From November 2015 through January 2018, UCLA sepsis lactate compliance has remained between 93% and 97% for both UCLA Santa Monica and UCLA Ronald Reagan. These data were then utilized as a secondary validation tool for the Vizient Sepsis Lactate Measure.

1. Chalupka AN, Talmor D. The economics of sep-sis. Crit Care Clin. 2012;28(1):57-76.

2. Shapiro NI, Howell MD, Talmor D, et al. Serum lactate as a predictor of mortality in emergency department patients with infection. Ann Emerg Med. 2005;45:524-528.

Improving Care Coordination and Saving Money by Working With Super-Utilizer Patients

Lesly A. Starling, BA, BSN, RN, and Lara J. Shadwick, MBAKalispell Regional Healthcare (in collaboration with Mountain Pacific Quality Health)

Background: Super-utilizer patients account for 1% of the patient population while accounting for more than 22% of the costs. These patients have complex medical, behav-ioral health, and social needs and often touch a wide vari-ety of community agencies and resources while taking hours of clinical team time. In addition to patient com-plexities, rural Montana also has barriers to care that include transportation, affordable housing, and provider shortages. Many of these shortages are in psychiatry and licensed substance abuse counselors. Other barriers are long distances to care, lack of a health information exchange, difficulty in identifying high-risk patients across health systems, and siloed systems of care that result in large gaps. To address some of these system-level challenges, Kalispell Regional Healthcare teamed up with Mountain Pacific Quality Health, the federally contracted Quality Improvement Network, to develop a community-wide coalition to reduce avoidable hospital readmissions and unnecessary emergency department

26S American Journal of Medical Quality 34(2S)

(ED) utilization. Community organization and the devel-opment of a community outreach team led to a novel approach to address system-level challenges by bringing collaborative community partners to the table in a solu-tions-oriented manner, which resulted in a community outreach team that addressed high-cost, high-need patients in their home setting. Intervention Detail. There are 2 key aspects of the intervention: creating the optimal climate for system change across community stakehold-ers and creating an effective nurse and community health worker (CHW) resource team to address patient needs appropriately. The intervention uses iPad technology to help nurses work at the top of their clinical licensure while the CHW addresses the nonclinical elements of the program. The team functions to better coordinate care for the patient while working directly with care coordinators in primary care settings. The team engages the patient in a patient-centered approach to understand patient-driven goals and motivations, as well as individual barriers to successful self-management. A plan of care is developed, incorporating medical and social objectives that rely heavily on clinical and community resources in the 90-day intensive intervention. Outcomes and Impact. The initial 36 pilot program patients yielded nearly $1.8 mil-lion in hospital savings by reducing hospital readmissions and avoiding unnecessary ED visits. Social determinants of health, patient demographics, and clinical information were tracked to show trends. Self-reported patient and provider team satisfaction was observed.

Orthopedic Pain Management Redesign Determined Tibia Game Changer

Laura M. Leal, MSN, RN, CNL, and Anisa Xhaja, MHA, MSHQS, LSSBBUAB Hospital

Background. The orthopedic unit at UAB Hospital strug-gled to manage postoperative pain for elective knee and hip arthroplasty surgery patients, as demonstrated by poor Hospital Consumer Assessment of Healthcare Providers and Systems pain satisfaction scores: in June 2017, pain management was at the 41st percentile and pain well con-trolled was at the 27th percentile. These low scores had several causative factors: pain management plans varied among orthopedic surgeons; patients routinely received patient controlled analgesia (PCA), which delayed physi-cal therapy milestones and resulted in unnecessarily pro-longed hospital stays; patient pain-specific education lacked consistency throughout the continuum of care; and no escalation pathway existed for pain management needs among different provider care teams involved in patient care (ie, orthopedic, critical care, anesthesia, geriatric). In

June 2017, the frontline nursing staff asked the clinical effectiveness team at UAB to help redesign the way pain was managed in their unit. As a result, an interdisciplinary team came together led by a lead orthopedic surgeon, a lead anesthesia provider, and the nurse manager of the unit. The team developed a standardized multimodal pain management plan including neuraxial anesthesia, evi-dence-based peripheral nerve blocks, early patient mobili-zation, and a stepwise approach to pain treatment modalities (ie, nonpharmacological therapies, nonopioid medications, opioid medications). Furthermore, great emphasis was placed on patient education around pain expectations and pain management pre, during, and post hospital stay. The care redesign process was centered on the patient and his or her pain experience. What makes this project unique is the amount of buy-in, engagement, and participation of frontline staff of all disciplines throughout the continuum of care. A similar project was attempted 3 years ago and never gained traction. This demonstrates the paramount importance of how, espe-cially in the face of the national opioid epidemic, listening to the frontline staff and engaging the right leaders can create a culture that drives and sustains quality improve-ment initiatives. Intervention Detail. Several qualitative and quantitative measures were put in place to assess the redesigned pain management pathways for the elective orthopedic hip and knee arthroplasty process. Fiscal year (FY) 2016 was established as the baseline performance for the following project measures: neuraxial anesthesia utilization, observed-to-expected average length of stay (O/E LOS) index, 30-day all-cause readmission, and vari-able cost per case. A scorecard specific to this patient pop-ulation was created for the team to monitor and measure the process. Data on the scorecard included outcome met-rics (ie, O/E LOS, mortality, readmission) and process outcome measures (ie, neuraxial anesthesia utilization, peripheral nerve blocks compliance, early patient mobili-zation, PCA utilization). Performance of outcome and process metrics is monitored by the UAB care team and the orthopedic team to track progress, identify areas for opportunities, and perform continual Plan-Do-Study-Act cycles to develop action plans and ensure the project pro-cess continues to meet the needs of patients. A weekly audit tool also was developed to aid in real-time monitor-ing of every step of the new process and includes monitor-ing of patient education, risk identification, preoperative medication, anesthesia, blocks, perioperative medications, postoperative medications, early mobility, and the use of standardized order sets. This process began on the first day of project go-live in December 2017 and continues to date by the orthopedic team. The tool is beneficial for all clinical leads in their respective clinical areas to watch processes within their areas, evaluate needs, and make real-time improvements when applicable. Outcomes and

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Impact. The UAB Care Orthopedic Pain Management Elective Hip and Knee Arthroplasty project has been suc-cessful, as demonstrated by the positive improvements seen since implementation in December 2017. A decrease in the O/E LOS index has been observed since implemen-tation. Primary total hip arthroplasty O/E LOS decreased from 1.23 (FY 2016) to 0.97 (December 2017 to July 2018). Primary total knee arthroplasty O/E LOS decreased from 1.21 (FY 2016) to 0.93 (December 2017 to July 2018). PCA utilization decreased from 93% (FY 2016) to 1.6% (December 2017 to July 2018). Neuraxial anesthesia utilization improved from 4.8% (FY 2016) to 50% (December 2017 to July 2018). Early mobilization (patients mobilizing on postoperative day zero) increased from approximately 3.2% (FY 2016) to 61.9% (December 2017 to July 2018). Last, utilization of multimodal oral medication pre- and postoperatively improved per weekly manual audits. What is interesting and encouraging about the newly implemented process is that the majority of the patients have not required 2 doses of intravenous hydro-morphone available for them post surgery. Additional positive qualitative outcomes include: improvement in frontline engagement and satisfaction, establishment of an orthopedic quality improvement committee, and develop-ment of a weaning process for high-risk patients on chronic opioids prior to their respective elective surgeries through a collaboration among the orthopedic clinic and primary care/pain physicians. In the face of the national opioid epidemic, engaging an interdisciplinary team that includes frontline staff, patients, and the right leaders is imperative to developing the best evidence-based prac-tices and empowering frontline staff to bring about the acknowledgment, desire, and excitement to drive change.

Leveraging Technology to Improve Access to Specialty Care

Esmaeil Porsa, MD, MBA, MPH, CCHP-A, Muthusamy Anandkumar, MD, MBA, and Jacqueline Sullivan, PhD, RNParkland Health & Hospital System

Background. There are more than 1 million uninsured adults in the Dallas County area. Parkland currently pro-vides primary care services to a little more than half of this population. We simply do not have enough resources (brick and mortar or personnel) to provide adequate access to health care for the entire indigent population of Dallas County. Parkland Center for Healthcare Innovations and Clinical Outcomes was created to use out-of-the-box thinking to address this demand/capacity issue. A handful of creative physician champions for delivery of high-value/high-impact care were gathered and challenged with establishing a core group obsessed with reducing

waste and creating value. This group received financial support in terms of 0.2 full-time equivalent protected time (1 day a week). This time was spent examining various inpatient and outpatient processes and pain points with the highest relevance and lowest resistance to change (high-impact initiatives or the proverbial low-hanging fruits). This work began with identifying and eliminating redun-dant laboratory tests, such as creatinine-kinase MB frac-tion for evaluation of myocardial infarction and serum amylase for evaluation of acute pancreatitis. After multi-ple quick successes, the group aimed at addressing the more global issue of access to specialty care. The innova-tion implemented was electronic consultation (e-consulta-tion) in the gastroenterology clinic. Intervention Detail. In April 2016, we launched a gastroenterology e-consult pilot program. The service was initially offered at one Parkland primary care site because it was the site that had been using tele-dermatology, so they were familiar with the concept and technology. The volume of e-consults received over the next several months was small. We knew that in order to make an impact, we couldn’t offer it to just one site; we had to go big. The issue was: How do we expect providers who are not familiar with e-consults to be able to figure this out without any formal training? Therefore, we worked with the ambulatory Epic team at Parkland to make the process as intuitive and user friendly as possible so that any provider, regardless of training, could feel comfortable using it. On August 3, 2016, with some apprehension, the program was made available to all primary and specialty care providers at Parkland. What we came up with was a single clinic referral order whereby the referring provider could choose between an e-consult or a face-to-face (F2F) visit. This is in contrast to the e-referral program at UCSF, where the specialist makes the determination after reviewing the referral. Leaving this decision up to the referring provider was something that we frankly agonized over because we weren’t sure if the referring providers would feel comfortable making this determination. In retrospect, this concern was simply unfounded. Referring providers are certainly capable of making the determination. Over the span of the next 18 months the percentage of e-consultations reached a high of 46% before a plateau of around 35%. Outcomes and Impact. Because access to clinic appointments is limited, avoiding unnecessary F2F visits is an important metric to track and trend. The clinic avoidance rate is the proportion of e-consults that can be addressed without converting the referral into a F2F visit. Although there are some differ-ences between the 3 gastrointestinal (GI) service lines (GI, liver, pancreas/biliary), the overall observed clinic avoid-ance rate was 69%. By avoiding F2F visits for routine GI questions, the specialists are able to provide care to patients with more acute GI issues. The e-consult program has been well received by referring providers, both in

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primary care and other specialties. About three quarters of e-consults are ordered by primary care providers and one quarter from other specialty clinics. The concern we had about referring providers being able to determine whether or not their question could be answered via e-consult was unfounded. We found that more than 90% of e-consults were appropriate. The small number of e-consults that were deemed inappropriate by the specialist were usually because the referral was simply soliciting a procedure rather than addressing a specific clinical question.

Success! Slowing the Revolving Door of Readmissions: A Multidisciplinary Collaborative Approach

Katharine Corbett, MBA, BSN, RN, Cecilia McGinley, BSN, RN, Kristen Smith, MPP, BA, and Rebecca Armbruster, DO, MS, FACOIJeanes Hospital

Background. With Jeanes Hospital’s administrative sup-port, a multidisciplinary Readmission Review Committee was established to help tackle the revolving door of emer-gency department (ED) visits, admissions, and readmis-sions. Our process was modeled after the University of Wisconsin Health System’s readmission review team. Our committee focused on reviewing referred readmis-sion cases and developing a plan of care using the FOCUS-PDSA (Find a problem, Organize a team, Clarify the problem, Understand a problem, Select an interven-tion—Plan, Do, Study, Act) performance improvement approach. The goal of the Readmission Review Committee is to improve the overall quality of care while reducing readmissions. The committee focuses on com-plex cases such as chronically ill patients and those patients with multiple clinical and social needs. Cases are presented by the transitional care coordinator and dis-cussed among our team members. Our committee mem-bers, chief medical officer, psychology, care management director, transitional care coordinator, care managers, social workers, nursing staff, palliative care, ED nursing, hospitalists, internal medicine, pharmacy, performance improvement, and other ad hoc members develop treat-ment plans and protocols as needed. With leadership sup-port, our frequently readmitted patients are assigned to the same hospitalists to maintain continuity of care. The transition of care coordinator also reviews the patient’s prior discharge plans and develops a new plan with the patient if he or she is rehospitalized. What makes this committee unique is that each patient is evaluated on an individual basis and every treatment plan is tailored to meet his or her unique needs. Our multidisciplinary

approach reaches far beyond our hospital’s walls. We work with community physicians, health centers, and other health systems. Everyone who impacts our patient’s care is included in the treatment plan. Readmission reduc-tion is important to every health system and we all strug-gle with ways to reduce readmissions. Through our efforts we are proud of the process we have developed and, more importantly, the outcomes we have illustrated. Intervention Detail. Prior to each Readmission Review Committee meeting, the transitional care coordinator completes an extensive case review on each patient, which is presented to the committee. The case review ele-ments include patient demographics, reason for referral/referral source, the patient’s primary care physician/attending/specialists, insurance, diagnosis, number of ED visits/admissions/readmissions per calendar year, medi-cal/surgical history summary, allergies, medication list, social history, home life, and if the patient has utilized a skilled nursing facility or home care. Each case is dis-cussed in detail during our committee meetings, focusing on improving care coordination, decreasing ED visits, decreasing preventable readmissions, developing treat-ment plans, and creating potential care protocols for simi-lar cases. During our first year, we reviewed a total of 25 cases and developed a case study tool that includes the number of ED visits, admissions, and readmissions per month per calendar year for 2015 through 2018. Each case had an individual intervention set in place to help prevent readmissions or unnecessary ED visits. After the first 6 months of reviewing cases, the team conducted a case analysis to determine if the interventions with the individual cases were having an impact on the number of ED visits, admissions, and readmissions. A 3-month pre-intervention and 3-month postintervention analysis was completed. This analysis was repeated after the second 6-month period. Some of our interventions included pro-tocols such as a sickle cell protocol and ongoing reevalu-ation of prior discharge plans and goals. Outcomes and Impact. The committee reviewed 25 cases during the first year. We conducted a case analysis to determine if the interventions were effective. Using our case study tool, we completed a 3-month preintervention and 3-month postintervention analysis. Overall we decreased the num-ber of ED visits from 123 pre intervention to 62 post intervention, the number of admissions from 94 pre inter-vention to 36 post intervention, and, most importantly, the number of readmissions dropped from 63 pre inter-vention to 20 post intervention. Our multidisciplinary approach has had a positive impact on our patients’ care coordination in preventing hospitalizations and ED room visits. Jeanes Hospital’s financial department has esti-mated that the direct cost per readmission is approxi-mately $5000 per case. For the 25 cases included in our analysis, Jeanes Hospital’s direct cost pre intervention is

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estimated at $315 000 and estimated at $100 000 post intervention. This is an estimated saving of $215 000 between pre and post intervention. For example, one of our major interventions that contributed to a large decrease in ED room visits and admissions was our protocol for our sickle cell population. When a patient presents in the ED department in potential sickle cell crisis, the staff order the sickle cell protocol workup. Pending lab results, a onetime dose of an appropriate pain medication is administered. On review of results, the decision is made to discharge or admit the patient. Working with a designated nursing unit, physicians closely monitor the patient’s inpatient narcotic usage and review his or her outpatient narcotic utilization through the Pennsylvania Prescription Drug Monitoring Program, and a discharge plan is developed. This committee has impacted our field of study by working very closely with our multidisciplinary team, insurance companies, com-munity physicians, health centers, and home care agen-cies, through transitional care coordination, protocols, and individual patient care plans.

Making Zero Harm in Patient Safety a Reality

Julie L. Fedderson, MD, MBA, and Nicole Turille, RN, BSNNebraska Medicine

Background. Nebraska Medicine underwent a focused redesign of its quality and patient safety structure in response to a renewed dedication to Vizient methodology. As part of this process, we created a unique multidisci-plinary committee structure to place Patient Safety Indicators (PSIs) and safety events directly into the hands of providers for evaluation and cause analysis. By coordi-nating definitions and documentation with clinical sce-narios, we have been able to identify persistent themes that affect the safety of our patients and design subse-quent interventions. In addition, having our providers closely examine real-time PSIs allows for collegial learn-ing about documentation and evidence-based practice. Intervention Detail. The quality department at Nebraska Medicine utilizes the Define, Measure, Analyze, Improve, and Control method of problem solving to ensure that solutions implemented are maintained and sustained. The overall metric of the project is to eliminate instances of patient harm across the organization. Each PSI in the Agency for Healthcare Research and Quality (AHRQ) PSI-90 composite is evaluated for improvement opportu-nities utilizing a customized template that focuses on cer-tain aspects of patient care. The Vizient Quality and Safety Management report allows staff across the organi-zation to quickly see how the organization is performing

each quarter. The committee tracks progress monthly uti-lizing data pulled from the Vizient Clinical Data Base (CDB). This allows committee members to easily iden-tify areas needing additional focus. Deeper dives to eval-uate service line, discharge provider, and procedure provider are completed by using the Case Profile report in the CDB. The committee not only reviews the trends in the observed to expected ratio, it monitors total events with the goal of eliminating harm. These data also are shared at a leadership level, including with our board of directors, to monitor progress toward zero harm. Outcomes and Impact. Nebraska Medicine ranked 87 in the Vizient Patient Safety Domain in 2015, climbing to fifth in 2016, and fourth in 2017, a testimony to the suc-cess and sustainability of this project. Our initiative focus groups also have seen a significant reduction in patient harm events. For instance, we are currently in the top 10 for observed/expected length of stay for perioperative venous thromboembolism. Evaluation of performance using AHRQ 6.0 specifications in fiscal year 2017 com-pared to the same time period in fiscal year 2015 also identified a 73% reduction in instances of patient harm. Our goal continues to be zero harm to patients.

Preventing the Post-Acute Bounce Back

Billie J. Kester, RN, BSN, MBA, and Shannon Hicks, RN, BSNReid Health

Background. Reid Health built upon an existing nursing home coalition and applied for a state-funded grant that turned the coalition into a collaborative. As part of the grant requirements, Reid needed to have 20 regional nursing homes partnering with it to conduct a minimum of 2 quality improvement projects over an 18-month period; one of those had to be focused on health care-acquired infections (HAI). The state funding was aimed to increase awareness and understanding of Quality Assurance and Process Improvement among nursing home professionals. Reid’s goal was to increase commu-nication and collaboration across the continuum. Reid was awarded funding for the collaborative and began recruiting nursing home partners who wanted to improve the quality of care being delivered. For the first process improvement project, the group decided to tackle HAI-related hospitalizations. This project uncovered many unknowns that existed between the hospital and nursing home providers. It was identified that patients and fami-lies had a level of comfort with the hospital setting, while they were less comfortable with care rendered in the nurs-ing home. In the hospital setting, patients often were being admitted for issues that could be handled in the nursing home. When patients were transferred back to the

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nursing home, the hospital often was sending orders that were confusing or not practical in that care setting. The combination of these elements led to a boomerang effect of patients bouncing back and forth. To combat this, we all needed to be working toward the same goal—keeping the patient in the least restrictive level of care and provid-ing the same message. This involved education for nurs-ing home staff, emergency department providers, medical directors, and patients and their families and adding 2 hospital positions to bridge the gap between the care set-tings. Intervention Detail. From a hospital perspective, Reid was already tracking its readmissions on a monthly basis. Readmissions also were tracked by the level of care setting the patient was discharged to on his or her index admission, so it was easy to identify that many of the readmissions the hospital was experiencing were coming from regional nursing facilities. Nursing homes were not all consistently tracking their readmissions, so this became the first step. A hospitalization log was created and the facilities began tracking any patients who were sent from the nursing home to the hospital, their diagno-sis, their admission status, the time of day, and many other elements. Census data also were collected from facilities to identify the hospitalizations and readmission per resident per day. These were then submitted monthly to Reid as the collaborative facilitator. All of the data were combined and blinded and presented in monthly collaborative meetings for discussion and action. Although hospital data identified that nursing home resi-dents were most frequently admitted meeting criteria for sepsis, nursing home data demonstrated that these same patients were being admitted for pneumonia or respira-tory infection. A baseline period of measurement was established with a performance period occurring after the interventions were implemented in the facilities. Nursing facilities began applying the “5 whys” approach to hospi-tal transfers and the collaborative used these data to com-plete a fishbone diagram to identify why patients were bouncing back. One key finding from this analysis was the lack of confidence that families and residents had with nursing home care, which prompted the request to be sent to the hospital for evaluation. The nursing facili-ties implemented a “Stop & Watch” program to pick up on changes in condition in a timelier manner and submit-ted monthly logs to the collaborative as a process mea-sure to ensure that this was occurring. Outcomes and Impact. Overall, Reid Health had 27 organizations par-ticipating as part of the collaborative. Prior to implement-ing interventions, the collaborative facilities demonstrated 0.6 HAI-related hospitalizations per 1000 resident days. This was reduced by 38.3% after intervention to 0.37 HAI-related hospitalizations per 1000 resident days. The percentage of residents with an HAI hospitalization dropped by 37.8%. Overall hospitalizations dropped

12.9% from 2.02 to 1.76 hospitalizations per resident per day after interventions were implemented. In the year prior to this project, Reid Health’s readmission rate for nursing home residents was at 18.55%. This was reduced by 21.1% to a readmission rate of 14.64% for patients discharged to a nursing home. Reid’s overall readmission rate also was impacted by this, dropping 14% from 11.4% in the year prior to 9.8%. As a Medicare Shared Savings Program Accountable Care Organization, Reid also was concerned about the Medicare Spending per Beneficiary, which is highly impacted by readmissions. By using the anticipated number of HAI-related hospitalizations from the collaborative’s baseline data compared to the actual number in the performance period, we were able to dem-onstrate $242 634 in Medicare spend savings over 4 months. We have continued to track and trend this and have grown this to more than $2 million in savings. One of the biggest barriers for the project overall was the high turnover rates in the nursing homes, which made it diffi-cult to keep interventions consistent. As a result of the project, Reid Health was able to justify the addition of 2 nurse post-acute transition coordinator positions. These positions serve as a liaison for patients identified as high risk for readmission who are transferring to a nursing home at discharge. They visit the patient in the facility weekly, conduct medication reconciliation, clarify any discrepancies from the hospital stay, and provide confi-dent and consistent messaging between the hospital and the nursing home.

Implementing a Sustainable Hazardous Drug Communication Program

Sarah J. Emanuele, PharmD, and Linda M. Stevens, DNP, RN-BC, CPHQ, CSPHPUW Health

Background. The Centers for Disease Control and Prevention estimates about 8 million US health care work-ers are potentially exposed to hazardous drugs (HDs). At UW Health, the estimated worker exposure is at 7000 and includes clinical pharmacists, nurses and physicians, facilities workers, and laboratory researchers. Mounting evidence of acute and chronic health effects are the impe-tus for changes in governing policies requiring facilities to close safety gaps. Opportunely, HD safety in the health care setting has the potential to utilize existing infrastruc-ture to its advantage. This abstract describes how the UW Health system developed a systematic and resourceful HD communication program that includes a system list of categorized HDs, electronic drug record indicators, elec-tronic health record warnings, and standard HD precau-tions. There have been many changes to the definition and

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categorization of HDs over the past 30 years. Contrary to some beliefs, HD awareness has generally been around since 1986 when the Occupational Safety and Health Administration first published guidelines on handling cytotoxic drugs. However, HDs have only recently earned a stand-alone regulatory category of their own. Prior to 2004, HDs often were categorized as chemotherapy, haz-ardous chemicals, or hazardous waste, all of which have similar yet different definitions of their own. In light of the known confusion with these categories and HDs, UW Health’s first approach was to develop a systematic and resourceful HD communication program. Intervention Detail. To start, a gap analysis was completed using the United States Pharmacopeial Convention <800> stan-dards. Although UW Health already had many pieces of the required hazardous communication program in place, the gaps identified were the result of an overly complex program that was difficult to maintain. Specifically, gen-eral drug information resources did not match our existing list, inconsistencies were found in electronic drug records, and the knowledge and use of personal protective equip-ment (PPE) was lacking. Based on these findings, a multi-disciplinary group of stakeholders was tasked with developing sustainable communication strategies. The operational and policy objectives developed by this group outlined that (1) workers should know the risks of HD exposure; (2) workers should have accurate real-time information at hand; and (3) HD communications should originate from 1 electronic source of truth. These 3 princi-pals formed the foundation of a system-wide policy revi-sion and implementation strategy to keep our health care workers safe. Data: The main component of the HD com-munication program was to align the UW Health HD list with the most recent National Institute for Occupational Safety and Health (NIOSH) List of Antineoplastic and Other Hazardous Drugs, and then to objectively define and assign risk categories. To meet operational objectives and to ensure that HD communications were accurate and originated from one electronic source, this change required a gap analysis to be completed. Drugs reviewed included those from both the existing and future HD lists. Upon completion of the analysis, 418 drugs were identified and classified as follows: update to new HD status (n = 83), removal of HD status (n = 48), update HD risk category (n = 182), no changes (n = 60), and deletion related to market discontinuation (n = 8). Drugs not on the UW Health formulary were included and categorized as need-ing electronic drug record build (n = 37) to trigger warn-ings from patient home medication lists. Outcomes and Impact. In October 2017, UW Health’s HD communica-tion program was implemented to meet regulatory and best practice guidelines. Aligning with the NIOSH list allowed for a reduction in resources dedicated to defining and categorizing HD risk levels. Quite simply, the

criterion for hazardous designation is inclusion on the published NIOSH list. Because this list is published bien-nially, during interim periods, a Drug Policy Program reviews newly approved drugs or established drugs with new safety warnings, and can submit for temporary addi-tion to the list until the next NIOSH review. HD formula-tions are separated into 2 categories: high risk or low risk. Two categories serve to simplify the requirements for PPE and engineering controls. High-risk HDs are defined as all drugs listed in NIOSH Group 1 except for individually packaged oral tablets or capsules. Low-risk HDs are defined as all drug formulations listed in NIOSH Group 2 and NIOSH Group 3. Based on the gap analysis, a total of 1466 electronic drug records were revised to allow order entry to drive preparation location, medication adminis-tration record instructions, directives on PPE selection, and caution warnings. A first warning looks across all patient care encounters and triggers an alert if an HD administration was documented within the past 48 hours or if an HD is found on the home medication list. This alert warns workers of possible body fluid contamination with HDs and can be silenced after assessment. A second warning looks for active HDs in inpatient and procedural areas and serves to initiate “Hazardous Drug Precautions,” a door signage program that mimics UW Health’s isola-tion precautions. Door signs serve to caution both workers and visitors of possible HD exposure.

Red Right 30 Pull Trap: A Systemwide Emergency Department Playbook

Julia A. Bossie, MSN, RN, CEN, CNL, and Freda G. Lyon, DNP, MSN, RN, NE-BCWellStar Health System

Background. WellStar Health System is on a journey to excellence. Emergency department (ED) patient expecta-tions are more than compassionate care; they include moving efficiently through the health care system, receiv-ing safe and quality care, and providing narration of care for every patient. The WellStar ED team designed a play-book with evidence-based tools and process plays to improve quality and patient experience. “Every patient, every time” allows the team caring for the patient to iden-tify ways to improve and become a force multiplier that amplifies process improvement efforts. Standardization of process flows in the ED provide a safety net for patients regardless of the facility location, size, or specialty ser-vices available across the health system. Intervention Detail. Like many EDs, we struggle with patient experi-ence and ensuring that patients feel cared for and trust their ED providers. It was important that our 682 000 patients per year across all facilities received the same

32S American Journal of Medical Quality 34(2S)

world-class care. This meant setting high expectations, based on evidence, and standardizing them across all 10 EDs. A playbook was developed and incorporated evi-dence-based tools that had statistical significance to enhance practice and that are highly reliable. We added throughput and quality tools, which highly impact the patient experience in the ED. Playbook implementation is innovative and guaranteed to win the game, much like the successful football play, “Red Right 30 Pull Trap.” Since introduction of the playbook in December 2017, we have been tracking the results of the implementation. The lag-ging measure is patient experience scores and our leading measure is playbook implementation percentage (hard-wired or implemented to standard). Outcomes and Impact. As of September 2018, more than 90% of the playbook has been implemented, and 52% of items are hardwired or implemented to standard. In 10 months, across all 10 EDs, more than 50% of the ED playbook has been implemented, with standard, system-wide Press Ganey scores moving in the right direction. The percentage of patients who answered yes to “Staff checked on me regularly” improved overall from 70% in July 2017 to 82% by April 2018 across all 10 EDs. The overall score went from the 25th percentile in July 2017 to the 52nd percentile in April 2018. As studies prove, July to October 2018 has shown a decrease in the percentage of patients answering yes to “Staff checked on me regularly” to 73%, as well as the correlated percentile ranking of 36% system-wide. Sites with more than 60% implementation of the playbook have Press Ganey scores in the 65th percentile for same-size facilities. Those departments with less than 30% imple-mentation of the playbook have Press Ganey scores in the eighth percentile. This tells us that the evidence-based tools work if we are diligent in implementing them.

Service Line High Reliability: A Multidisciplinary Approach

Thanh K. Dao, MS, Sean I. Savitz, MD, Nicole Harrison, MBA, RN, BSN, NEA-BC, and Randi R. Toumbs, DNP, MS, RN, AGACNP-BCMemorial Hermann Health System

Background. At Memorial Hermann Texas Medical Center (MHTMC), we believe the foundation of organi-zational high reliability is the achievement of service line high reliability. Our journey to high quality began in June 2013 when service lines were mandated to partici-pate on this journey. At the time, our stroke quality per-formance was undesirable, performing at the University HealthSystem Consortium’s (Vizient) 25th percentile. The Stroke Service Line was formed with a physician

champion, co-chaired by nursing/hospital executives, and members from multidisciplinary teams. The stroke team’s vision in 2014 was to become “The Number One Center for Stroke Care.” Our phased approach began with mortality and marched right on to length of stay (LOS), utilizing the same self-defined 5 traits of high reliability: physician engagement, zero tolerance, shared accountability, multidiscipline, and continuous monitor-ing. After achieving high quality and efficiency, we expanded our focus to a more holistic approach and incorporated volume growth, case mix index (CMI), patient satisfaction, patient safety, cost, and profitability. The MHTMC service line approach has proven effec-tive, and helped MHTMC achieve University HealthSystem Consortium (Vizient) “Top 10” elite status in 2014 and 2015. Intervention Detail. MHTMC utilizes the power of peer comparison from the Resource Manager, a data enhancement tool within the Vizient Clinical Data Base, to monitor and identify opportunities for improvement. A special task force was formed to address negative mortality trends with physician team members and comparative analytics. Vizient Transfers and Early Deaths Matrix report was instrumental in steering the investigation. Charts were reviewed, data were analyzed, and the root cause was identified (high transfer early deaths and low expected mortality in this group). To address these problems, an “appropriate transfer protocol” was implemented and a history and physical template was created to improve expected mor-tality performance. Service line collaborative teams also combined efforts to analyze LOS from multiple aspects of the quality delivery processes. Discharge to rehab was identified as an area of opportunity. Case management conducted chart reviews on LOS indexes greater than 1.0 to identify barriers to discharge, while the physician team focused on documentation improvements. Our self-defined 5 traits of high reliability fuel our journey to high quality:

•• Physician engagement—Vizient peer comparative data helped move physicians from denial to accep-tance. A special task force with physician leader-ship was formed as needed to review undesirable outcomes, determine performance improvement strategies, and standardize measures of success.

•• Zero tolerance—All unfavorable trends are reviewed and causes identified. Total transparency was determined necessary and a physician-specific report card was created.

•• Shared accountability—A comprehensive service line report card was created to track accountability between collaborative teams.

•• Multidisciplinary teams—Stakeholders include a hospital executive, physician staff members,

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nursing, case management, a documentation improvement specialist, and quality and compara-tive analytics.

•• Continual monitoring—A service line multidisci-plinary team meets monthly. The service line report was used to monitor performance and facili-tate meeting discussions. A special task force forms with service line members and special invited guests as appropriate to address the prob-lem at hand.

Outcomes and Impact. Service line engagement is the first step toward a high-reliability organization. Achievement of high-quality performance is a challeng-ing journey. Maintaining high-quality performance requires added efforts. Activities at the service line level help MHTMC achieve and maintain high quality and efficiency outcomes. For the Stroke Service Line, execu-tion of the self-defined 5 traits of high reliability gave birth to service line-level comprehensive quality and effi-ciency metrics, a physician-specific scorecard, a history and physical template, and an appropriate transfer proto-col. Expected mortality improved from 13.06 to 14.45, CMI increased from 1.66 to 1.71, and the percentage of early deaths decreased from 5.08 to 4.89. The Stroke Service Line maintains a high performance ranking among Vizient academic medical center (AMC) peers, ranking second in expected mortality and seventh in observed to expected (O/E) mortality. Observed LOS improved from 6.27 to 5.52, expected LOS increased from 6.36 to 8.17, the LOS index went from 0.99 to 0.68, and CMI increased from 1.64 to 1.8. The Stroke Service Line O/E LOS ranking also improved, moving from 45th to first among Vizient AMC peers. Improvements in LOS translate to a total savings of $1.7 million in cost avoid-ance. Although mortality outcomes do not show statisti-cal significance, they do show a desirable positive trend. The biggest improvement observed was in O/E LOS, with a concurrent improvement in CMI.

How to Herd Cats: Successful Implementation of an Evidence-Based Diabetic Ketoacidosis Pathway in an Academic Health Center

Ilona Lorincz, MD, MSHP, Emilia J. Flores, PhD, RN, Scott Appel, MS, and Nikhil Mull, MDPenn Medicine

Background. At our urban, academic hospital, use of out-dated protocols and unnecessary variation in the care of patients with diabetic ketoacidosis (DKA) led to multiple safety events, delays in care, and increased costs. Intensive

care unit (ICU) care for this condition varies according to hospital, and ICU resources often are not required for safe and effective medical management. Triage to the ICU was the default in our hospital. After multidisciplinary stake-holder adaptation of the 2009 American Diabetes Association DKA Guidelines, we implemented an intrave-nous (IV) and subcutaneous DKA pathway on November 7, 2016, using our institution’s cloud-based pathways development and dissemination platform. The project aim was to reduce inpatient ICU utilization and overall length of stay (LOS). Senior leadership, including the chief med-ical and nursing officers, were the executive sponsors. The DKA pathways team comprised physicians, pharmacists, and nurses from endocrine, critical care, emergency, and hospitalist medicine, along with an innovations manager to assist with deployment of novel ways to implement a clinical pathway. Our pathway development and imple-mentation approach differed significantly from our typical process. We utilized innovative methods and focused on the following 4 tenets to help facilitate rapid development and adoption: (1) engaging frontline staff during the development of the pathway and prior to implementation; (2) testing the pathway in controlled clinical settings such that changes could be made iteratively and rapidly based on end user feedback prior to approval from policy com-mittees; (3) using an online dashboard to identify patients and contact providers in real time to promote pathway adoption; and (4) targeting efforts to challenge the percep-tion that all patients must be managed in an ICU with an IV insulin infusion by creating clear triage parameters. Other health care teams seeking to improve the value of care may benefit from the innovative methodology we used to promote adoption and sustainability. Intervention Detail. We used innovation methods typically employed in the business world (eg, “vapor tests,” “fake front ends,” “fake back ends”) to rapidly conduct small experiments to test provider and nursing willingness and ability to man-age DKA out of the ICU setting. In February 2017, our emergency department (ED) also implemented a 5-bed critical care resuscitation unit to optimize care of patients needing temporary critical care resources, with DKA being a preferred diagnosis for this resource. We con-ducted a retrospective, single-center pre/post analysis of disposition and LOS for DKA patients older than age 18 years presenting to our ED who met DKA criteria pre (November 7, 2015, to November 6, 2016) and post (November 7, 2016, to November 6, 2017) implementa-tion of the pathway. Pre- and post-implementation χ2 anal-yses were performed to assess for change in hospital resource utilization, and mean LOS was analyzed using a paired t test with P < .05 considered statistically signifi-cant and corresponding 95% confidence intervals reported. We hypothesized that within 6 months of implementing our pathway, ICU utilization would decrease by 25%.

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Outcomes and Impact. Pre and post implementation 129 and 158 patients were treated for DKA, respectively. Significant findings included decreased ICU disposition (67.0 vs 39.0%, P < .0001) and decreased transfers to other health system hospitals because of ICU bed con-straints (23.3 vs 5.7%, P < .001). Median ED LOS was longer in the post-implementation period (12.5 vs 8.4 hours, P < .01). There was a nonsignificant trend to decreased overall hospital median LOS (overall: 2.9 vs 3.2). The pathway was the most viewed among nearly 160 total pathways, with an average of more than 200 monthly views. After understanding the barriers to using a subcuta-neous insulin rather than an IV insulin infusion in the management of DKA, we implemented a pathway for eli-gible patients with mild-to-moderate DKA beginning February 19, 2017, relying exclusively on subcutaneous insulin for treatment of DKA. Utilizing real-time text message alerts to notify providers of eligible patients, the subcutaneous pathway was chosen by 27 of 59 potentially eligible patients (46%). A significant decrease in ICU uti-lization was found among subcutaneous pathway-treated patients compared to those eligible for the subcutaneous pathway but treated with the IV pathway (4.0% vs 31.0%, P < .01). Among patients enrolled, there was a nonsignifi-cant trend for discharge to home (31.0% vs 20.0%). Our findings demonstrate that evidence-based recommenda-tions are not enough to change care. The evidence behind our recommendations was almost a decade old, but had not been implemented. Effective adoption and sustainabil-ity of pathways relies on continual solicitation of provider feedback, rapidly acting on requested changes, and dem-onstrating the willingness and capacity to remove barriers to implementation in real time.

Beyond Reimbursement: Targeting Vizient Risk Models With Clinical Documentation Improvement

Tim Williamson, MD, FCCP, David Wild, MD, and Rebekah May, MBA, MSN, RNThe University of Kansas Health System

Background. The University of Kansas Health System implemented a plan to further enhance our interdisciplin-ary huddle process with the goal of reducing length of stay (LOS) index. High opportunity units/services were identified mid-year 2017 using the prior year’s LOS index, and areas of focus for each unit/service were developed. Bringing case management, clinical docu-mentation improvement (CDI), and physicians together during the huddle process to discuss medical milestones and the expected discharge date based on the working diagnosis-related group (DRG) was a key component of

improving LOS index. We also identified opportunities to improve the mortality index with the support of our CDI team. The CDI team engaged with a 3-prong approach: (1) the CDI team received focused education on the academic medical center (AMC) mortality risk model, resulting in the team widening its scope to iden-tify diagnoses beyond those that only had financial impacts; (2) CDI specialists began attending huddles 2 to 3 times per week; and (3) shared the working All Patient Refined-DRG with the associated average LOS in hud-dles daily. Participating in huddles allows the CDI nurse to hear nursing and provider reports of clinical concerns and ask whether there is a clinical diagnosis associated with the care provided. These efforts resulted in CDI spending more time in huddles and less time reviewing medical records. The benefits were immediately appar-ent. For those teams who don’t huddle regularly, CDI’s innovative approach using the Harris Analytics Suite and risk model comparisons of LOS and mortality data showed opportunities for CDI to engage in real-time conversations for accurate and concise documentation. These efforts brought great awareness, allowed for new discoveries, and allowed a test of change to be intro-duced into daily practice, resulting in stunning improve-ment to both the LOS and mortality index as physicians, case management, and CDI partnered together in innova-tive ways. Intervention Detail. Our CDI team has reviewed 100% of mortality cases with a focus on ensur-ing the highest capture rates for severity of illness and risk of mortality. By implementing and utilizing the AMC mortality risk model in 2017, CDI adopted an additional process by reviewing the secondary diagnoses listed within the risk model of each mortality patient, and later all inpatient charts. Reviewing the Mortality Risk Model data allowed for queries or coder collaboration to ensure accurate and concise documentation and coding. Physician resistance to increased documentation was addressed through benchmarking their documentation outcomes against other AMC peers. Utilizing the docu-mentation and coding data within the Harris Analytics Suite and the Clinical Data Base allowed for real-time data to be presented that displayed service rankings and opportunities for improvement. We began reviewing multiple layers of detail specific to each service line, ranging from rankings and scoring within pertinent DRGs, diagnoses and procedures per case, and variance of cases capturing LOS and mortality secondary diagno-ses. This approach not only presented the “facts” but stirred engagement and competition between peers. For some departments, this process for data reporting was most effective and allowed for CDI to present Vizient outcomes quarterly to show trends and discuss opportu-nities. These data also were monitored and tracked at a newly implemented weekly patient progression meeting.

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These focuses allowed for strategic LOS monitoring and evaluations of huddles in phases. Dashboards displaying observed versus expected LOS by units/services quickly identified gaps and wins for CDI, nurse managers, case management and, most of all, our patients. Over the course of the year, The University of Kansas Health System saw a widening margin between observed and expected LOS using these methods. Outcomes and Impact. Sharing of information has resulted in great suc-cess at The University of Kansas Health System. Implementing and sharing Vizient data helped CDI and our general surgery service improve our 2016 mortality index of 0.87 to 0.78 in 2017, and to go on to an amazing low of 0.50 year to date for 2018. Our cardiology mortal-ity index was 1.08 in 2016, 0.88 in 2017, and an out-standing low of 0.41 for 2018 year to date. The enterprise’s overall inpatient mortality index continued to decline from 0.84 in March 2017 to a record low of 0.56 in February 2018. This same type of focus on data is driving down our LOS index. CDI was averaging 87% to 90% in monthly inpatient review rates prior to placing CDI at the elbow of the clinical teams. During imple-mentation, CDI review rates dropped to 83%. With ongoing level loading of service lines and streamlining workflows, CDI was able to bring its review rate back up to 90% in January 2018, with a record high of 92% in February 2018. This change in process quickly showed substantial reductions to our LOS index. A decrease of 0.10 in observed LOS equates to about 10 inpatient beds in our system. The University of Kansas Hospital’s aver-age LOS index was 1.01 from January 2017 to June 2017. Since implementing reporting of the working and arithmetic mean LOS in huddles and engaging CDI more in the huddle process, we have maintained an LOS index of 0.92 or better since July 2017. Our inpatient capacity has improved because discharges have increased as actual LOS decreased, all without the physical addition of inpatient beds. This LOS impact allows patients who are in a community hospital or emergency room waiting to be admitted to receive the excellent care they desire sooner.

Leveraging the EMR to Improve Sepsis Care in a Limited Resource Environment

Christina English, RN, CPHQ, and Kirlyn Richardson, MSN, RN-BC, ACNS-BCEmory Decatur Hospital*

Background. Sepsis is a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs. Associated with high morbidity and mortality, sepsis treatment often involves a prolonged

stay in the intensive care unit and complex therapies, which incur high costs. With an estimated $20 billion in annual cost, sepsis is the most expensive condition treated in the United States. At DeKalb Medical’s 2 acute care facilities, sepsis was identified as a driver of opportunity associated with inpatient mortality, as well as length of stay (LOS) and cost. With the support of organizational leadership, the DeKalb Quality Institute sought to improve all processes related to the care of patients with sepsis. By employing the framework provided by the Vizient Sepsis Collaborative, initial stages were designed to assess cur-rent practices and identify key areas for improvement. By utilizing a Lean methodology and implementing a collab-orative approach, the team was able to analyze various data, prioritize, and target its efforts toward the early iden-tification of septic patients. This, in conjunction with enhanced use of our electronic health record, led to the development and implementation of a sepsis-specific screening tool in the emergency departments and inten-sive care units (ICUs). Since implementation of the tool, we have seen significant improvement in our sepsis core measure performance as well as reductions in overall LOS, mortality, and cost of care for our sepsis population. After attending the 2017 Vizient Clinical Connections Summit and viewing its sepsis presentations, we feel that it is important to highlight the ways organizations with limited resources and financial constraints can still make positive changes in the overall care of this disease process. Intervention Detail. This project utilized a variety of both quantitative and qualitative metrics to determine success. Qualitatively, we focused on process measures, which included the overall SEP-1 core measure compliance as well as the compliance rates of each component of both the 3- and the 6-hour care bundles. Quantitatively, we assessed our performance based on the outcomes metrics of mortality and average LOS. Specifically, we tracked observed mortality rates and the observed/expected index ratio (benchmarked to the top 25% of hospitals). As it relates to LOS, we monitored overall inpatient LOS and have just recently begun to assess ICU specific LOS as well. Outcomes and Impact. During the baseline period, the SEP-1 core measure compliance rate was approxi-mately 10%. After implementation of various process improvement efforts, specifically an electronic screening tool in both the emergency room and the ICU, the compli-ance rate rose to 37%. Additionally we experienced a mor-tality rate reduction of 30%, as well as an 18% decrease in our observed/expected index ratio; these data translated into roughly 48 lives saved! We also had an overall decrease in average observed LOS of approximately 20% across the system, which equated to an overall cost sav-ings of $2 755 511.

*DeKalb Medical is now a part of the Emory Healthcare System.

36S American Journal of Medical Quality 34(2S)

A Barcode-Based Safety System Using Audio and Visual Drug Confirmation Dramatically Reduces Anesthesia Drug Errors

Srdjan Jelacic, MD, FASE, Andrew Bowdle, MD, PhD, FASE, Bala G. Nair, PhD, and Logan BusseyUniversity of Washington

Background. Drug administration errors are a significant cause of morbidity and mortality. Numerous studies have shown that anesthesia drug administration errors are common. Because there are many different types of errors with different mechanisms, there is no single solution. Most experts in this field recognize that simply attempt-ing to increase human vigilance will have limited benefit given that anesthesia providers are highly trained profes-sionals who do their best to avoid errors. Some attempts have been made to use technology to improve human per-formance and reduce errors. Although there are some data suggesting that barcode scanning of drug vials and syringes prior to drug administration would be beneficial, this approach has not been used widely in anesthesiology practice. We developed a uniquely innovative approach to barcode scanning of drugs in anesthesia practice and applied a behavior modification bundle to encourage anesthesia providers to use the barcode-based safety sys-tem. Intervention Detail: We combined a commercially available syringe label printer (Codonics Inc., Middleburg Heights, Ohio) with a handheld barcode reader and our decision support software, Smart Anesthesia Manager (SAM). The Codonics label printer scans the barcodes on drug vials, speaks the name of the drug, and prints a syringe label. The handheld barcode reader is then used to scan the syringe label barcode prior to drug administra-tion. SAM speaks and displays the name of the drug along with a field for manually entering the dose in the Anesthesia Information Management System. SAM is a unique anesthesia decision-support software, which func-tions in conjunction with our Anesthesia Information Management System. By using barcodes to identify vials and syringes, the anesthesia barcode-based safety system is intended to prevent “vial swap” errors and “syringe swap” errors wherein providers misidentify vials or syringes and administer the wrong drug. After implemen-tation of the anesthesia barcode-based safety system, a behavior modification bundle was needed to encourage anesthesia providers to scan syringe label barcodes prior to drug administration. The behavior modification bundle consisted of provider education and monthly performance reports sent by email to individual providers, along with coffee gift cards for top performers. The coffee gift cards were awarded for the first 2 months of the intervention while the email performance reports continued on a

monthly basis. We also utilized facilitated self-reporting of drug errors to compare the rates of errors before and after implementation of our anesthesia barcode-based safety system. Facilitated self-reporting means that self-reporting is a part of normal, routine workflow, is expected for every anesthetic case, and does not require an exceptional action on the part of the provider. Completion of the computerized drug error form was a “hard stop” that was required in order to finalize the anes-thesia record. Outcomes and Impact. After implementa-tion of the anesthesia barcode-based safety system, we accumulated 60 197 cases with a total of 653 355 syringe drug administrations. Average scanning performance improved from 8.7% of syringe barcodes scanned during the 17-month baseline period to 64.4% of syringe bar-codes scanned during the 7 months after behavior modi-fication bundle implementation (P < .001). A behavior modification bundle was associated with a substantial improvement in average performance of syringe barcode scanning that was sustained over a 7-month period. During the 10 months prior to the anesthesia barcode-based safety system implementation, there were 14 572 cases with 57 errors (0.39%) reported, including 5 vial swaps and 1 syringe swap. Following implementation of the barcode-based safety system, we collected 24 264 cases over 13 months with 54 errors (0.23%) reported, including zero vial swap errors and 2 syringe swap errors. The reduction in errors and vial swaps was statistically significant (P = .0045 and P = .004, respectively). There was no statistically significant difference in syringe swap errors. There were no cases of permanent physical injury related to drug administration error. Implementation of a uniquely innovative barcode-based safety system utiliz-ing Codonics Safe Label System printers and syringe bar-code scanners driven by SAM software was associated with a statistically significant 41% reduction in self-reported anesthesia drug errors.

Advanced Practice Providers: An Innovative Team-Based Approach to Spine Care Delivery

Angela M. Jolivette, APNP, Megan Bellman, PA-C, Shekar N. Kurpad, MD, and Marjorie C. Wang, MDMedical College of Wisconsin

Background. Spine-related disorders are one of the most common reasons to seek medical care and are a major cause of disability among adults. A positive patient expe-rience requires prompt access to the right care with the right provider. Our spine center receives more than 7000 referrals annually. This high volume led to frequent delays and lost referrals related to limited access.

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We created a streamlined triage process and innovative team-based advanced practice provider (APP)-led access clinic. This resulted in more patients seen, shorter lag-times, and expedited guidelines-based treatment while maintaining patient satisfaction. The number of referrals as well as spine provider satisfaction increased. This model has now been implemented across the health care system. Prompt access to care, defined as the ability of a patient to get the correct care expeditiously, in the correct location, and with the correct provider, is essential for a positive patient experience. At our high-volume spine center, more than 7000 patients are referred annually. To manage this high volume, we were using a time-consum-ing triage system that required extensive administrative support and provider input. Patients answered approxi-mately 40 questions during the triage review process, which often took more than 10 days to complete. If an appointment was offered, the time line was, on average, an additional 16 days after completion of triage review. Just under half of referrals ultimately were not seen at our center for various reasons. Patients seen by surgeons often were referred without first undergoing guidelines-based medical management or optimization of their comorbidities, resulting in further delays to treatment and inefficient use of limited resources. Patients, referring providers, and spine providers registered complaints about this system. To address this problem, we created an innovative team-based triage system for new referrals using 10 patient-centered questions that focused on patient expectations, previous care, and red flag symp-toms indicating complexity that would necessitate a higher level of care. Patients were then assigned to either an APP-led access clinic or a surgeon clinic and offered an appointment during the initial phone call. Patients tri-aged to APP clinics were typically those who had no recent imaging, limited prior nonoperative treatment, or complicated medical conditions requiring further optimi-zation for treatment pathways. Our goal was to improve timely patient access to guidelines-based care and to increase efficient resource utilization without decreasing patient satisfaction. Our secondary goal was to increase the number of referrals and improve spine provider satis-faction with this process. Intervention Detail. This novel triage system and APP-led clinic model were piloted over a 2-month period, and data were compared before and after the pilot. First, a diverse leadership group was cre-ated, including APPs, physicians, service line leaders, intake staff, and administrators. We reviewed the total number of referrals compared to the total number of scheduled appointments, and the most common reasons for declined referrals. The triage system was redesigned to be patient centered. APPs and physicians were paired in a dyad structure to promote teamwork, improve conti-nuity of care, and encourage top-of-license practice.

Regularly scheduled leadership meetings were held to evaluate this new model. To measure timely access to care and efficient resource utilization, we evaluated referred patients seen, patient lag time, physical therapy utilization, and patients who ultimately underwent sur-gery before and after the pilot. We analyzed the total number of referrals and the reasons for declined referrals by using data in the original triage system and compared this to data after pilot implementation of the innovative triage system. We defined patient lag time as the time from referral to appointment with a spine provider. We compared the number of physical therapy sessions in the community clinics to the number of physical therapy ses-sions in our spine clinics. We also measured the percent-age of new patients seen who ultimately had surgery. To measure patient satisfaction, we used Clinician and Group Consumer Assessment of Healthcare Providers and Systems scores before and after the pilot. Referring provider and spine provider satisfaction with this pilot was qualitatively measured at leadership meetings. Finally, this model was presented to the entire spine fac-ulty of the health system. Outcomes and Impact. This novel system resulted in an increased number of patients evaluated by spine providers, shorter lag times, and expe-dited guidelines-based treatment. Patient satisfaction, as well as the number of referrals and spine provider satis-faction, also increased. Prior to the pilot, only 56% of new referrals were ultimately seen in our spine clinic. After implementing the novel triage system and APP-led access clinics, more than 75% of new patients referred were seen in our spine clinic—a 28% increase in the total number of new patients seen. Even with this increased volume of new patients seen, our lag time shortened by 6 days (16 days pre pilot to 10 days post pilot). Guidelines-based physical therapy treatment initiated at the spine clinic by a spine provider averaged 4.5 visits compared to community physical therapy programs, which averaged 7 visits. The pilot also optimized nonoperative treatment and comorbid condition management prior to surgeon evaluation, leading to a 5% increase in surgeon-evaluated patients who went on to have surgery, demonstrating improved utilization of appropriate resources. Satisfaction among patients and providers was high following imple-mentation of the new model. Patient satisfaction scores improved slightly (81% to 82%), showing that patients were satisfied with team-based care. Referring providers registered far fewer complaints with our spine clinic. Physicians and APPs alike reported improved satisfaction with this new model. Value-based health care delivery models stress a team-based approach that encourages top-of-license work for all team members. These outcomes show that restructuring the role of APPs within our department to promote top-of-license work had a trans-formative impact on patient care, and also led to improved

38S American Journal of Medical Quality 34(2S)

job satisfaction and professional growth within the APP group. As a result of this project, the novel triage system and APP-led access clinic have been implemented across the entire 6-clinic system.

Restoring Revenue After Epic

Timothy Harlin, DSc, and Elizabeth Fingado, BSMT, MBADenver Health and Hospital Authority

Background. Five months into Denver Health’s (DH) Epic install, revenue was down 3.3%, or $33 million, from pre-Epic levels and was not improving. For a safety net hospi-tal with 70% government payers plus uninsured budgeting only a 1.5% operating margin, it was untenable. Providers, coders, and Epic analysts were blaming each other. To help determine the root cause, 2 physician leaders from obstetrics and surgery participated in a comprehensive value stream analysis (VSA) to understand the revenue cycle process from start to finish. For 5 days subject mat-ter experts mapped every step in the cycle. Every pain point and potential problem was identified, validated, or disproven. DH learned that not all registrations are accu-rate and complete, not all services are authorized when required, not all appropriate patient payments are made at point of care, not all services are documented, not all doc-umentation accurately reflects care provided, not all care provided is billed accurately, and not all appropriately billed services are paid. The variability in process, fre-quency, reporting, and escalation was stunning. Intervention Detail. This work verified the existence of system problems, not people problems. This story begins when the VSA ended, and illustrates how we improved revenue capture across the entire system based on what we learned in obstetrics and surgery. Solutions include imple-mentation of new workflows and standard work, software modifications, improved reporting, enhanced measure-ment, and accountability, all leading to better results. A steering committee oversees the work monthly, a manage-ment team keeps the work on track weekly, and daily huddles cover the mind-boggling detail that exists from one area to the other. Bringing standard reporting and standard work to the reconciliation process across all clin-ical settings was one of the project’s big successes. DH used trained facilitators to go into the outpatient, inpatient, and ancillary areas to watch and record daily charge rec-onciliation that highlighted the power of direct observa-tion to our leadership. Experts were brought in to evaluate our denials. Rapid improvement events were used to find disconnects between what providers documented and what coders were able to code, leading to better relation-ships and improved clinical documentation. One unique report that DH used to identify opportunities was a pre and

post analysis during which every diagnosis-related group and procedure code was reviewed to look for positive or negative variances. Outcomes and Impact. Results include the following:

•• Increased realization rate from 27.7% to 30.5% (approximately $56 million of net revenue)

•• Improved provider documentation in the neonatal intensive care unit, resulting in $400 000 net reve-nue; with approximately $700 000 in clinical doc-umentation improvement system wide

•• $1.9 million in trauma net revenue improvement•• $3.2 million in denials improvement•• Primary care open encounter rates >7 days from

1.39% to 0.67%•• Specialty care open encounter rates >7 days from

3.29% to 1.89%•• Days in accounts receivable from 39.2 to 30.7•• Charge lag (>7 days old) from 41.22% to 13.0%•• Case mix from 1.43 in February 2017 to 1.53 in

February 2018

Alternative Payment Models in Total Joint Arthroplasty: Time to Unbundle?

Michael D. Rudy, MD, Neera Ahuja, MD, Jason Bentley, PhD, and Nidhi Rohatgi, MD, MSStanford Heath Care

Background. Alternative payment models (APMs) including the voluntary Bundled Payments for Care Improvement initiative and, more recently, the mandatory Comprehensive Care for Joint Replacement (CJR) model, have been proposed by the Centers for Medicare & Medicaid Services (CMS) for total hip and knee arthro-plasty (THA/TKA) to reward providers and institutions for providing cost-effective, well-coordinated, and high-quality care for these common and costly surgical proce-dures. Under these APMs, hospitals may either be penalized or share profits based on the fixed pricing tar-gets determined by CMS. Payments are linked for multi-ple services for a specific episode of care, including those rendered during their index hospitalization for THA/TKA and subsequent post-acute care (which can cost one third of the total episode). Because these APMs for THA/TKA have minimal-to-no risk adjustment for medical com-plexity or patient demographics, a possible unintended consequence of implementing APMs is the prospective selection of younger and healthier patients by participat-ing institutions to minimize financial risks. We sought to examine the impact of patient demographics, medical complexity, and surgical characteristics on variation in

A Report on the 2018 Vizient Fall Connections Summit 39S

the total direct cost of the index hospitalization for elec-tive THA/TKA at Stanford Health Care. We also exam-ined the association between these patient characteristics and rate of post-acute care utilization after THA/TKA, because these costs would also be included in the same episode of care. Intervention Detail. We performed a ret-rospective study of 3524 patients who underwent elective THA/TKA between September 1, 2012, and February 28, 2017, using administrative data at Stanford Health Care. Patient demographics included age, sex, race/ethnicity, marital status, primary insurance, and household income. Medical complexity was calculated and reported using the Charlson comorbidity index, Elixhauser comorbidity index, American Society of Anesthesiologists (ASA) class, All Patient Refined-Diagnosis-Related Group severity of illness (APR-DRG SOI), and/or APR-DRG risk of mortality classification. Surgical characteristics were defined as use of either regional or general anesthe-sia, and the cut-to-close operating time. There is no con-sensus on which risk adjustment tool of those listed best correlates with patient outcomes or cost of care. Thus, we assessed combinations of medical complexity tools in a model that already included financial year and patient demographics, choosing the model generated with the lowest quasi-likelihood under the independence model criterion. Multivariable generalized estimating equations were used to quantify the impact of patient demograph-ics, medical complexity, and surgical characteristics with variation in total direct inpatient costs. We also performed subgroup analyses on 1505 patients who had Medicare insurance and were ≥65 years of age to mimic the popu-lation included in the CJR model. Our cost assessment is unique in that we used direct cost variation, rather than hospital charges or charge-to-cost ratios that are widely reported in the literature. Total direct costs included room and board, operating room services and supplies, labora-tory, medications, imaging, blood products, physical ther-apy, and wages of personnel involved in direct patient care. Multivariable logistic generalized estimating equa-tions with exchangeable correlation were then used to evaluate the association between patient demographics and medical complexity with discharge with home health services compared to discharge home for THA/TKA. This analysis was then repeated for discharge to rehabili-tation facility compared to discharge home. Outcomes and Impact. For THA, patient demographics, medical complexity, and surgical characteristics explained 3.4%, 2.8%, and 37.1% of direct inpatient cost variation, respec-tively. With financial year (R2 = 7.0%), these models explained 50.3% of direct inpatient cost variation for THA. For TKA, patient demographics, medical complex-ity, and surgical characteristics explained 1.7%, 3.9%, and 35.3% of direct inpatient cost variation, respectively. With financial year (R2 = 4.0%), these models explained

44.9% of direct inpatient cost variation for TKA. Similar results were observed in both THA and TKA Medicare subgroups. After THA, 807 (50.0%) patients were dis-charged with home health services, and 399 (24.8%) patients were discharged to a rehabilitation facility. After TKA, 1076 (56.3%) patients were discharged with home health services, and 638 (33.4%) patients were discharged to a rehabilitation facility. Patients with a Charlson comorbidity score of 3 to 4 (THA) and patients with Medicare (TKA) were more likely to be discharged with home health services. Factors associated with discharge to a rehabilitation facility after THA included the follow-ing: age ≥75 years, Medicare insurance, a Charlson comorbidity score of ≥3, and ASA class 3 to 5. Factors associated with discharge to a rehabilitation facility after TKA included: married/partnered status, Medicare insur-ance, major/extreme APR-DRG risk of mortality and ASA class 3 to 5. Our work had several important find-ings. First, addressing surgical factors (eg, operative time, anesthesia type, implant costs) rather than prospective patient selection is more likely to yield a reduction in inpatient cost variations for THA/TKA. Second, because patient demographics and medical complexity were asso-ciated with post-acute care needs (a major factor in THA/TKA costs), APMs should focus on post-acute care ser-vices to ensure high-quality, cost-effective, and well-coordinated care. A shared model of financial risk between acute and post-acute care services and additional risk adjustments could be considered in APMs for THA/TKA to hold all stakeholders accountable and ensure equal access to care for patients.

Journey to Engagement: Strategies That Improved Patient Experience and Staff Engagement

Cassandra A. Cuesta, MHA, CPXP, and Roxana E. Taveira, MHSATemple University Hospital

Background. Temple University Hospital (TUH) is an academic medical center in North Philadelphia. TUH serves as a level 1 trauma center and safety net hospital in one of the country’s poorest neighborhoods. Our patients have a high disease burden, low health literacy, and 85% of our reimbursement comes from Medicare and Medicaid. With that in mind, many of our patients are particularly disadvantaged and lack the information and resources to properly understand their disease. In 2016, stagnant first percentile scores caused the hospital’s Cancer Committee to identify patient satisfaction as a goal for accreditation. Along with the challenging patient population of North Philadelphia, the department has

40S American Journal of Medical Quality 34(2S)

dedicated nursing staff, but many were disengaged and unaware of patient experience initiatives. Another chal-lenge was that the department consists of 3 bargaining unions: Cancer Center and patient experience leadership created the Cancer Center Patient Experience Committee (CCPEC) with multidisciplinary staff from radiation oncology and the Infusion Center. The CCPEC met monthly to review patient satisfaction data and priority indices and brainstorm projects to enhance patient and staff experience. The CCPEC categorized the top areas for improvement as perceived lack of teamwork/low morale, communication, and wait time. Communication and teamwork were addressed through

•• Enrolling staff in customer service and empathy training

•• Installing team photo boards in waiting spaces for patients to see, eliciting staff recognition on surveys

•• Hanging a bell that patients ring at treatment completion

•• Having nurses and therapists create FAQ sheets that explain side effects

•• Having a nurse navigator meet with new patients to view an interactive patient education video

•• Updating the resource room with information on support groups and lifestyle changes, as well as relevant educational materials

Wait time was addressed through

•• Using a “fast track” infusion chair for patients receiving shorter treatments

•• Restructuring physician schedules

Intervention Detail. Quantitative measures included the Press Ganey Outpatient Satisfaction Survey (oncol-ogy and nononcology infusion), Press Ganey National Database of Nursing Quality Indicators (NDNQI) Data Benchmark Comparisons: Press Ganey AHA Region 2 50th percentile, and Data Measures: Press Ganey Outpatient Oncology Survey.

Press Ganey Outpatient Oncology survey questions asked about

•• Overall assessment•• Likelihood of recommending•• Chemotherapy (Infusion Center only)•• Wait time•• Explain what to expect•• Explanation of managing side effects•• Staff concern for comfort•• Staff courtesy

Press Ganey NDNQI survey questions asked about

•• Job enjoyment•• Percentage of staff planning to stay in direct patient

care on same unit•• I am thanked and recognized for what I do

Outcomes and Impact. From fiscal years 2016 to 2018, radiation oncology patient satisfaction data increased in the “overall assessment” domain from the 13th to 56th percentile. Specifically, the “likelihood of recommend-ing” category improved from the 6th to 52nd percentile. Additionally, the overall response to the question regard-ing “care given at this facility” improved from the 12th to 56th percentile. For the Infusion Center, the “chemother-apy” domain improved from the 8th to 76th percentile. The “wait time” category improved from the 25th to 75th percentile. The “explain what to expect” category increased from the 6th to 63rd percentile, and “explana-tion of managing side effects” improved from the 22nd to 97th percentile. The “staff concern for comfort” category improved from the first to 84th percentile and “staff cour-tesy” increased from the first to 51st percentile. NDNQI data showed that for the categories of “job enjoyment,” “percentage of staff planning to stay in direct patient care on same unit,” and “I am thanked and recognized for what I do,” each improved from below the median in 2016 to the 70th, 99th, and 80th percentiles, respectively, in fiscal year 2018.

Community Paramedicine: Maximizing Team Relationships to Reduce Readmissions

Jennifer P. Goldstein, MD, and Patricia C. Anderson, MBA, LSSBBPenn State Health

Background. With increasing focus on the Triple Aim of providing better care, lowering costs, and improving health, the Centers for Medicare & Medicaid Services (CMS) instituted value-based programs that impact the reimbursement rate through the Inpatient Prospective Payment System (IPPS). Through this initiative, CMS began reducing Medicare payments for IPPS hospitals with excess readmissions. The root cause of readmissions is multifaceted and may vary because of patient popula-tion, socioeconomic status, and psychosocial determi-nants of health, as well as local hospital systems. We present a low-cost, effective intervention that allows appropriate allocation of limited resources to areas of greatest need. Patients with congestive heart failure (CHF) were identified as a high-risk population for

A Report on the 2018 Vizient Fall Connections Summit 41S

readmissions at our institution, regardless of payer. This patient population also was ideal to pilot an innovative intervention, given our inpatient volume of patients with the primary discharge diagnosis of CHF. Transitional care management for these patients identified some potential root causes leading to readmissions. Patient understand-ing, navigation, and access post discharge appeared to be a gap. Intervention Detail. The CONNECT Community Paramedic Program was utilized to do an in-home assess-ment of all patients post discharge within 72 hours of dis-charge to home. Both an environmental and needs assessment are performed, allowing the team to engage the appropriate resources during this critical transition time. In conjunction with nursing, care management, pharmacy, and medical group administration, we devel-oped pathways dependent on the results of the needs assessment. During this visit, CONNECT Community Paramedics conduct a focused review of symptoms and medication list review, as well as validate that expected interventions were completed, allowing for identification and resolution of gaps. Patient understanding of discharge instructions is assessed, including heart failure action plan and disease-specific education. This real-time inter-vention was felt to be most effective because it is timely and within the patient’s home. The ability of the CONNECT Community Paramedics team to meet and develop a rapport with the patient prior to discharge was deemed critical for successful engagement. With this cost-effective intervention, we are able to identify those patients who need high-intensity interventions and navi-gate patients to the most appropriate resource given their individual needs. Close attention to data allows for iden-tification of process gaps and rapid cycles of improve-ment. Outcomes and Impact. Using our CMS performance as a directional guide to identify populations of need, we evaluated our payer-agnostic 30-day All-Cause Hospital Readmission rate for heart failure. Preintervention bench-mark and performance:

•• 30-day All-Cause Hospital Readmission rate:○ CMS target: 21.52%○ Fiscal year 2018 CMS performance: 22.25%

(year 1—18.23%, year 2—23.32%, year 3—25.60%)

○ Payer-agnostic baseline: 21.5% (April 2016 to March 2017)

Postintervention implementation:

•• 30-day All-Cause Hospital Readmission rate (2018 year-to-date)○ Patients with CHF who received community

paramedicine (CP) visit: 12.4%

○ Patients with CHF who did not receive CP visit: 37.5%

○ Relative risk reduction from baseline (attrib-uted to CP visit): 41%

Process metric:

•• Percentage of patients with CHF who received a CP visit: 48%

•• Percentage of patient engagement (referred to completed visit): 76%

Impact to contribution margin for target population (April 2017 to April 2018):

•• Current impact—$850 000 (68 fewer readmissions than if no intervention)

•• Additional opportunity with 100% satura-tion—$888 000 (71 additional readmits)

Reviving Nonpharmacological Modalities: Acute Care in Response to the Opioid Epidemic

Bert Lindsey, PT, Ashley Wilson, PharmD, Jay Morange, PT, DPT, Jo Watkins, RPh, Lisa Dantin, PT, MPT, Michael Hill, MD, Sun Chaney, MD, and Josie Gaitan, SPTSt. Tammany Parish Hospital

Background. The opioid epidemic has become a veritable monster in our service district; in 2016 alone 23% (70/305)1 of all deaths were related to opioid abuse, and 115 opioid prescriptions were written per every 100 citi-zens.2 St. Tammany Parish Hospital (STPH) acute care (233 beds) and emergency department (ED) (33 beds) often struggle to meet the unrealistic expectations of this population. At STPH, patient safety outweighs the physi-ological/psychological demands of the opioid-tolerant patient, negatively impacting Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) pain domain national ranking scores. In 2016, 2 events solidified the development of what would become STPH’s Opioid Stewardship Committee. In May, an effort between hospitalists, pharmacy, and physical therapy (PT) set forth to seek out innovative alternatives to opioids. After gleaning valuable input from staff, the decision was made to pursue nonpharmacological modal-ity options to reduce pain. In December, STPH was awarded a prestigious mentorship from the Society of Hospital Medicine’s (SHM) Reducing Adverse Drug

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Events related to Opioids (RADEO) Program. With administration’s support, PT began offering both estab-lished and innovative modalities to the opioid tolerant—and then by popular demand—the opioid-naive patient. Pioneering STPH PT alternatives into the RADEO pro-gram was acknowledged as “groundbreaking” according to SHM. Paramount importance was placed on staff edu-cation, addressing physiological aspects of pain, pharma-cological effects of current treatment options, and innovative modalities of dry needling (DN) and kinesio-taping. Substantial emphasis was placed on the patient education component—modifiable based on the patient’s “willingness to learn.” Both program content and direc-tion proved prophetic, as shown in The Joint Commission’s “R3 Report,” which focused on pain assessment and man-agement standards for hospitals. In light of the opioid epi-demic, these results offer the promise of a replicable alternative pain management program for the acute care setting. Intervention Detail. A total of 35% of all STPH adverse drug events (ADEs) were attributed to opioids in 2016. Concurrent (HCAHPS) pain domain scores repre-sented an all-time low percentile ranking of 22%. An exhaustive study identified a plethora of published data on the efficacy of alternative treatments. However, none addressed the acute care setting for DN and kinesiotap-ing. Adapting these modalities to acute care is a novel idea, and no benchmark data exist. Kinesiotaping was implemented in 2016 primarily in the STPH ED. This helped with joint stabilization and edema reduction where boots and/or casts were the only previous alternatives. As with DN, no publications existed when tying this modal-ity directly to the acute care/ED setting. The Opioid Stewardship Committee wholeheartedly approved pilot-ing an acute care program offering alternative treatments specific to the acute setting. STPH offered cryotherapy (ice packs vs ice massage), thermotherapy (K pads vs heat packs), Kinesio tape (Rock Tape), electrical stimula-tion as interferential current, and DN. Limitations spe-cific to DN included patient positioning restrictions with regard to intravenous line management. Patient education was integral to preserving the patient/staff relationship. Staff consistently reiterated to patients the existence of a physiological component relating to their subjective assessment of pain. Explanations of how and why pain reduction occurred without opioids assisted in treatment efficacy as well as proper post-discharge placement. Included in patient education was a focus on safety asso-ciated with opioid use. The patient education component was presented via iPad during each treatment session to reinforce opioid-induced hyperalgesia. Measurable data included pre and post pain scores, functional limitations specific to pain, treatment times, reduction in opioid use for breakthrough pain, and the percentage of patients

referred to outpatient services. DN data collection was expanded to incorporate the percentage of subjective per-ception of functional improvement, which was measured 3 days post treatment. Outcomes and Impact. A tightly controlled study limited to 30 patients (5 refused) began in April 2017. Traditional modalities administered to the opioid-tolerant patient resulted in an average pain score reduction of 3.45 six hours post treatment. Modalities were timed to attempt a reduction in breakthrough pain medications by “bridging the gap” between scheduled medications. Significantly, 4 patients who refused ser-vices qualified as “unwilling to participate” with regard to both acceptance of education and consideration of alternative treatments. Receiving our first opioid-naïve referral became the catalyst to quickly alter both the tone and direction of this program. The first patient’s pain dropped from 9 to 3 utilizing electrical stimulation and ice twice daily. This patient required no opioids—only acetaminophen during the admission! As word spread of this success, referrals increased for both opioid-naïve and opioid-tolerant patients from 8 diverse physician special-ties. Treatment goals included pain reduction in conjunc-tion with reducing the patient’s functional limitation caused by pain. The average post treatment pain score decreased by 4.95 six hours post treatment (n = 25). Acute patients (n = 14) showed a decrease of 5.46 in their average pain score 6 hours post treatment. A total of 11 of the 25 patients treated with conventional modalities agreed to an outpatient referral for nonpharmacological modalities. In preparation for offering DN house-wide, treatments were initially offered to staff. Limitations in trained staff purposefully affected this sample size, giv-ing DN therapists the opportunity to refine both technique and patient positioning, and mimic the acute care envi-ronment. Functional improvement percentage was cap-tured 3 days post treatment. Acute pain patients (n = 19) reported a 71.8% average improvement of symptoms; chronic patients (n = 41) averaged a 41% improvement. A total of 34% of chronic pain patients complied with referrals to outpatient services. One of the original data points driving this endeavor—the STPH HCAHPS pain domain score—improved 54% from January 2016 to December 2017.

1. US Census Bureau. Population and housing unit estimates. https://www.census.gov/programs-sur-veys/popest/data/data-sets.2016.html. Accessed November 2017.

2. Louisiana Secretary of State. Louisiana vital records index. https://www.sos.la.gov/Historical Resources/ResearchHistoricalRecords/Pages/OnlinePublicVitalRecordsIndex.aspx. Accessed November 2017.

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Readmission Review Team: Expanding the Continuum of Care

Kristine M. Leahy-Gross, MSN, RN, CPHQUW Health

Background. Unlike frequent-flyer airline programs that reward loyalty, there are no rewards for frequent hospital admissions or emergency department (ED) visits. Although this organization had engaged in multiple efforts focused on decreasing avoidable readmissions, a core group of patients remained for whom the identified interventions were not working. As a result, the organi-zation created the readmission review team (RRT), a multidisciplinary team to review the clinical care of fre-quently admitted patients, strategize how best to help these patients, and coordinate providers to implement efforts across the care continuum. RRT addresses the needs of complex, chronically ill patients with multiple clinical and social needs. It is co-led by a geriatrician and nursing director along with the transitional care program manager as the team facilitator. Additional core team members include social workers, case managers, nurses, physicians, advanced practice providers, patient rela-tions staff, and palliative care representatives. Ad hoc members include community partners from skilled nurs-ing facilities, assisted living facilities, home health care agencies, dialysis centers, community case management, community support organizations, and managed care payers. The involvement of community partners is pos-sible through teleconferencing; this involvement has been instrumental in keeping all team members closely connected, ultimately ensuring a positive impact on patients. Referrals target patients who have had multiple admissions and ED visits. The referral for case review is scored for appropriateness. This organization developed a scoring tool that accounts for patient utilization pat-terns (eg, at least 3 hospital admissions or ED visits in the last 90 days), number of chronic medical conditions, and social issues. RRT discussion focuses on a care plan to improve coordination with primary care providers/staff and community partners to decrease preventable readmissions and ED visits. RRT meetings are held twice monthly. Intervention Detail. A cross-sectional data analysis was performed on patients reviewed by the RRT from January 2014 to June 2016. Electronic medical record chart reviews were conducted to obtain demo-graphic data, comorbid medical conditions, psychosocial issues, hospital admission frequencies, and ED visit fre-quencies during the 6 months pre and post RRT interven-tion. Total variable cost during each of these periods was calculated by the organization’s business analytics department. Data tracking on team recommendations,

interventions, and frequency of RRT reviews were col-lected from meeting notes. Frequency of ED visits, hos-pital admissions, and total variable costs during the 6 months prior to the intervention compared to the 6 months thereafter were analyzed using a paired Student t test. To avoid overestimating the success of the interven-tion, patients with more than 1 review between January 2014 and June 2016 (N = 10) and those who expired before the 6-month postintervention period had ended (N = 23) were excluded from data analysis. Of the remain-ing patients (N = 97), there was a 47% decrease in read-missions and ED visits between 6 months prior to and after the RRT intervention (746 vs 398, P < .001). Additionally, the total variable cost showed a decrease of over $2.4 million ($3 555 221 vs $1 141 464, P < .001). Average length of stay decreased 42% (3.6 vs 2.1, P < .001), which equates to 1.5 days per encounter or a total of 146.2 days. Outcomes and Impact. The highly engaged multidisciplinary RRT has had a statistically significant impact on reducing hospital readmissions, ED visits, and total variable costs to the hospital among highly medi-cally and socially complex patients identified and reviewed by the RRT. Facilitating across-the-continuum communication between inpatient and community pro-viders, and developing individualized treatment plans contributed to these reductions in health care utilization. Involvement of community partners has been instrumen-tal in keeping all team members closely connected, ulti-mately ensuring a positive impact on patients. Although there is little literature available detailing use of a multi-disciplinary team to prevent hospital admissions among patients, this project supports increased communication across the care continuum with decreases in total vari-able costs ($3 555 221 vs $1 141 464, P < .001). These savings likely reflect the reduction in utilization of health care in high-cost settings, such as the hospital and ED. By strengthening outpatient care plans, RRT encourages management of patient concerns in lower cost settings, including the clinic. Development of personalized ED management plans helps reduce unnecessary interven-tions and imaging studies that otherwise might lead to higher costs. RRT provides an opportunity for multidis-ciplinary communication by bridging the inpatient, out-patient, and community settings of care. Addressing the complex social situations that many of these patients face is critical to ensuring the development of an indi-vidualized plan of care that acknowledges the nonmedi-cal challenges to the patient’s ability to adhere to a treatment plan. Through the RRT intervention, patients are able to obtain personalized plans of care that come from a skilled multidisciplinary team that is cognizant of community and medical resources, better addressing the social determinants of health that may drive health care utilization beyond medical needs alone.

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Harnessing Telemonitoring to Break the Pediatric Asthma Readmission Cycle

Michael T. Crocetti, MD, Susan M. Huff, RN, MSN, Melissa D. Lantz-Garnish, RN, BSN, John M. Adamovich, MHA, and Martha D. Mueller, MDJohns Hopkins Home Care Group

Background. Pediatricians often do not hear from their asthma patients until an exacerbation occurs, resulting in this disease being the third leading cause of hospitaliza-tions among children younger than age 15 years, and a leading cause of school absenteeism in the nation (10.5 million days/year).1,2 Our first participant exemplified these statistics, as he repeated the first grade because he missed too many school days because of his asthma. To transform care delivery in this high-cost population, Pediatrics at Home (PAH) created a transdisciplinary team with Johns Hopkins Community Physicians (JHCP) and a Hopkins-based digital health start-up (Quantified Care) to leverage the home as the most cost-effective care setting and improve the flow of information between patients and providers. PAH’s asthma program begins with an in-home environmental assessment, provision of education and connection to housing resources to assuage identified asthma triggers, onboarding the patient/care-giver onto the mobile application, and reconciliation of medication and supplies. Through their mobile applica-tion, patients/caregivers record symptoms data, access their asthma action plan, receive educational information, and securely communicate with PAH clinicians. A web portal is used by PAH clinicians to engage with patients/caregivers, review patient-collected information, and tri-age. Intervention Detail. The PAH team started with Baltimore, Maryland, as hospitalization and emergency department (ED) visit rates in the city are more than dou-ble the state average.3 Furthermore, Maryland’s asthma prevalence is significantly higher than the national aver-age.4 Outcomes are reported from data analyzed through the end of March 2018. Data were aggregated from pre- and post-program surveys, interactions logged by the mobile app, and chart review of patient electronic medi-cal records. Across 3 areas, outcomes were evaluated based on individual and study population improvement over a period before and after enrollment:

Engagement:

•• Enrollment of pediatric asthma patients•• User engagement•• Overall rate of participants who are regularly

engaged compared to total PAH asthma program population

Utilization:

•• Patient high-cost, high-risk clinical resource utili-zation (ED visits/hospitalizations)○ 90-day pre- and post-enrollment comparison○ 180-day pre- and post-enrollment comparison

•• Overall change in high-cost, high-risk clinical resource utilization○ Participants whose utilization improved com-

pared to total PAH asthma program population•• Effect of ongoing participation after graduation on

high-cost, high-risk clinical resource utilization

Satisfaction:

•• Patient/caregiver satisfaction and technology acceptance

•• Provider satisfaction with the program•• Changes in engagement throughout the program

and the effect of ongoing participation on engage-ment levels after graduation

Outcomes and Impact. Study participants were aged 5 to 21 years and were referred from JHCP Baltimore City locations. Participants graduate at 90 days.

Measure:

•• Participants: 77 (99% Medicaid)•• Graduates: 62 (90-day program)•• Engagement: 87% (users engaging at least 4 times

per 30 days)

Reduction in high-cost utilization (comparison for ED, hospitalization, or urgent care visit):

•• 55% in year-over-year, same 90-day period (for seasonality)

•• 79% in same year, pre/post 90 days of enrollment•• 55% in same year, pre/post 180 days of enrollment

(to assess for “stickiness” after graduation)

The asthma program provides significant evidence that remote monitoring programs have the potential to realize a high level of engagement along with compelling clinical outcomes. Importantly, the reduction in high-cost utilization encompasses both participants who did and did not graduate. For those who failed to graduate, there still was an improvement (reduction of ED and hospital visits). The ability to aggregate regular medical insight while facilitating real-time communication and coordina-tion between patients and their clinical teams represents a burgeoning and scalable model of care management made possible by digital health technology.

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1. Centers for Disease Control and Prevention; National Center for Health Statistics. National Hospital Discharge Survey, 1995-2010. https://www.cdc.gov/nchs/fastats/hospital.htm. Last updated May 3, 2017. Accessed July 17, 2018.

2. US Environmental Protection Agency. Asthma. http://www.epa.gov/asthma/pdfs/asthma_fact_sheet_en.pdf. Updated January 29, 2019. Accessed January 30, 2019.

3. Maryland Department of Health and Mental Hygiene; Family Health Administration; Maryland Asthma Control Program. Asthma in Maryland 2012. https://phpa.health.maryland.gov /mch/Documents /As thma%20in%20Maryland%202012.pdf. Published June 2012. Accessed January 30, 2019.

4. Maryland Department of Health and Mental Hygiene; Family Health Administration; Center for Maternal and Child Health. Jurisdiction pro-file: Asthma in Baltimore City. https://phpa.health.maryland.gov/mch/documents/asthma_control/Profile_BaltimoreCity.pdf. Published August 2011. Accessed January 30, 2019.

Driving Practice Change Through Clinician Collaboration

Christopher S. Weaver, MD, MBAIndiana University Health

Background. The American health care landscape contin-ues to shift from volume to value and fiscal challenges are increasing. With the increased focus on quality per-formance and decreasing costs, unwarranted care varia-tion is increasingly recognized as a critical risk to performance. Like other health care organizations across the country, Indiana University Health (IU Health) is challenged with unwarranted clinical variation leading to increased costs and, more importantly, unsatisfactory patient outcomes. Looking to improve clinical outcomes and identifying a way to engage clinicians across a multi-site hospital organization, IU Health formed clinical councils. Councils are tasked with promoting statewide collaboration and leadership to provide high-value patient care and delivering optimal clinical outcomes. Using evi-dence-based clinical practice, councils bring provider leaders from each region in the health system together to address opportunities in areas such as quality variation, supply chain, pharmacy, and information services (IS; eg, order sets, care pathways). The councils drive provider engagement and strongly encourage leadership to remove unwarranted variation and enhance the value of care IU Health provides to our patients and the communities we

serve. Intervention Detail. In 2016, Vizient researched the performance of health systems across the country and evaluated variation within systems. The study evaluated variation and performance within and between health systems in 6 areas: percentage of uncomplicated joint replacement patients discharged to skilled nursing or inpatient rehab facilities, percentage of emergency room visits for back pain with computed tomography (CT) or magnetic resonance imaging (MRI), incidence of repeat abdominal/pelvic CT or MRI within 3 months, percent-age of cancer decedents with less than 2 days of hospice care, percentage of cancer decedents with intensive care unit stay in the last 30 days of life, and percentage of attributed chronically ill patients receiving 90% of facil-ity care within a health system. The study demonstrated a large amount of variation within health systems across the country and IU Health was no exception. IU Health had significant variation from site to site on each of the questions evaluated. In addition, each facility in the sys-tem demonstrated great variability in the Vizient observed direct cost/expected direct cost ratio. Leadership identi-fied tens of millions of dollars of opportunity if each facility could perform in the top quartile of Vizient hospi-tals in relation to this ratio. After considering these data points, IU Health leadership evaluated best practices around the country and developed a plan to address the unwarranted care variation noted. Outcomes and Impact. IU Health clinical councils have achieved significant results related to IS, quality, pharmacy, and supply chain in just a year. More than 600 order sets have been retired in efforts to decrease variation. This work, along with efforts to clean up our alerts in the electronic health record (EHR), has resulted in decreasing the percentage of transactions in our EHR taking >5 seconds by more than 75%. Quality outcomes that are representative of achievements include a decrease of emergency depart-ment discharges with narcotic prescriptions of more than 40% from 2017 to 2018. Another example is the decrease in the IU Health length of stay index for total joint patients from 0.9 to just over 0.7. The overarching effect of these efforts on our pharmacy spend has resulted in a decrease in the IU Health inpatient drug expense per pharmacy intensity score adjusted discharge from $409.55 in 2017 to $403.36 over the same months in 2018. A specific example of evidence-based practice across the system leading to decreased costs stems from the use of liposo-mal bupivacaine. The spend decreased to less than half of the spend of the previous year ($135 000/month in 2017 to approximately $65 000/month in 2018). In addition, off-formulary medication use across the system decreased from 2388 episodes a month to 383 in just 8 months. Supply chain success examples include an annual decrease in spine implant costs of more than $3 million dollars on an annual basis and a significant decrease in

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variable direct cost of total joint procedures. These are just some examples of the success IU Health has recog-nized with the introduction of clinical councils. These councils will be critical for IU Health as we drive to increase value for our patients.

Ignore the Squeaky Wheel: Target What’s Broken

Jeanne M. Huddleston, MD, MS, and John Menzies, MBBS, MHP, FRACMA, AFACHSMMayo Clinic

Background. Health care quality improvement is famous for applying Band-Aid solutions to big problems, using too many resources for smaller problems, and standard-izing to the point of losing important nuances between facilities. As providers working to improve quality of care and patient safety, we were frustrated with the allo-cation of resources being directed only toward the tip of the iceberg. All of us who work in the trenches are aware of the broken process of care, yet these issues rarely receive attention from leadership because they reside below the surface of the water . . . under the tip of the iceberg. An international collaborative was founded on the belief that providers could meaningfully shape lead-ers’ priorities. Through a universal organizational learn-ing methodology developed at Mayo Clinic, frontline providers have a voice in defining and quantifying the process of care failures that negatively impact organiza-tional metrics. Intervention Detail. This international col-laborative of more than 100 hospitals implemented the standardized organizational learning methodology devel-oped at Mayo Clinic for their mortality reviews. The prin-ciple tenets of this methodology include performing a system review (not a peer review); deference to expertise; consensus-driven multidisciplinary, multispecialty case discussions; centralized learning through a shared data-base; and localized operationalization of the method. A case review heuristic was implemented at each hospital through standardized training of all reviewers. This pro-cess described and quantified the issues that patients experience during an episode of care. Through a shared, standardized taxonomy, patient experiences are evaluated to identify and define process of care and system failures that create care vulnerabilities for patients and providers. A key component of this work is aligned with high reli-ability principles, specifically deference to expertise. Each episode of care is reviewed by a practicing nurse and physician to identify any issues in care. This clinical expertise is crucial because more than 80% of the oppor-tunities identified with this method are classified as acts

of omission. As a result, reviewers have to identify what is missing. This is more easily done if the reviewers know what is supposed to be present at any point in a patient’s care journey. Case reviewers share their findings with each other in a multidisciplinary, multispecialty meeting where the issues identified are discussed with the intent of reaching 100% consensus regarding which issues pres-ent opportunities for improvement. Only those opportuni-ties that reach consensus are included in the data. Outcomes and Impact. Early on in its mortality review journey, Mayo Clinic recognized that more than 80% of the opportunities identified were acts of omission, not commission. Since 2016, this finding was replicated in more than 100 hospitals in the United States, Canada, and Australia. Hospitals reported spending the majority of their time and resources addressing hospital-acquired conditions and infections, yet they found that these issues represented less than 10% of the opportunities identified through the multidisciplinary and multispecialty review and consensus process. The top 4 categories of opportuni-ties for improvement from all participating hospitals include end of life (41% of all cases reviewed), documen-tation (25%), treatment (22%), and delayed or missed diagnosis (15%). In addition, when hospitals reconciled their findings from this multidisciplinary, multispecialty process with existing safety reporting mechanisms, less than 10% of the opportunities identified were found in their existing data systems. Although we cannot stop working on the very important health care-associated infections and hospital-acquired conditions, we must fig-ure out a way to shift some of our resources toward fix-ing those system failures that impact thousands of lives every year.

Imagine Perfect Care: University of Utah Health’s Vision of Innovation

Julia Beynon, BSN, RN, and Teri Olsen, MS, SHRM-SCPUniversity of Utah Health

Background. How does a health system known as a nationwide leader in quality continue to innovate and improve the care it delivers to its patients? For University of Utah Health (U of U Health), the answer is a program called Imagine Perfect Care (IPC). Since the opening of the IPC Resource Center in July of 2016, IPC has engaged, challenged, and empowered staff to improve the quality and value of care they deliver to their patients, all while partnering with patients to ensure outcomes meet their needs and wants, and improve the patient experi-ence. IPC offers opportunities for employees to innovate within our system and empathize with our patients

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through several initiatives, including seed funding and the “Speak Up Touch Up” initiative. These platforms have led to improved patient care processes, smarter deci-sion making, and increasingly higher standards for patient-facing environments, and have supported U of U Health’s culture of innovation and patient-centered think-ing. Seed funding offers employees—who are often on the front line of patient care—the chance to turn ideas into reality by providing grants and support for their proj-ects. After applications are reviewed and funding is granted, IPC provides oversight while still allowing grantees to take charge in seeing the project through. Speak Up Touch Up is a way for staff to speak up about physical and aesthetic issues in patient-facing spaces. Our staff send submissions about issues such as torn fur-niture and squeaky wheels to IPC. Through connections to campus resources, the IPC team ensures the problem is resolved in a timely manner. Additionally, as of fall 2017, IPC has been charged with leading our efforts to improve the patient experience and patient satisfaction on the inpatient units of the hospital. The truth is that patients do not want to be in the hospital so we are working with them, and the staff who care for them, to improve their experience while under our care. Intervention Detail. IPC received 50 applications for seed funding, 21 of which were approved for funding. Over the course of the year, a vast majority of projects have either concluded or have achieved proof-of-concept for further funding. The scope of these projects varies, but each has direct patient care impacts as the desired key outcome—from a community garden in one of our clinics, to a tooth technology proto-type designed to lock down molecules related to chronic disease states and epidemics. A second round of funding recently closed. Of the 44 applications that were submit-ted, 18 have been awarded funding. Since its inception, the Speak Up Touch Up initiative has addressed more than 90 aesthetic issues in U of U Health’s patient-facing areas, often resolving problems that have been there for months or even years. As more staff learn about Speak Up Touch Up, it is our hope that they feel empowered to help keep our patient spaces up to the highest standard, rather than expecting others to take care of them. IPC’s 3 pri-mary initiatives rely on the power of employee innova-tion and engagement to impact patient care, and have so far been successful. Despite IPC’s patient experience efforts being relatively new, positive results are already being observed. IPC helped plan and participate in 13 patient experience retreat sessions focused on improving nurse communication. In the months following these retreats, nurse communication Hospital Consumer Assessment of Healthcare Providers and Systems scores have risen 10%. Outcomes and Impact. Since the opening of the IPC Resource Center just over 2 years ago, there have been visible strides to improve patient care by

supporting employee-led innovation, listening to patients and fellow employees, and improving our everyday envi-ronment. Although IPC is a physical resource, it has developed into a frame of mind for our employees to con-tinually improve and aspire to reach excellence on behalf of our patients. IPC anticipates high levels of successful outcomes with the newly funded round of staff-led proj-ects as were seen with the initial round of funding. Additionally, the early successes of IPC’s patient experi-ence efforts have led to many more inpatient units reach-ing out for help in engaging their staff to improve the patient experience. IPC plans to engage in more retreats focused on patient experience, in addition to implement-ing other innovative approaches to improving the patient experience. Efforts to engage staff have revealed long-standing information gaps that affect the patient experi-ence. By working with staff, a solution has been developed that will not only improve the patient experience but also will allow for staff development and building of interde-partmental relationships. This gap would never have been filled and a solution never found if IPC had not engaged staff in efforts to improve the patient experience. IPC believes it has developed a framework that can be applied to any area in need of innovation; this includes engaging staff to identify issues and areas of opportunity, empow-ering them to come up with solutions, and supporting them in implementing those solutions. Innovation is the key to continued success. The only way to keep innova-tion moving forward is to have staff own and be engaged in the process.

Wiping Out CDI, One Ply at a Time: A Multilayered Approach

Tigre Suder, BSN, RN, and Derek W. Forster, MDUniversity of Kentucky HealthCare

Background. University of Kentucky HealthCare (UKHC) developed and implemented a Clostridium dif-ficile Bundle, a multidisciplinary approach to reduce the rates of hospital onset (HO) C difficile infections (CDI). HO CDI is defined by the National Healthcare Safety Network (NHSN) as a positive test collected from an inpatient location more than 3 days after admission to the facility. Emerging literature supports that many cases of HO CDIs occur in patients who are known to be colo-nized. This suggests that the typical infection prevention approaches may have a low impact and likely explains why previous efforts to reduce HO CDI nationally have not demonstrated consistent and lasting results. From 2013 to 2015, the HO CDI rates at UKHC were increas-ing. To help reduce rates and improve patient safety, the

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following opportunities were identified: (1) delays in iso-lation; (2) inappropriate testing; (3) hand hygiene and personal protective equipment (PPE) compliance; (4) surface disinfection; (5) inconsistencies in charting; (6) laxative use; and (7) inappropriate antimicrobial use. A fiscal year 2017 goal was set to reduce the number of hospital-acquired infections at UKHC by 30%. With leadership from infection prevention and control (IPAC), the opportunities identified were addressed through the development and implementation of the C difficile Bundle. Our bundle included testing and antibiotic stew-ardship interventions, automation of isolation, enhanced terminal room cleaning, education, and optimization of our electronic medical record (EMR) to provide clinical decision support for these interventions. This approach was a collaboration between IPAC, antimicrobial stew-ardship, clinical microbiology, information technology, environmental services, pharmacy, nursing, and addi-tional physician groups. With our bundle, we have seen a 74% reduction in HO CDI. Intervention Detail. We saw a spike of HO CDIs in 2015, which was temporally associ-ated with the introduction of a multiplex Gastrointestinal Polymerase Chain Reaction (GI PCR) Panel, which included C difficile. This testing platform has unique lim-itations to testing restrictions and discussions with other similar institutions that identified the same association. For this reason, the C difficile result was removed and providers were encouraged to order standard C difficile testing if clinically indicated. We retrospectively reviewed the performance of the GI Panel and identified that it was associated with a false positive rate of 27.5% for C. dif-ficile. This confirmed suspicions that this was contribut-ing to the overdiagnosis and inflation of our HO numbers. We reviewed our HO CDIs reported to NHSN for 2015 and found that 53% (125/234) of our “infections” received laxatives within 48 hours of the positive test. We then designed hospital-approved testing recommendations based on national guidelines along with a “laxative alert” when a provider orders a C difficile test. To ensure appro-priate testing and help standardize charting, we incorpo-rated the Bristol Stool Scale into our EMR with the recommendation to only send types 5 through 7 for test-ing. We also incorporated an automated process for plac-ing patients into appropriate isolation when a C difficile testing order is placed to help prevent delays in isolation. Recent data suggest that approximately 15% of all patients admitted to the hospital may be colonized with toxigenic C difficile. This information led to the trialing and ultimate expansion of the use of a sporicidal disinfec-tant. An enterprise-wide hand hygiene initiative has also been implemented to address opportunities of noncom-pliance with hand hygiene and PPE. Antibiotic steward-ship efforts to address inappropriate antimicrobial usage include indication-based ordering, 48-hour antibiotics

time-outs, and urinary tract infection and pneumonia treatment guidelines. Outcomes and Impact. Our bundled approach is unique because, in addition to standard infec-tion prevention practices, it also incorporated strategies to minimize inappropriate testing and to improve the use of antimicrobials at our facility. We believe these initia-tives would impact patients who are known to be colo-nized and thus have the greatest impact on the number of infections. To benchmark our performance, IPAC utilizes the Centers for Disease Control and Prevention NHSN standardized infection ratio (SIR). After implementation of the interventions identified, UKHC’s HO CDI rates are trending down based on the NHSN SIR data. Our highest HO CDI SIR in 2015 was 1.28. We finished the second quarter of 2018 with a SIR of 0.34 (a reduction of 74%). Our 30% reduction goal also was met.

Motivating Physicians With Motivational Data

Saria Saccocio, MD, and Scott Hultstrand, JDGreenville Health System

Background. In a large, complex system consisting of 34 hospital-employed primary care practices, a lack of moti-vation to focus on Medicare clinical quality initiatives prevailed, with overwhelmed providers and clinical staff, and issues with nonstandardized approaches. We addressed this challenge head-on by using a unique collaborative approach between data science and clinical and practice operations leaders to actively engage physician practices in a structured curriculum. The goal was to motivate pro-viders and staff to take a renewed interest in high perfor-mance in clinical quality measures related to our value-based contracts. This was accomplished by focus-ing energy on the most impactful metrics while providing data-driven strategies and simplifying the pathways to achieve desired patient outcomes. Intervention Detail. In fiscal year 2018, Greenville Health System’s family and internal medicine practices focused on 5 quality measures: falls risk screening, body mass index (BMI) screening and follow-up, depression screening and follow-up, colorectal cancer screening, and poor diabetes-hemoglobin A1c con-trol. The data source was the electronic medical record feeding into a centralized proprietary database technology that created individualized scorecards for providers. Additional data visualization tools were used to create “motivational data” for providers, which included trans-parent data on performance across providers and prac-tices, while also producing targeted visualizations for key leaders and other drivers of performance across the sys-tem. Targets were set based on the previous year’s perfor-mance, with expectations for significant improvement. Data were shared in conjunction with a structured and

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manageable curriculum agenda that involved physician leaders from each practice and practice managers who scaled the quality improvement ideas to each practice. Support for all action plans was provided via clear and digestible pathways to success and support from a team of quality specialists. Outcomes and Impact. With an initial focus of our curriculum calendar on the BMI and depres-sion screening measures, we were able to see positive movement almost immediately, with remarkable efforts in January and February by providers on the BMI measure, especially in light of the challenging flu season that made practice operations more difficult than usual. The BMI measure, which required physician and other advanced practice professional participation and documentation as opposed to staff-driven measures, showed significant improvement: 25% of providers above 75% performance in September 2017, and 80% of providers above 75% per-formance by February 2018. The overall primary care BMI score in June 2018 was 91.40% compared to 57.50% in July 2017. The challenging flu season led to staff-driven measures such as depression screening declining through March 2018, but after our motivational data intervention was implemented in March 2018, staff were able to drive that measure from 60.9% in March to 85.0% in June. Finally, in terms of the colorectal cancer screening mea-sure, after showing physician leaders data in February on the minimal usage of non-colonoscopy options such as Cologuard for patients who refused colonoscopies, a sus-tained 40% increase was seen in the use of Cologuard from March through June of that same year. On a more global scale, the interventions collectively resulted in a Medicare Shared Savings Program quality score of 97.94% in 2017 versus 90.91% the previous year, leading to a significant increase in shared savings retained.

From Vizient’s Learning Collaborative to a Comprehensive Post-Acute Care Program

Jonathan Chapman, LCSW, and Yasin Patel, MPHUniversity of Chicago Medicine

Background. As health care continues to transition from volume to value, hospitals need to manage and coordinate care beyond the index hospital stay to be successful under risk-based contracts. In 2017, University of Chicago Medicine (UChicago Medicine) embarked on a journey to develop a comprehensive post-acute care (PAC) strategy to improve capacity while ensuring patients receive safe, effective, and appropriate care in the PAC setting. To iden-tify high-quality PAC providers, we formed a multidisci-plinary team inclusive of social work, quality improvement, geriatrics medicine, case management, physical therapy,

and nursing to select, evaluate, and develop relationships with 8 to 10 PAC facilities. Using insights from the Vizient Post-Acute Care Learning Collaborative and Medicare Spend per Beneficiary (MSPB) Insights report, the team designed a process that included the following: (1) defin-ing goals and expectations for PAC preferred providers; (2) understanding PAC utilization through data; (3) select-ing a narrow network of PAC facilities for strategic meet-ings; (4) identifying areas of opportunity; and (5) establishing a scorecard to monitor patient quality and safety metrics. To develop areas of collaboration, we met with senior leaders from each PAC facility. These discus-sions resulted in identifying innovative strategies that UChicago Medicine and PAC preferred providers are implementing together. The strategies include the follow-ing: (1) integrating PAC liaisons into multidisciplinary rounds; (2) partnering UChicago Medicine physicians with PAC medical directors to evaluate and transition patients to the PAC setting; and (3) partnering with high-acuity service areas (eg, medical intensive care unit [MICU], trauma) to establish formal programs with select PAC providers. Intervention Detail. To understand patient geography compared to the PAC facilities that serve them, we conducted an objective analysis of our catchment area. This analysis provided insights into which PAC facilities were receiving the majority of our patients after their hos-pital stay. We further utilized the Vizient MSPB study to understand which conditions provided the biggest oppor-tunities for improvement in the Medicare population. This information helped inform the selection of PAC facilities that we engaged for initial dialogue to become a preferred provider. To select the final network of preferred provid-ers, we developed selection criteria that evaluated each provider for (1) geographic location; (2) overall quality performance; (3) medical coverage; (4) clinical capabili-ties; (5) existing relationships and collaborations. Each PAC facility was requested to review this information at initial meetings to then discuss with key internal stake-holders. After selecting the preferred providers, standard-ized metrics for throughput, quality, safety, and patient experience were established. These metrics were devel-oped in conjunction with PAC preferred providers, physi-cians, and hospital leaders. An online survey tool also was used to standardize data reporting by all PAC facilities. We subsequently created a scorecard to visualize key per-formance metrics at the network and individual facility levels. The scorecard informs conversations with PAC facilities, hospital leadership, and frontline staff on how we are performing in areas such as readmissions, PAC average length of stay, health care-acquired infections, and other quality and safety metrics. Outcomes and Impact. Our work over the past year has resulted in many exciting changes that have impacted our ability to more proactively identify, assess, and transition patients into

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PAC settings, as well as our ability to track and influence PAC utilization through preferred partnerships. We have successfully integrated 4 PAC liaisons into multidisci-plinary rounds to assist with identifying the right patients for the right care setting. Additionally, we have engaged clinical leadership in cardiology, neurology, MICU, trans-plant, burn unit, and trauma to develop targeted programs with PAC preferred providers. These targeted interven-tions include the following: (1) PAC medical directors rounding on patients at UChicago Medicine; (2) develop-ing custom care pathways and protocols for patients; and (3) establishing mechanisms for providing medical updates on high-acuity patients. To expand patient throughput, UChicago Medicine developed standard work with PAC facilities to accept patients on weekends. These efforts have resulted in 57% of all UChicago Medicine patient placements to preferred provider facilities and an average of 6 additional patients being discharged to pre-ferred providers compared to fiscal year 2017. Overall, this effort had a central role in the clinical length of stay reduction of 5.1%. Future efforts to strengthen the PAC preferred provider network include developing a lung transplant program, engaging additional service areas to partner with PAC providers, and scheduling quarterly meetings with PAC providers to review quality and safety data and identify opportunities for continued improve-ment. Each of these directions can influence patient care and satisfaction, and contribute to meeting the organiza-tional and community capacity needs.

The Quality Data Fruit Salad

Jennifer L. Lamprecht, MS, RN, CNL, CPHQ, and Lorna L. DeRaadSanford Health

Background. Prior to implementing the Vizient Clinical Data Base (CDB), Sanford did not have an enterprise solution for external benchmarking of quality outcomes. Substantial resources were invested in clinical data regis-tries, but they were only in a few hospitals. The purpose of CDB participation was to create a single source of quality benchmarks to compare outcomes in all Sanford Prospective Payment System (PPS) hospitals. Sanford is in all 3 quality and accountability (Q&A) cohorts because of differences in size and scope of services. CDB coordi-nators were challenged to create standardized reporting methods to compare 7 diverse hospitals to one another and to external benchmarks. Quality plans, improvement methods, and prioritization of initiatives were standard-ized prior to launching the CDB. Sanford’s CDB steering team unanimously agreed to enter the CDB with full internal transparency. Although there is a specific process to follow, anyone can become a user if their supervisor

determines it is applicable to their role. CDB users have access to data for all Sanford hospitals in the CDB and providers in Physician Insight. Transparency is a strategy for engagement in measuring and improving value. The number of quality measures and programs for leaders to manage can be overwhelming, so centralized experts make strategic decisions regarding which measures are reported internally. Enterprise leaders need to review per-formance across all sites with internal and external com-parisons. Quality dashboards and physician and executive portals are a conduit for communicating the best level and combination of information to various audiences. Standardized quality reporting also is maintained within the CDB because there are so many users. CDB Report Builder queries were developed and shared with all users to ensure that consistent report parameters are used for key performance indicators. Interestingly, we do not actu-ally utilize the “system-level” report option in Report Builder because we are looking at variation between hos-pitals to target opportunities for standardization. Intervention Detail. Seven of 45 hospitals were enrolled in the CDB. The group consisted of 6 PPS hospitals and 1 critical access hospital with a range of 35 to 583 beds. The CDB steering committee considered multiple options in terms of how to display performance data using bench-marking with CDB cohorts. CDB coordinators developed an academic medical center (AMC) and community ver-sion of each internal reporting metric. Top Q&A perform-ers were used in the calculation of benchmarks. This strategy aligns with the internal standard of goal setting at top decile. Historically, Sanford hospitals individually participated in a number of clinical data registries to cre-ate a benchmarking profile of services at their facility. These types of registries do not have system-level partici-pation options, making it very difficult to perform inter-nal data comparisons. They also are very resource intensive because of the need for manual abstraction. Implementing the CDB allowed us to adapt internal and external benchmarking within a single database for all hospital services. Sanford has already saved $212 000 through the reduction of registries and more through the avoidance of starting new ones. CDB is also a more uni-versal tool for users than individual clinical data regis-tries. Registries typically have only a couple of users who then distribute data and information. Sanford has 216 CDB users because of the transparent access to data from all inpatient care at any of our participating hospitals. Users comprise a variety of roles, such as quality, data and analytics, operations, physicians, executives, phar-macy, and lab. Users each write an average of 20 reports per month, while CDB coordinators write more than 200. Outcomes and Impact. Multiple reports have been cus-tomized using CDB data to allow direct comparisons of hospitals with different benchmark cohorts. Reports are

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tailored to each audience and are updated quarterly to reflect the release of Report Express Management reports. Email reminders are sent to regional and system-level leaders to log in and view their own hospital reports. A brief system-wide analysis is included in the email along with hospital-specific trends and improvement high-lights. A system-level, color-coded report is attached to the Quality and Safety report email reminder. This Excel file has a sheet for the Q&A calculator, Clinical Outcomes report, hospital-acquired conditions, patient safety indi-cators, and pediatric complications. This document pro-vides side-by-side hospital comparisons for the AMC and community cohorts separately. The complex teaching cohort also is incorporated into the Q&A calculator results. An executive-level system report is created with CDB data for presentation at the quarterly operational performance review meeting. This is a vice president–level meeting to hold leaders accountable for high-value hospital care. PowerPoint slides contain bar and trend graphs for length of stay (LOS) index, mortality index, readmissions, complication rate, infection counts and standardized infection ratio, and patient satisfaction. Separate slides display AMC and community cohorts. Our complex teaching hospital is pooled with community hospitals. The benchmarks used for comparison on these graphs are group A with top Q&A AMC and group B with top Q&A community. These reports help summarize per-formance for system-level leaders while identifying vari-ation in performance and prioritizing improvement initiatives. In the first year of using CDB (fourth quarter of 2016 to fourth quarter of 2017), the LOS index has improved in both our AMC and community hospitals (AMC from 0.98 to 0.91 and community from 0.87 to 0.82). The mortality index has improved for Sanford AMC hospitals from 1.32 to 1.11.

Psychiatrists Make a Hockey Stick

Howard Weeks, MD, and Adam McDougal, MSIMUniversity of Utah Health

Background. Studies have shown the use of antipsychotic medications increases the risk of developing metabolic syndrome. University of Utah Health sought to increase the percentage of patients receiving a metabolic screen within the preceding year for patients discharged on an antipsychotic medication. Baseline data revealed poor performance on this Centers for Medicare & Medicaid Services (CMS) measure. Utilizing rapid-cycle improve-ment and progressively transparent reporting methodol-ogy, we implemented an initial best practice alert (BPA) in November 2016. When an antipsychotic medication is ordered, a BPA is triggered and shows what is needed to

complete the order: body mass index, blood pressure, lipid panel, glucose, or hemoglobin A1c. Physicians pro-vided feedback that the antipsychotic medication list needed revision and fasting blood sugars needed to be identified. Review of the data revealed that the initial BPA was frequently ignored or canceled. The second iter-ation BPA incorporated provider feedback and resulted in the BPA being implemented with a hard stop. Knowing this would generate considerable resistance, the team relied heavily on medical leadership to discuss the evi-dence and benefit to change. Data that were initially shared with individual physicians by the medical director became fully transparent with department and peer-to-peer comparisons. It is now fully automated and available in real time to all providers. Using rapid-cycle improve-ment and physician champions/leaders, transparent reporting has become and will continue to be an impor-tant trend in health care quality improvement. BPAs have become commonplace in quality improvement. The criti-cal insight from this intervention was utilizing a risk/ben-efit judgment to determine when a hard stop is warranted. Maximizing physician leadership to educate providers on the evidence for such decision-making and doing rapid cycle improvement on the alert itself resulted in an extremely successful intervention. Intervention Detail. University of Utah Health started pulling data when the metabolic screening measure began on October 1, 2015. The data showed University of Utah Health’s compliance for fiscal year (FY) 2016 was at 16.2%, which was below CMS benchmarks and internal expectations. Once we were able to capture the data in an automated fashion, we became increasingly transparent by sharing the data with providers. We graduated from individual data, to peer and departmental comparison data, to currently having the providers able to see their data in real time. Increasingly timely data, moving from monthly reporting to real-time data, facilitates provider engagement and continual improvement. We display the data through our online data analytics tool, with which we provide heat maps and rankings of compliance by provider. We also provide data on which metabolic screening component was missed and which antipsychotic drug triggered the screening. This allows behaviors to be changed almost immediately if a component of a process is being missed. Having these data available drew attention to the low performance and resulted in a “hockey stick”-shaped trend line, with our compliance rate increasing from 16.2% in FY 2016 to 89.9% as of March FY 2018. Outcomes and Impact. Having identified a clear need for improvement in our metabolic screening rate, provider guidance and feedback shaped our BPA iterative intervention process. Listening to and incorporating physician feedback fostered trust and respect for the process. Physician leadership coupled with information technology reporting capabilities

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facilitated a culture shift among providers to a real engagement in this quality measure and acceptance of transparency.

Improving Patient Safety Through Interprofessional Collaboration

Dara Dilger, MSN, CCRN-K, CNRN, NE-BC, and Krista Morgan, MSN, RN-BCDeaconess Health Systems

Background. At Deaconess Hospital, Inc., a medication security event (MSE) is defined as a medication removed from an automated dispensing cabinet (ADC) that is not documented, returned, or wasted. An MSE creates poten-tial issues that impact patient safety (potential of double dosing), nurse dissatisfaction and turnover (disciplinary action), revenue and expense (loss of charge for medica-tion and potential $10 000 Drug Enforcement Administration fine), and loss of productivity (follow-up on missing medication). Organizational values are strongly based on a commitment of continual quality in patient care and a culture of safety. Therefore, 2 manag-ers and a pharmacist chose this project as part of a Lean Six Sigma Green Belt Training Program. The purpose of this Lean Six Sigma project was to improve patient safety, nurse satisfaction and turnover, loss of potential revenue and productivity, and avoidance of substantial fines. The project focused on Class II through Class V medications. In order to substantiate the problem, data were collected over a 23-day period resulting in an aver-age of 25 MSEs per day in the organization. Intervention Detail. The methodology used to reduce MSEs was Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control):

•• Define—The team listened to the “voice of the customer” and created a process map of how the nurse removes medications from the automatic dispensing system, dispenses them, and docu-ments administration of the medication.

•• Measure—Baseline data, collected for a 3-month period, revealed 316 MSEs. This resulted in a pre-implementation Sigma score of 4.3.

•• Analyze—A tool was created for unit managers to audit MSE data over 1 month in order to further define the X or key factors (root causes). During this time frame, there were 55 MSEs. Analysis of the events revealed significance in 2 areas: as-needed (PRN) medications (96%) and the process of medication administration and documentation (69% of staff thought the process was completed).

The analysis identified that unlike the scheduled medications, PRN medications did not have a due time on the medication administration record (MAR); therefore, a link was missing between the ADC and electronic health record (EHR) for PRN medications.

•• Improve—An interprofessional team (information systems staff, nurses, risk management and safety, and managers) collaborated and benchmarked on developing a link between the ADC and EHR. Thereafter, a link was made accessible so that upon removal of a PRN medication, a due time populated on the MAR. If the medication was not administered, the MAR indicated an overdue med-ication to remind the registered nurse that the doc-umentation process was not completed. This change was piloted on 2 nursing units for 1 month, which resulted in only 1 MSE. After house-wide education on the new process, it was implemented on all inpatient units.

•• Control—As part of the control plan, pharmacy is monitoring MSEs on all inpatient units. Safety and risk management staff are monitoring for possible changes in diversion.

Outcomes and Impact. After the 3-month house-wide implementation, pre and post MSE data were collected and analyzed. The postimplementation Sigma score improved to 4.8. Comparison of the preimplementation MSEs (n = 316 out of 115 552 total events) to postimple-mentation MSEs (n = 78 out of 161 592 total events) showed a statistically significant reduction by 81.5% (P < .001). Because of the significant impact on staff per-formance in medication management and reduction in MSEs, a specialty hospital within the health system implemented the new process as well. Interprofessional teamwork and collaboration are key to successfully creat-ing innovative solutions to medication process issues. The change in technology (creating a link between the ADC and the EHR) made an enormous impact on reduc-ing MSEs and has maintained patient safety (ie, adminis-tration and documentation of PRN medications). The process improved patient safety, nurse satisfaction, and workflow while improving revenue and meeting regula-tory requirements. Interprofessional teamwork and col-laboration are key to successfully creating innovative solutions to process issues using the expertise of each member. Listening to frontline staff (end users) about the workflow in the beginning of process change is impera-tive. Including the end user in development and resolu-tion of the improvement process using Lean Six Sigma methodology is key to understanding the “why” and driv-ing change in the organization.

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Change the Conversation: Let’s Talk About “Redesign”

Rahil A. Tai, MD, MBA, and Miriam M. Morales, PhDMemorial Hermann Health System

Background. Identifying the national shift from volume- to value-based care, clinical care redesign focuses on 4 core objectives: (1) reduce unnecessary clinical variation by redesigning care delivery and implementing best practices; (2) reduce length of stay (LOS) by developing proactive care plans, ensuring discharge readiness and identifying post-acute placement; (3) increase the accu-racy of clinical documentation so it reflects the true severity of illness; and (4) better manage care coordina-tion through earlier involvement of case management in patient placement and discharge planning. Vizient data were very useful at the academic hospital within the Memorial Hermann System at the Texas Medical Center. It allowed neurosciences to focus on efficiency of care by regularly evaluating care practices and observed LOS, with an emphasis on capacity and bed turnover because 40% of admissions are transfers from other hos-pitals. Administrative and clinical leadership have been highly invested in data-driven performance improve-ment initiatives for more than 10 years; however, more recently there has been direct physician involvement. The Vizient benchmark methodology of observed to expected (O/E) ratio and utilization of risk models has been vital to physician buy-in—eliminating concerns surrounding different types of cases and complexity, and accounting for patient demographics, conditions present on admission, comorbidities, and surgical interven-tions—which provides more clinically appropriate benchmarks and peer comparison than geometric mean length of stay. The neuroscience service line has extended complex care to 3 major system hospitals—Memorial Hermann Southwest Hospital, Memorial Hermann Memorial City Medical Center, and Memorial Hermann Woodlands Medical Center—with the establishment of acute stroke and neuro-critical care services and imple-mentation of a transfer program between these hospitals and the Texas Medical Center. Continued analysis of data is important in maintaining quality of care standards throughout the system, while empowering physicians to understand and utilize data to lead performance improve-ment initiatives. Intervention Detail. We analyzed O/E LOS and direct cost per case for neuroscience service lines at our comprehensive academic hospital at the Texas Medical Center. Vizient data have been critical in identifying areas of opportunity and achieving meaning-ful improvements in patient outcomes for neurosurgery and neurology service lines. Physician education and

understanding surrounding Vizient risk models and methodology were essential in gaining their active par-ticipation in process improvement initiatives. The Vizient Clinical Data Base was used to generate patient outcomes reports, while direct cost and other utilization data were obtained from internal financial and clinical databases. Targeted clinical review of service-specific cases, coupled with Vizient case profiles, helped us iden-tify specific gaps in clinical documentation and coding and to accurately capture severity of illness. Review of outlier LOS cases and a deep dive into operational pro-cesses with case management brought to light inefficien-cies in patient disposition, particularly in discharges to rehab and skilled nursing facilities. Furthermore, in part-nership with physician groups, resource utilization anal-ysis revealed unnecessary use of postoperative computed tomography (CT) scans and consults to physical therapy in the elective neurosurgical population, and high vari-ability in use of laboratory services in the stroke popula-tion. These data were systematically shared with administrative, physician, nursing, and ancillary service leaderships in various forums to formulate a multidisci-plinary plan of action. Similar efforts are underway at Memorial Hermann Health System hospitals with estab-lishment of physician partnership, implementation of clinical case reviews utilizing Vizient case profiles, a direct cost of care analysis with a focus on clinical and operational process standardization, and a resource utili-zation analysis concentrating on specific care compo-nents. Outcomes and Impact. We have created a data-enriched environment by regularly reporting unblinded physician-level performance data, which are easily accessible to them through Tableau dashboards. This was achieved by extensive data integration, a cen-tralized data repository, and development of meaningful dashboards to help physicians and operational leaders track performance. Furthermore, we have enhanced our physician documentation system by providing physi-cians with a quick pick list highlighting acute factors associated with selected diagnoses, which has signifi-cantly impacted capture of severity of illness. During fis-cal year (FY) 2018, these documentation enhancements were implemented at Memorial Hermann Southwest Hospital with planned expansion to other system hospi-tals. Additionally, implementation of multidisciplinary rounds involving physicians, nurses, and case manage-ment has helped streamline the discharge process by pro-actively identifying disposition early in the hospitalization and minimizing delays and denials. Overall, the neuro-science service line entertained a 26% reduction in LOS index, a change from 1.0 in FY 2016 to 0.74 through FY 2018 year to date, because of a decrease in average observed LOS from 6.4 days to 5.5 days and an increase in average expected LOS from 6.4 days to 7.6 days per

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case. Postoperative CT scans utilization decreased by 44% with the establishment of standard practice guide-lines. Neurosciences has utilized Vizient data to drive improvement for many years at Memorial Hermann-Texas Medical Center. The vision of system-wide quality of care has extended Vizient data analytics across other hospitals during FY 2018. Vizient’s update on peer groupings into academic, complex, and community is a testament to its resolve in providing the most accurate benchmarking capability. We believe Vizient provides true peer-to-peer comparisons, allowing hospitals to appreciate and implement data analytics in executing care redesign.

GET OUT: Physical and Occupational Therapy Helps Patients Escape the ICU

Devin R. Roloff, MBA, Patrick J. Cornelius, PT, DPT, CCS, Kristin R. Hall, MS, OT, MBA, Caitlin A. Polley, PT, DPT, Tanya A. Terman, PT, DSc, and Emily A. Bodensteiner Schmitt, OTMayo Clinic

Background. Early mobilization of patients in the inten-sive care unit (ICU) has been shown to have positive out-comes, including a decrease in length of stay (LOS) and ventilator days. At Mayo Clinic in Rochester, Minnesota, there was an absence of an embedded therapy team within the ICUs. The absence of the embedded therapy team was thought to negatively impact patients’ access to therapy care, leading to higher LOS in the ICU and hospital. A few of the factors contributing to this gap in care were the following: (1) the physical and occupational therapy staffing model did not support prioritization of patients in the mixed medical ICU; (2) lack of therapy coverage on the weekends; and (3) gaps in staff knowledge regarding when therapy services were needed. The aim of this proj-ect was to implement an embedded and comprehensive early mobilization and activity program in a mixed medi-cal ICU, with the goal of delivering the right therapy to the right patient at the right time, leading to an overall reduction in ICU LOS by 1 day, within 6 months, for patients receiving therapy. This program’s focus is directly aligned with Mayo Clinic’s primary value: The needs of the patient come first. The project was approached as a partnership between physical medicine & rehabilitation (PM&R) and critical care, with oversight and guidance provided by key stakeholders from both areas. A multidisciplinary team was formed that included PM&R leaders, physical and occupational therapists, a physical medical tech, and a health systems engineer. Intervention Detail. The Define, Measure, Analyze,

Improve, and Control framework was followed and a variety of quality improvement tools and methods were used to identify gaps and develop solutions to improve therapy care in the mixed medical ICU. A comprehensive literature review was performed to get a better under-standing of the measures and outcomes expected from implementing an early mobilization and activity program in the ICU. The team also benchmarked with Mayo Clinic in Florida and Johns Hopkins, because both have estab-lished early mobility programs. The literature reviews and benchmarking helped set realistic expectations for project outcomes. Based on the literature reviews and benchmarking, a data collection plan was created. Key quantitative metrics were extracted from the electronic health record and included the following:

•• ICU, hospital, and floor LOS•• Discharge location•• Number of missed therapy visits•• Highest level of activity at first therapy visit•• Days on ventilation (invasive and noninvasive)•• Percentage of days with documented delirium•• Total treatment times by physical and occupational

therapists•• Percentage of patients receiving therapy in the ICU

A staff satisfaction survey was created using REDCap, a secure survey tool. Baseline data were calculated for each data point and target measures were put into place. Microsoft Excel was used for all calculations and analy-sis. Tableau, a data visualization software, was used to visualize staff satisfaction results. Through the literature review, a financial model for implementing an ICU Early Physical Rehabilitation Program, published by Johns Hopkins, was found. Direct costs per day in the ICU and on the floor were obtained by a Mayo Clinic financial analyst. This model was used to project cost savings from LOS reductions in the ICU. All project metrics were mea-sured both pre and post implementation. Outcomes and Impact. Four key interventions were put into place:

•• An embedded therapy model on the 21-bed mixed medical, surgical, and transplant ICU. The embed-ded model includes 3 physical therapists, 2 occupa-tional therapists, and 1 rehabilitation technician.

•• A 7-day-per-week coverage model.•• A process for therapists to attend the charge nurse

handoff meeting at 7 am each day to screen every patient for the appropriateness of therapy.

•• A comprehensive training and orientation process for embedded therapy staff.

Upon completion of the 6-month project, data were collected and compared to baseline in the mixed medical,

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surgical, and transplant ICU. The data compared patients who received therapy prior to the embedded therapy model versus after implementation of the embedded ther-apy model. The following outcomes were observed:

•• ICU LOS (days) decreased by 23%•• Invasive ventilator days decreased by 29%•• ICU patients who received therapy increased from

18% to 36%•• Physical therapy minutes per patient in the ICU

increased by 45%•• Occupational therapy minutes per patient in the

ICU increased by 140%•• Percentage of ICU therapy patients who were dis-

charged home increased from 32% to 51%•• Projected 7-figure annual cost savings from reduc-

tion in ICU LOS•• Staff satisfaction with therapy services improved

Because of the results of the project, the embedded therapy model became the new standard of care at Mayo Clinic. An additional 9 therapy staff members were approved for diffusion to the medical ICU. In addition, the project team received several awards, including the Mayo Clinic Excellence Through Teamwork Award, and Mayo Clinic Gold Quality Project certification.

Potential-Based Staffing Model: Transforming the Hiring Practices of the Ambulatory Staff Float Pool

Karen H. Tally, BA, and Panissa B. Caldwell, RN, BSN, MHANovant Health Medical Group

Background. Novant Health Medical Group embraced a different outlook on hiring practices for float pool staff-ing than what is typically used in today’s health care mar-ket. While developing strategies to meet market staffing needs, we realized that the fundamental approaches used for hiring, training, and retention would need to be altered to accommodate the uniqueness of the staffing float pools. We fundamentally reformed the hiring framework to focus on potential-based hiring, rather than traditional experiential hiring methods. Our success is based on an innovative hiring framework that has spanned the bound-aries on what staffing can look like in our current health care market. Intervention Detail:

1. Surveyed clinics•• Asked for ideas

2. Surveyed team members•• Ideas for creating stability

•• Job opportunities3. Held meetings with internal departments to dis-

cuss hiring inexperienced nurses•• Met with resistance from most departments•• Lack of experience could lead to patient

incidents•• Additional cost associated with training•• Training allotted for 2 to 3 weeks

4. Began new hiring and staffing practices in 2015 in the Winston-Salem market in North Carolina•• The initial staffing size was 20 staff members,

including licensed nurses, a phlebotomist, and 2 types of clerical staff. Since implementation of the potential-based staffing model and the expansion of community college partnerships, the staffing pool has expanded to 65 staff members.

•• In 2015, four positions were offered: licensed practical nurse (LPN), registered nurse (RN), phlebotomist, and patient services coordinator (PSC) III

•• In 2017, eight positions were offered: LPN, RN, phlebotomist, PSC III, referral coordina-tor, radiation technician, sonographer, and interim clinic services manager(Similar outcomes are taking place in the Charlotte and coastal markets of North Carolina and the Northern Virginia market.)

5. Created committee to assist with Interim Clinic Services Manager (CSM) project•• Resistance from several higher level

departments•• Barriers encountered while trying to fill the

position with an experienced clinic administrator

•• 49 sample cases where clinic administrative gaps occurred (Clinic Administrator func-tional role per clinic sizes and open positions):○ Clinic administrator I: 31 (63%) mini-

mum to moderate level of complexity○ Clinic administrator II:17 (35%) moder-

ate to high level of complexity○ Clinic administrator III: 1 (2%) high level

of complexity6. Strengthened internal department relationships

•• Started clinic site visits•• Clinic group meetings for each market•• Formed Float Pool Council to assist with

ideas7. Developed partnerships with community

colleges•• In 2015, we began reaching out to community

colleges to develop partnerships to assist with

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upcoming nursing graduates looking for job opportunities

•• In 2015, we began with 1 community college partnership

•• In 2018, we have 11 colleges partnerships and 1 high school partnership

•• Join college boards•• Conduct mock interviews•• Attend job fairs

Outcomes and Impact. We observed that changes occur in stages: zero to 6 months—planning stage; 7 to 12 months—implementation begins; 13 to 18 months—measureable outcomes.

•• Clinic surveys○ Increased staffing positions: supervisor, sched-

ulers, radiology technician, referral coordina-tor, sonographer, interim CSM

○ Increased clinical staffing•• Team surveys

○ Formed committees for input on changes○ Benefited positions created for stability○ Advancement opportunities

•• Inexperienced nurses○ Monitored alongside clinic services:

■ One experienced transfer nurse within our organization□ Set training for 2 to 3 weeks□ Successful outcome

■ One experienced nurse new to our organization□ Training increased to 2 to 4 weeks□ Increased training to 6 to 8 weeks

■ One new nurse with no experience□ Training increased to 4 weeks□ One failure□ Training then increased to 6 to 8 weeks□ Two years: 100% complete success

•• New hiring outcome○ Increased staffing by 325%○ Increased position offers by 100%

•• Interim CSMs○ Planning began October 2016○ Majority of gaps in smaller clinics○ Clinic gaps averaged 4 to 8 weeks○ Job class changed to hire 1 interim CSM II

who would mentor and manage interim CSM○ Training developed for 12 to16 weeks, depend-

ing on experience■ Scenario 1: CSM I

□ Novant Health supervisor or manager without clinical operations experience

□ May need more financial/operational guidance

□ Some leadership development□ Outside leader with management

experience but no health care experience

□ Leadership/Novant Health culture development

□ Health care–specific operational guidance

■ Scenario 2: CSM II□ Mentor/partner for CSM I positions□ Tackle more challenging clinics

○ Department implemented in 12 months○ Staffed 4 clinics within first 2 months

•• Strengthened internal relationships○ Developed trust and cohesive relationships○ Mind-set changed to include us as a

department•• Colleges

○ Colleges reaching out for dates for mock interviews

○ Colleges request assistance with resumes○ Offer graduates the opportunity to work with

us and let us invest in their future

Power Huddle Abstracts: Vizient Solutions

Can Color-Coded and Treaded Socks Help Prevent Patient Falls?

Carolyn J. Sun, PhD, RN, ANP-BC, Yue (Sally) Yin, and Ray Liu, MS, MBAColumbia University School of Nursing/NewYork-Presbyterian; and Vizient (Liu, Yin) [Vizient Solution: Ediom]

Background. Despite increasing health care costs in the United States, critical health outcomes rank lower than in other high-resource countries and many Americans lack high-quality care and suffer poor outcomes. In an effort to improve health care quality and concomitantly reduce costs, Congress identified serious and expensive but pre-ventable hospital-acquired conditions. Some health care associated conditions, such as patient falls, would no lon-ger be reimbursed by the Centers for Medicare & Medicaid Services. There are nearly 1 million patient falls in hospitals each year. On average, each additional fall costs a hospital $17 483. Hospital fall prevention interventions are diverse and multidisciplinary, ranging from staff and patient education, to visual risk indicators, to different types of alarms and alerts. One method, color-coded socks, utilizes uniquely colored socks (eg, yellow,

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red) to provide a visual cue to alert patients and staff when a patient has scored as a fall risk on a standardized fall risk assessment (such as the Morse Fall Scale). Double-treaded socks are another prevention measure wherein the socks are treaded both on the bottom and the top to provide additional traction. Therefore, we evalu-ated 2 such interventions—color-coded and treaded socks—through a systematic and objective literature review using a machine-assisted tool called EvidenceEngine to determine their potential impact on fall prevention. Intervention Detail. Methodology: Ediom’s EvidenceEngine is a proprietary software that uses a systematic and replicable methodology developed together with supply chain and value analysis profession-als to evaluate evidence. Eligibility and Search Strategy: Digitally accessible full-text articles and abstracts pub-lished between 2009 and 2018 were collected and sys-tematized using EvidenceEngine, a new machine-assisted instrument intended to aid health systems in the clinical value analysis process by providing comprehensive and objective analyses of the latest relevant information. Using pertinent keywords, formal searches of MEDLINE, PubMed, Cochrane, Embase, and Google Scholar were performed for meta-analyses, systematic reviews, ran-domized controlled trials, prospective cohort studies, lit-erature reviews, case reports, and other study types. Data Analyses: A total of 15 articles were analyzed. Each study was assigned an evidence quality score—a calculation of a study’s level of merit as determined by study design, population size, publication date, peer-review status, and potential for conflicts of interest—and a direction score (a measure of its directional sentiment as it relates to the claims under consideration). The evidence quality score is used as a weighting factor to compute overall results for each claim investigated. The resulting direction scores and evidence quality scores are plotted relative to one another for a visual representation of the total evidence for any given topic of evaluation. Outcomes and Impact. Overall, evidence for both color-coded socks and double-treaded socks is limited. The literature suggests that color-coded or double-treaded socks are unlikely to be sufficient as solitary measures in fall prevention. Color-coded socks: Only 3 studies of low quality were identi-fied on the effectiveness of color-coded socks alone. The evidence showed medium support that color-coded socks may help prevent patient falls. Color-coded socks were found to be an easy visual cue to alert staff of high-risk patients and promoted higher awareness of fall risk when combined with an interdisciplinary program. Four addi-tional studies of low to medium quality were identified that offered strong support that a multidisciplinary pro-gram that includes color-coded socks may help prevent patient falls. Double-treaded socks: Only 3 studies of low-to-medium quality were identified on the

effectiveness of double-treaded socks alone. The limited literature reported discordant results, with 2 supporting and 1 opposing double-treaded socks for fall prevention. Two additional studies investigating double-treaded socks as part of a multidisciplinary program that includes nonslip socks to prevent patient falls also showed mixed results with 2 supporting and 1 opposing the effective-ness. Additional research could clarify these results. Additionally, a cost-benefit analysis may provide addi-tional rationale for implementation of such measures.

Clinical-Supply Integration: From Buzzword to Practice

Simrit SandhuCleveland Clinic [Vizient Solution: Excelerate]

Background. In 2017, the median operating cash flow mar-gin for hospitals nationally was down by 11.4%, reaching its lowest level in the last 10 years. According to Moody’s Investors Service, roughly 50% of all hospitals had operat-ing cash flow margins below 8% in 2017. Modern Healthcare recently reported that US hospitals have a col-lective opportunity of $25.4 billion in cost reductions through increasing supply chain effectiveness, including engaging physicians in the sourcing process. There contin-ues to be an opportunity to address the drivers of operating expense, which increased 4.5% from 2016 to 2017 through clinical-supply integration by: engaging physicians in activities to continually evaluate operating expense reduc-tion initiatives and facilitate change; evaluating opportuni-ties for service line performance improvement on a routine basis; understanding the near- and long-term impact of supplier consolidation and supply cost reduction potential leveraging clinical and supply data. This project focused on practical lessons of clinical-supply integration in action from a supply chain leader and physician perspective. Participants learned how the Cleveland Clinic has effec-tively engaged physicians with supply and clinical data, integrated their process into newly acquired facilities, and debunked many clinical-supply integration myths along the way.1,2 Intervention Detail. Cleveland Clinic has been on a multiyear journey to ensure that supply contracting supports clinical needs. As part of its “Patients First” focus, the Clinic has a strong focus on reducing clinical variation, including supply selection and usage. Utilizing clinical evidence and physician experience is vital to ensuring that supply chain strategies support optimal patient care. With actionable, complete data, physicians can evaluate varia-tion opportunities, inform sourcing strategies, develop uti-lization guidelines, and help reduce costs. The Cleveland Clinic has found that 5 steps are critical to success in estab-lishing a foundation for clinical supply integration and variation reduction activities.

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1. Ensure physicians are meeting. Ideally, an organi-zation’s physicians already have regular meetings to discuss clinical quality improvement. Introducing supply initiatives into existing forums and practices dramatically increases the likeli-hood of success.

2. Leverage clinical data. Physicians are reviewing clinical data on a regular basis and understand and accept the data. Supply data must be clinically rel-evant and readily available to engage in action-able dialogue.

3. Focus on quality improvement. Physicians are using clinical data to implement best practices and improve quality. Supply can be an extension of these existing processes.

4. Engage in cost discussions. Physicians are look-ing at costs and variation for ways to improve value for their patients.

5. Bring it all together. Physicians have created and follow clinical and supply guidelines in all areas. Physicians are actively engaged in supply chain, ideally through the creation of supply chain medi-cal directors who inform sourcing strategies, develop supply utilization guidelines, and engage in peer-to-peer discussions with other practicing physicians on initiative implementation.

Leveraging an organization’s existing practices and experiences of physician engagement enhances the like-lihood of success when introducing supply-focused activities. Outcomes and Impact. Cleveland Clinic con-tinues to strengthen partnerships with physicians and supply chain to reduce costs, drive efficiencies, and tighten physician supply variation to drive short- and long-term financial sustainability. Quantifiable results include reducing supply chain costs by more than $400 million in the past 10 years; developing and implement-ing more than 45 supply utilization guidelines focused on reducing clinical variation; and establishing Excelerate Strategic Health Sourcing, a provider-led supply chain solution that currently supports more than 60 hospitals and has produced more than $100 million in savings over the past 3 years. Cleveland Clinic has successfully integrated practicing physicians into sup-ply chain activities. Starting with a single supply chain medical director, the program has expanded to engage 4 practicing physicians with specialties in spinal surgery, cardiothoracic anesthesiology, adult reconstructive orthopedics, and general surgery. These physicians actively guide supply chain staff and engage physicians broadly across the clinic and within Excelerate to ensure the success of highly complex supply initiatives impact-ing high-cost physician preference items.

1. iProtean. Moody’s: Preliminary medians show declining hospital profitability. https://www.ipro-tean.com/blog/moodys-preliminary-medians-show-declining-hospital-profitability/. Published May 29, 2018. Accessed 2018.

2. Kacik A. Hospitals have an unrealized $25.4 bil-lion supply chain opportunity. https://www.modern healthcare.com/article/20181018/TRANSFOR MATION02/18101989. Published October 18, 2018. Accessed October 2018.

Poster Presentation Abstracts

Strategic Targeting of the Patient Journey: The Ideal Patient Experience

Mark R. Athey, MS, MHAUniversity of Kentucky HealthCare

Background. University of Kentucky HealthCare (UKHC) has seen dramatic growth in a little more than a decade. We have grown from a 486-bed hospital to one with 945 beds, and our ambulatory activity has grown more than 2-fold to greater than 1.5 million encounters per year. This dramatic growth has led to many initia-tives to discover how to help and better understand our patients. The Patient Journey Mapping project had sev-eral objectives: (1) discover which pathways patients use to move through our system; (2) the key moments that affect their journey; (3) the resources and tools they use or need; (4) where we were not meeting their expec-tations; (5) the gaps in communication; and (6) what the ideal patient experience might look like. This project had initial support from our executive leadership and was written into our 5-year strategic plan as a way to increase patient-centered care. We had several unique characteristics that have helped make this project so successful. We interviewed a wide array of staff and patients, allowing us to find direct correlations between what staff and patients were saying. Additionally, we used videos and quotes from the patient interviews to illustrate the importance of the changes resulting from this project. Once the overall data were compiled, ser-vice line leadership was tasked with driving change and creating work groups to find solutions to identified problems. Intervention Detail. This project is unique because we chose to map whole service lines instead of a single patient. This allowed us to generalize about our entire population and compare patients in different ser-vice lines. We collaborated with Sg2 and Fusion Hill on this project. Staff interviewed represented a broad spec-trum of disciplines, from frontline staff to physicians,

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with feedback kept anonymous. Identified patients had multiple inpatient and outpatient appointments within the service line in the past 9 months. After creating the list, we generated a screener in order to diversify the population within the service lines. For patient inter-views, we used a mixture of focus groups and individual interviews. These were all recorded and took place behind 2-way glass so physicians and leaders could watch and ask additional questions if needed. Participants did a variety of activities beforehand to help generate ideas about their journey through our sys-tem and provide meaningful images and quotes. Once the interviews were complete, themes started to emerge. By segmenting the identified populations, we were able to make targeted interventions for specific patient popu-lations in order to reduce resource use. Once multiple service lines were mapped, we could create enterprise-wide initiatives that patients and staff identified as pain points at UKHC. Outcomes and Impact. There have been many different initiatives from this project. Physicians in the service lines have changed how they round as teams, increasing patient satisfaction as well as including families more in the process. As an enterprise, we have been focusing on provider and staff communi-cation, making all staff undergo training on communica-tion with patients. Videos and quotes from patients illustrate the importance of these changes. This has increased our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and CAHPS Clinician & Group Survey in certain domains. We have standardized patient notification of test results, which eliminates the ambiguity patients felt about receiving their results from clinic to clinic. They were unsure of what to expect, and each clinic and physician could have a different method. Medical directors sup-port streamlined notification related to patient feedback from this project. We are running trials in certain clinics to call patients a week before their next appointment after the initial cancer diagnosis and discuss their insur-ance benefits with them. We are expecting this to decrease our no-show rate as well as increase our co-pay collection and reimbursement rate. This is a direct result of feedback we received about patients not knowing what to expect for their appointment and the financial stress cancer may bring. Because of the feedback we received from our patients and staff, additional social workers, financial counselors, nurse coordinators, and many other positions were approved. This project also resulted in funding for redesigning some of our current facilities. Discharge materials have been streamlined to decrease patient confusion after leaving the hospital. We also have created groups to support our patients once they leave to help them cope with their lifestyle change as well as prevent readmission.

Stop Delirium: Establishing an Operational Definition of Delirium to Support Performance Improvement and Research

Karen A. Baatz, APRN, ACNS, and Casey C. Riedberger, BSN, RN, CPHQSanford Health

Background. Delirium is referenced as far back as Hippocrates’ time, and a plethora of literature related to delirium exists. Despite an extensive body of knowledge, a universal set of International Classification of Diseases, Tenth Revision (ICD-10) codes to define delirium that could then be subsequently entered into the Vizient Clinical Data Base could not be identified. The conse-quences of delirium, a hospital-acquired syndrome, are comparable to other recognized harm events. Similar to sepsis, mortality rates for delirium are as high as 33%.1 Delirium adds 5 to 10 hospital days,2 while catheter-asso-ciated urinary tract infections increase length of stay (LOS) by 2 to 4 days.3 National costs associated with hospital-acquired delirium (HAD) are estimated between $50 billion and $200 billion/year when taking into account costs both during and after hospitalization.1 The purpose of this project is to establish an operational defi-nition of HAD utilizing pertinent ICD-10 codes in order to electronically abstract data. Our organization’s leader-ship identified delirium prevention and management as a priority. A delirium interdisciplinary team, led by a clini-cal nurse specialist and psychiatrist, was formed. The team understood great quality efforts must be grounded in a strong foundation. A team charter and objectives were developed. Aligning with organizational priorities, outcome measures included incidence, LOS, mortality, and 30-day readmission rates. To measure the team’s suc-cess and ongoing opportunities for performance improve-ment (PI), data would be abstracted through Vizient. Intervention Detail. A documentation specialist described 283 coding pathway descriptions for confusion, delirium, encephalopathy, and psychosis. Through an iterative pro-cess with clinical experts, the list was narrowed to 20 coding pathways consisting of 8 ICD-10 codes. Diagnoses related to obstetric patients, neonates, newborns, and pediatrics were excluded. Substance abuse and psycho-sis-related diagnoses also were excluded based on differ-ences in clinical management. To address HAD, the selected diagnoses could not be present on admission. All hospitalized adult patients would be included, as delirium is known to be prevalent in both medical and surgical populations regardless of an intensive care unit (ICU) stay. The following are the finalized ICD-10 codes: F05 (delirium due to known physiological condition); G93.40 (encephalopathy, unspecified); G93.41 (metabolic encephalopathy); G93.49 (other encephalopathy); G92

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(toxic encephalopathy); E51.2 (Wernicke’s encephalopa-thy); I67.4 (hypertensive encephalopathy); and R41.0 (disorientation, unspecified). National experts were con-tacted for validation. Vizient recommended any diagnosis code of R40.4, R41.0, R44.0, R44.1, R44.2, or R44.3 not present on admission, and must include an ICU stay. A nearby statewide hospital PI network acknowledged sim-ilar challenges to define delirium. This group included patients who were aged 70 years or older, delirium not present on admission, and who had ICD-10 codes of F05, G93.40, G93.41, G93.49, G92, or I67.83. We felt confi-dent in our selected codes. All delirium patient data would be run using the operational definition. However, know-ing delirium is often a secondary diagnosis or comorbid condition, the medical patient comparison group (MPCG) was created. Comprising the diagnoses of heart failure, pneumonia, chronic obstructive pulmonary disease, and acute myocardial infarction, the comparison group would facilitate meaningful analysis of outcomes in patients with and without delirium. Outcomes and Impact. Monthly delirium cases ranged from 27 to 62, or approxi-mately 2.4% of total patients discharged. The highest mean LOS in the all delirium group was 15.69 days (N = 142) versus 22.22 days (N = 27) for patients in the MPCG with delirium and 5.32 days (N = 584) for the MPCG patients without delirium. The all delirium group mortality rate was as high as 19.01% (N = 121). For patients in the MPCG with delirium, mortality ranged from 19.05% (N = 21) to 38.24% (N = 53) versus 6.53% (N = 551) to 7.88% (N = 584) for the MPCG without delirium. Patients with delirium consistently had a mor-tality index above 1. The MPCG with delirium had higher LOS and mortality rates than the all delirium group. With the exception of 2 quarters, 30-day readmission rates were consistently higher in patients in the MPCG with delirium than the MPCG without delirium. LOS, mortal-ity, and 30-day readmission rates are similar to findings reported in the literature, suggesting congruency of this methodology. The approach requires a documented diag-nosis, as delirium frequently goes undocumented. Our population size reflects this reality. As PI efforts increase awareness, identification and documentation can be expected to increase. Despite limitations, data show a negative association between the identified outcomes and HAD, adding up to 16 hospital days, elevating the risk of death, and increasing readmission likelihood. Delirium has significant consequences for the patient and family as well as the organization. A robust and expert process for data abstraction is imperative. This innovative approach provides the necessary standardization to drive improve-ment. A surgical comparison group is forthcoming. Sharing this work is essential to begin a national conver-sation regarding how HAD is defined and the subsequent clinical standardization and ongoing establishment of best practices that will follow.

1. Inouye SK. Delirium or acute mental status change in the older patient. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 25th ed. Philadelphia, PA: Elsevier Saunders; 2016.

2. Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin. 2008;24:657-722.

3. Gould C. Catheter-associated urinary tract infec-tion (CAUTI) toolkit. www.cdc.gov/HAI/pdfs/toolkits/CAUTItoolkit_3_10.pdf. Accessed January 31, 2019.

Breaking Down Silos to Solve Complex Problems

Micah W. Beachy, DO, FACP, Tammy M. Winterboer, PharmD, BCPS, CPHQ, Charlotte L. Brewer, BSN, RN, and Michael A. Ash, MD, FACPNebraska Medicine

Background. Large academic institutions often structure improvement projects solely through a single lens. These projects are initiated within quality, finance, or even a spe-cific service line with little input from other areas. Many times, this leads to incomplete solutions or eventual regression back to preintervention status. Ensuring com-prehensive and sustainable solutions are implemented is becoming increasingly important with complex patients and changing payment structures. To address these silos, Nebraska Medicine developed an innovative Clinical Effectiveness (CE) program with a cross-sectional mem-bership. The program consists of a team including repre-sentatives from quality, informatics, analytics, and finance, as well as epidemiology experts from the College of Public Health (COPH). The inclusion of COPH helped form a unique collaboration between the health care sys-tem and its partnering academic institution. The mission of this team is to reduce variability through the develop-ment and implementation of best practices that realize cost savings and develop programs while improving qual-ity, patient safety, and outcomes. CE analyzes variability of key metrics (eg, total cost, mortality, readmissions) to determine possible projects. Any potential initiative must have opportunity in multiple CE strategic goal areas (ie, quality, safety, cost savings, program development) to be prioritized by enterprise senior leadership who serve as the sponsors. Clinical leaders in the prioritized care areas are engaged to vet initial data, select targeted outcome metric(s), and identify project champions. These leaders also serve as project owners and assist in defining a best practice for the care area. The identified project champi-ons and subject matter experts utilize this best practice definition to brainstorm necessary process changes and

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tools required for success. Once process initiatives are designed and implemented, CE assists with reporting on both process and outcome metrics. CE also ensures qual-ity and financial data are reviewed on a regular basis by project owners, sponsors, and enterprise leadership. Intervention Detail. CE strives to facilitate data-driven project initiatives and relies on several different data sources to inform decision making and track success. For inpatient prioritization, the Vizient Clinical Data Base (CDB) is used to gather key clinical data (eg, mortality, readmissions, length of stay [LOS]), and appropriate benchmarking information. This is paired with Nebraska Medicine’s financial data to identify Medicare Severity Diagnosis-Related groups (MS-DRGs) with the highest variability in multiple domains. For ambulatory prioritiza-tion, value-based payer contracts and the Vizient Quality and Accountability scorecard are utilized to identify data in key ambulatory conditions. In instances where second-ary analysis of prioritized initiatives is needed, COPH and analytics resources utilize data from the electronic health record and the Vizient CDB to further scope. Goals for outcome and process metrics are set by enterprise senior leadership and clinical leaders, incorporating an evalua-tion of variation from benchmarks when available. At the completion of a project, these metrics are used by clinical leaders to monitor performance. If predefined metrics are not met, issues are reprioritized along with other possible initiatives for sequencing of reengagement with CE. Over the past 3 years, CE has worked on several projects, each with unique process and outcome metrics defined prior to implementation. A sepsis initiative focused on implement-ing tools aimed at reducing mortality, while LOS reduc-tions were targeted in projects related to complex intensive care unit (ICU) patients and advanced heart failure man-agement. The telemetry and lab utilization projects aimed at improving appropriate use and adherence with best practice utilization standards. Outcomes and Impact. The CE sepsis team implemented numerous initiatives con-centrated on early identification and early treatment to achieve fewer deaths as measured by the Vizient mortality index. As a result of these efforts, a nearly 50% reduction in mortality index (1.29 vs 0.69) over 2.5 years without regression to preimplementation status was achieved. More concretely, lives were saved as a result of this work. Early postoperative ambulation was the focus of the heart transplant and ventricular assist device CE project. Achievement of earlier ambulation reduced overall LOS by 1 day, decreased time spent in the ICU, and reduced pressure ulcer rates by 69%. The complex ICU initiative addressed LOS by focusing on proper selection of extra-corporeal life support patients and earlier tracheostomy placement, resulting in an average 1-day LOS reduction across DRGs. By focusing on earlier discontinuation, patient days on telemetry decreased modestly by 23%

(4.16 vs 3.2 days). Despite this modest decrease, signifi-cant savings were achieved in nurse time and equipment equaling $1.5 million over a 2.5-year period. Additionally, the project helped mitigate the need for additional teleme-try monitoring technicians despite increasing telemetry-capable beds across the organization. Similarly, appropriate utilization was the aim for the CE GI pathogen panel proj-ect. The inclusion of specific point-of-care clinical deci-sion support within the electronic health record placed restrictions on ordering, thereby leading to a savings of approximately $243 000 over 1 year. The unique cross-sectional membership has allowed the program to priori-tize and execute achievement on several CE strategic goals areas for Nebraska Medicine. This includes more than $6 million in savings over approximately 3 years through LOS reductions and appropriate utilization of resources while improving quality outcomes and saving lives. Other health care organizations would benefit from considering a similar program to help them compete in the changing market.

Improving Sepsis Outcomes in a Community Hospital Without 24-hour Intensivist Coverage

Emily K. Bradshaw, BSN, RN, CCRN, and Amy Stanfill, BSN, RN, CCRN-KWellstar Health Systems

Background. Sepsis is the leading cause of death for patients admitted to the hospital, with a 25% mortality rate at diagnosis. Treatment of sepsis begins emergently at presentation. In October 2015, the Centers for Medicare & Medicaid Services (CMS) started monitoring compli-ance with measure SEP-1 to track hospitals that follow best practice. It was linked to value-based purchasing in October 2017. The WellStar Health System was at 0% compliance with the measure when it was initially pre-sented in September 2015, which was consistent with the national benchmark. The failure to achieve compliance with sepsis treatment measures was a result of a lack of education regarding new treatment regimens, and a lim-ited number of sepsis patients seen at Paulding Hospital. It was determined that there was poor compliance among physicians using the sepsis order set bundle. Most physi-cians wrote their sepsis orders “a la carte,” which resulted in practice that was susceptible to falling out of compli-ance. Once the sepsis order set was adopted it was discov-ered that the timing for a repeat lactate order defaulted to the next morning rather than being completed within a 6-hour limit of the initial level. This caused another devi-ation from compliance. In assessing procedures it was noted that most of the breakdown in communication between caregivers occurred at shift change and at a

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change in level of care between departments. Intervention Detail. After a thorough assessment of the practice and procedures in place, education was done regarding the current CMS sepsis measures. Without an intensivist in the intensive care unit to drive sepsis protocols, physician education focused on the primary admitting doctors in the hospitalist group. Goals and standards of sepsis care were presented at shift huddles, staff meetings, and mandatory educational events. With the formation of a hospital-wide sepsis team, chaired by educator Emily Bradshaw, cur-rent best practices and missed opportunities were reviewed. In order to mitigate poor handoff communica-tion, an acute care handoff tool was created and imple-mented in January 2017. The tool addressed the problem of drawing a second lactate level on time by clearly emphasizing the time the next lactate level was to be drawn. This component allows for clear handoff between shifts and caregivers in different departments. This tool is now used at a system level within WellStar for patient admissions from the emergency department to the acute care floor. Outcomes and Impact. Knowledge of current best practice in sepsis treatment as well as thorough hand-off communication between providers has led Paulding to exceed the national benchmark, and to sustain these results throughout 2016. Initial compliance was 0% in September 2015; currently, Paulding has a 60% compli-ance rate for January through July 2016. Completing the lactate assessment with a repeat lactate being checked within 2 hours was initially 0% and is now currently at 100%, with an average of 81.2% for 2016.

Innovation in Readmission Reduction: Using Community Volunteers to Decrease CHF Readmission

Teresa Jackson, BA, Debra S. Welsch, BSN, RN, Alma Villanueva, MSN, RN, and Carla C. Braxton, MD, MBA, FACSHouston Methodist West Hospital

Background. The rate of unplanned readmissions is an important indicator of a hospital’s quality of care and effectiveness. Hospitals have developed multiple approaches to help decrease the likelihood of a patient requiring an unintended return. In our complex teaching hospital, we have determined that an important contribu-tor to congestive heart failure (CHF) readmissions is a lack of timely follow-up with the primary physician or the specialty consultant. Lack of follow-up is often pre-ceded by the following challenges: (1) issues with com-munication, patients’ inability to advocate for themselves, and lack of understanding of the importance of the time frame required for outpatient follow-up; (2) patients and caregivers may encounter busy office staff who also lack

knowledge about the timeliness necessary for follow-up of certain medical conditions such as CHF; and (3) patients may be feeling too ill to make appointment calls. We describe an innovative approach to support transi-tions of care using trained community volunteers to assist CHF patients with the often frustrating task of making timely outpatient follow-up appointments. Intervention Detail. Of 210 total volunteers at our hospital, 5 were picked to be assigned to the CHF program. They were trained in aspects of service quality and were given spe-cific scripting for how to assist patients with outpatient follow-up visits. Volunteers utilized a daily specific work list of admitted CHF patients generated through the elec-tronic health record. Charge nurses on each inpatient unit identify individuals with a CHF diagnosis who are expected to be discharged home within 2 days. Using the CHF discharge list, the trained volunteers conduct rounds on the medical-surgical units. A volunteer visited each CHF patient to offer assistance with making follow-up appointments with cardiology and/or primary care. The volunteer made the appointment call from the patient’s room in order to include the patient in the process. The patient/caregiver was physically present to be part of the dialogue with the physician’s office. A critical component of this program is the direct involvement of the patient or family member and the volunteers’ modeling of appropri-ate self-advocacy. Patients were assisted with obtaining follow-up appointments with both hospital affiliated and nonaffiliated cardiologists and primary care physicians. Outcomes and Impact. Data were collected for calendar year 2017. A total of 867 patients were identified as hav-ing CHF by primary or secondary diagnosis. Of the 867 identified by our screening process, 568 patients were deemed appropriate for assistance by a volunteer with making follow-up appointments. Patients were excluded from the program if they were planned for discharge to a long-term acute care hospital, skilled nursing facility, acute rehab or hospice. A total of 33% (186) of the patients who were approached declined to be helped by volunteers. Of patients who accepted assistance, volun-teers were able to successfully schedule 188 appoint-ments. A total of 62% (118) of the patients with appointments scheduled with volunteer assistance actu-ally attended the appointments. Of those who attended the appointments, 3 (2.5%) required readmission within 30 days of discharge home. By comparison, the 2017 all-cause, all-payer 30-day readmission rate for CHF was determined to be 16.3% for our hospital (Vizient data). There were 194 patients who were identified by our screening process for follow-up assistance but were missed because of unexpected or weekend discharge. An important challenge for the program included the 30% “declination rate” for volunteer help. Reasons listed for declining volunteer assistance with scheduling included: the family member will make the appointment, patient’s

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preference to make own appointments, patient wants to speak to physician prior to making appointment, patient already had an appointment, and “no reason given.” Future interventions will include “declination scripting” for volunteers describing the potential impact of not fol-lowing up with the physician within the week following discharge. Early success with our volunteer discharge planning program suggests that CHF patients may benefit from directed, scripted assistance with obtaining critical outpatient follow-up appointments.

“A Sure Thing”: Connecting Heart Failure Patients Through the Inpatient Heart Failure Navigator to the Outpatient Care Coordinator

Mitchell T. Saltzberg, MD, Laura Weiloch, RN, Mary Conti, RN, Jamie Fleischman, RN, Jennifer Rentmaster, RN, Joanna Zillner, RN, Asim Mohammed, MD, and Jonathan Truwit, MDMedical College of Wisconsin

Background. Heart failure (HF) readmissions remain a critical quality issue for health care systems to address. Multiple strategies have been employed with variable suc-cess. The critical importance of successful transitions of care from the inpatient (IP) to outpatient (OP) care envi-ronment has been established as a factor to reduce readmis-sions. Furthermore, there is interest in the use of HF navigators (HFNs) as well to promote HF education and streamline the care transition process. Intervention Detail. We sought to establish a continuity of care axis for HF patients by utilizing an IP HFN to not only educate hospi-talized HF patients but also coordinate post-discharge care by “handing off” patients to a HF care coordinator nurse in the outpatient setting. Key aspects of this process included establishment of early follow-up with a “famil-iar” provider and ongoing telephone contact by the care coordinator nurse. These roles were established specifi-cally to improve care transitions and reduce readmission rates. Accountability for these positions is split between IP and OP nursing leadership. We had the unique opportunity to assess the incremental role of the navigator and care coordinator, both in isolation and when combined to test the independent effect of each of these roles. In our hospi-tal system, HF patients can be admitted to multiple IP units with equal probability while the navigator initially focused efforts on a limited number of units. Therefore, we could test similar populations, some of whom had isolated navi-gator services or had the benefit of access to both a naviga-tor and care coordinator nurse. Thirty-day readmission rates were measured for patients admitted to Froedtert Hospital between October 17, 2016, and December 31, 2017. Patients with a primary discharge diagnosis of HF

were analyzed. HF navigator services were provided on the dedicated HF unit (3NW) as part of a pilot program and were not available on other IP units during this period. Furthermore, patients with a prior history of left ventricu-lar assist device implant or cardiac transplant were excluded from the analysis as they are not comparable to the general HF population. Concurrent readmission data were then stratified and reported based on admitting unit and involvement of the HF navigator with or without sub-sequent referral to care coordination. Outcomes and Impact. Of 757 patients with a primary diagnosis of HF discharged to a unit other than 3NW during this period, there were 160 patients readmitted within 30 days (21.1%). A total of 254 patients were admitted specifically to 3NW; these patients typically are more complicated, advanced HF patients. In the cohort who had the involvement of an HFN but did not receive a referral for care coordination, there were 75 patients readmitted within 30 days (29.5%). However, when HF patients benefited from the services of an HFN and received a referral for care coordination upon discharge, 30-day all-cause readmission rates were drasti-cally reduced. There was a total of 169 patients admitted to 3NW who received care from an HFN and who were referred to care coordination; in this cohort there were 9 patients readmitted with a 30-day all-cause readmission rate of only 5.33%. This pilot program and the drastic reduction in readmission rates have prompted efforts to expand the HFN program. Our work has extended and improved upon the published literature regarding the impact of HF nurse navigator care to reduce the risk of readmissions. Our 5.33% 30-day all-cause readmission rate is significantly better than rates achieved by other pro-grams and reflects the critical role of combining HFN care with care coordination in the OP setting. Unlike previously published work, which included a heavy focus on remote monitoring to reduce the risk of readmissions, our care coordination model is based on protocolized follow-up schedules based on risk stratification for readmissions fol-lowing an index HF hospitalization. Insights gained from this work have led to the systematic referral of all HF patients to care coordination.

Using EPIC Real-Time Dashboards to Improve Heart Failure Outcomes and Care Transitions

Mary M. Conti, BSN, RN, Laura Wieloch, MS, RN, Diane Herbstreit, BSN, RN, Megan Fedders, MBA, Asim Mohammed, MD, Mitchell Saltzberg, MD, and Svetlana Zaharova, APNPFroedtert Hospital

Background. Froedtert and the Medical College of Wisconsin cares for nearly 2000 heart failure (HF) patients

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across our system, with growth each year. With this increase we also are seeing a more complex patient popu-lation. To better manage these patients we identified the need to benchmark evidence-based care and implement strategies across the continuum of care to improve out-comes. We developed 3 EPIC dashboards to facilitate this work and we participate in the American Heart Association’s “Get With the Guidelines” (GWTG) data-base. GWTG helps us to track and improve HF gaps in care to improve the overall population health. We also had an opportunity to reduce the readmission rate for this pop-ulation. One EPIC real-time dashboard is used by the reg-istered nurse (RN) HF navigator to identify inpatients with a likely principle diagnosis of HF. We used our EPIC HF registry and we developed a loop diuretic order hard stop, asking the provider if the loop diuretic is being ordered for HF to better identify patients in real time. Prior to discharge, the navigator uses this information to ensure timely interventions on evidence-based practices. The second dashboard is utilized by the RN HF navigator to place a care coordinator referral and to track the 7-day follow-up appointment. This dashboard ensures patients who are discharged after hours or over the weekend are not missed. The third dashboard is used by the RN care coordinator. This dashboard includes important informa-tion such as the discharge date, last and next contact with care coordination, primary care provider (PCP), last PCP visit, ejection fraction, and statin use. These 3 dashboards facilitate our use of evidence-based best practice and pro-vide a safety net for our patients. These dashboards have allowed our organization to use our electronic health record in a meaningful way to improve patient outcomes. Intervention Detail. Our GWTG best practices have shown improvement in the following achievement mea-sures: angiotensin-converting enzyme inhibitors/angio-tensin II receptor blockers prescribed at discharge has seen a 28.9% increase, while evidence-based beta-blocker prescribed at discharge has an improvement of 13.7%. Left ventricular ejection fraction has sustained 100% and the follow-up appointment at discharge has remained the same. We have also seen improvement in the following quality measures: influenza vaccination rate has improved 92.3%, pneumococcal vaccination rate has improved 14.5%, anticoagulation for fib/flutter has improved 5.9%, and deep vein thrombosis prophylaxis is nearly 100%.These results have led to Gold Plus Quality Award status. For a small subset of patients on our high-risk inpatient unit we have been piloting a post-discharge care coordina-tor program in collaboration with the inpatient navigator program. This program excludes ventricular assist device and transplant patients. For patients who have received the full intervention of inpatient navigation plus outpa-tient care coordination, the 30-day all-cause readmission rate is 5.33% (9/169). The unit overall has demonstrated a

decrease in the 30-day all-cause readmission rate from 20.04% to 15.53%, a drop of 4.5%. Hospital-wide, our overall HF readmission rate has remained flat. Therefore, we are planning to expand this model across the enter-prise. Outcomes and Impact. Utilizing the 3 customized dashboards within our electronic health record, RN navi-gation and care coordination have led to improved evi-dence-based outcomes and a lower readmission rate. Tracking and identifying our HF patients using these dashboards is the foundation for our evidence-based work and has directly impacted our results. Use of these tools, the meaningful use functionality of our health record, and our learnings related to evidence-based practice, naviga-tion, and care coordination can now be expanded to other high-risk patient populations. Other organizations also can create these tools, apply them locally, and develop these programs.

Zero Harm: NYU Langone Health’s Journey to Eliminate Hospital-Acquired Complications

Kelly A. Feldman, and Martha J. Radford, MD, FACC, FAHANYU Langone Health

Background. NYU Langone Health received a Centers for Medicare & Medicaid Services’ hospital-acquired conditions (HAC) penalty for fiscal year (FY) 2017, and senior management chartered the Zero Harm initiative to decrease our hospital complications. Eighteen multidisci-plinary teams were formed, and each took responsibility for improving a particular aspect of care (eg, environment of care, optimizing antibiotic use, bundles to eliminate surgical site infections, improving timeliness of apparent cause analyses, methicillin-resistant Staphylococcus aureus [MRSA] screening and decolonization). Each team started by revising existing standards, creating new ones where necessary, and ensuring staff received proper training and education on these new standards. Many teams implemented electronic health record fixes to enhance documentation, and with the help of the Zero Harm measurement team, developed process of care met-rics to track staff compliance with our standards. Both an executive steering committee and an operations group continue to meet monthly to provide oversight and sup-port for the initiative, and to bring both success stories and barriers to the table. In just under 2 years, we suc-cessfully decreased our incidence of HACs by 47% and our unrecoverable care costs by about $4.1 million, with continued downward trends in HACs and costs. Intervention Detail. We developed an “HAC composite score,” comprised of National Healthcare Safety Network hospital-acquired infections and Agency for Healthcare

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Research and Quality patient safety indicators, to track incidence of HACs. Each working group identified and developed process of care metrics related to HAC pre-vention to ensure our processes are reliably followed. Some process metrics involve performing objective live direct observations of practice at the bedside, called Kamishibai Cards (K card), on patients with central lines on our units who are at high risk for developing central line-associated bloodstream infection (CLABSI), with real-time coaching along the way. We distributed tablets to each unit and developed electronic forms so that this audit data can be collected instantly at the bedside, allow-ing us to more efficiently track our process compliance. The hysterectomy and colorectal surgery, central venous catheter maintenance, and pressure injury pre-vention process of care bundles we’ve implemented are evidence based. We built a Zero Harm dashboard so that we could track process of care compliance along-side outcome metrics; this has helped us identify areas where more work needs to be done. Outcomes and Impact. Our HAC composite score dropped from 9.8 per 1000 discharges in FY 2016 (fourth quarter) to 5.2 per 1000 discharges in FY 2018 (third quarter), exceed-ing our goal to cut HACs by one third. The CLABSI K card initiative proved to be a huge success: compliance audits steadily increased from 80% to 100% over a 7-month period, and the CLABSI rates on K card units dropped from 2.1 per 1000 device days in the first quar-ter of 2017 to 0.81 in the first quarter of 2018. Our overall catheter-associated urinary tract infection rate dropped from 3.4 per 1000 urinary catheter days in the first quarter of 2017 to 0.99 in the second quarter of 2018, and the incidence of Clostridium difficile dropped from 0.65 to 0.31 per 1000 patient days during that same time period. Since the beginning of FY 2019, the Zero Harm initiative is shifting its focus to the HACs that remain problematic: hospital-acquired pressure injury, MRSA, and hospital-acquired venous thrombo-embolism. Although our results so far look promising, there is still work to be done, and the Zero Harm initia-tive continues to provide a focus area for our journey toward becoming a high reliability organization.

We’ve Got Your Backside (Colorectal Cancer Screening)

Sammi J. Davidson, BS, and Tessi L. Ross, BSN, MPA, RN, CPHQSanford Health

Background. Colorectal cancer is the second leading cause of cancer death for men and women in the United

States and has become a national public health initiative. Sanford recognized that to improve colorectal cancer screening, a one-size-fits-all approach would not work. The goal was to get more people screened, make the larg-est impact we could to detect colorectal cancer, and ulti-mately save lives. Intervention Detail. Sanford Health signed the National Colorectal Cancer Roundtable 80% by 2018 pledge. We sought ways to use nursing and other care staff beyond physicians to improve our screening rates. Multiple screening methods were offered to meet patients’ needs. The initiative included the following improvement strategies: reducing structural barriers for patients, improving patient and clinical team reminders, utilizing a recall system, and implementing provider assessment and feedback initiatives. Physician leaders and care teams led the initiative across the Sanford foot-print with executive leadership support. Our primary intervention was to optimize the electronic tools our care teams use to promote screening by enhancing the health maintenance reminders that alert clinic staff and patients that they are due for preventive screening(s). Reporting workbench registries allow clinic teams to identify patients outside of the clinic who are due for screening and allow for improved efficiency in patient outreach via letter, phone call, or MyChart message. Sanford’s self-referral MyChart system also reduces structural barriers by allowing active patients to request a colorectal cancer screening from the convenience of their home. In addi-tion, Sanford has collaborated with employee health to offer colorectal cancer screening options during influenza vaccine clinics. We deployed the Sanford improvement methodology to guide this work, which includes Plan-Do-Study-Act cycles and project management. If we as a nation can achieve 80% by 2018, 277 000 cases and 203 000 colorectal cancer deaths could be prevented by 2030. Outcomes and Impact. As of February 2018, 21 of Sanford Health’s primary care clinics are exceeding the 80% screening goal. As a system, Sanford Health is mov-ing closer to the 80% goal with a system-wide screening rate of 75.6%, up 6.9% from 2015. This percentage reflects more than 103 000 patients up-to-date with colorectal cancer screening, an increase of more than 20 000 patients receiving screenings since 2015. In recog-nition of Sanford Health’s exemplary efforts to increase colorectal cancer screening, the organization is the inau-gural recipient of the Organization of the Year for the 2018 North Dakota Colorectal Cancer Screening Achievement Awards given by the North Dakota Colorectal Cancer Roundtable. Dr Dan Heinemann, Sanford Health Network Medical Officer, is the recipient of the 2018 Champion of the Year by the South Dakota Comprehensive Cancer Control Program Colorectal Cancer Task Force.

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Big Safari: Data Infrastructure Guiding the Hunt for Major Opportunities in Clinical Documentation

Wes Dickson, BS IE, and Matt Luedke, MDDuke University Health System

Background. Accurate clinical documentation is critical to measuring hospital performance: it determines reim-bursement, justifies length of stay (LOS), and contextual-izes severity of illness and risk of mortality—all of which factor into national rankings. Last year we presented a targeted approach to stroke documentation supported by an on-demand, robust, and secure data analytics platform and demonstrated improvements in stroke documentation measures. This year, we have expanded our reach to diag-noses in the entire neurosciences service line and our data collection to the health system level. In addition, we inte-grated a broader set of documentation measures, includ-ing Vizient risk-adjusted models for mortality, LOS, and severity of illness. We are using these Vizient metrics to engage neuroscience providers across the health system and to drive improvements in the documentation of care and outcomes. Furthermore, our documentation efforts and data package dovetail with ongoing health system efforts to improve mortality and rankings, providing syn-ergy and support for efforts beyond our clinical documen-tation work. Intervention Detail. In the previous iteration of this project, we identified medical strokes—Medicare Severity Diagnosis-Related Group 64, 65, and 66—as a high-yield target for documentation improvement and created a data package to track the case mix index (CMI) impact of template redesign, provider education, and face-to-face provider engagement by clinical documenta-tion specialists. Improvements in stroke documentation stabilized, proving our concept, but forcing us to look beyond stroke for other clinical documentation opportu-nities. In our second phase, we have expanded our data monitoring to include all neuroscience diagnosis groups, a broader range of documentation measures beyond CMI, including Vizient-modeled severity of illness (SOI), risk of mortality (ROM), mortality index, and LOS index. Moreover, we expanded our reach to track these mea-sures at all 3 of our health system institutions. We are using these data to engage physician stakeholders in neu-roscience subspecialties at our university and affiliated community hospitals to drive relevant and meaningful documentation improvements, and to provide them with on-the-fly data monitoring for feedback on their interven-tions. Outcomes and Impact. Outcomes from the initial stroke documentation improvement efforts were extremely promising and led to further expansion of this project. Fifteen months of preintervention data were

compared with 9 months of postintervention data to mea-sure the extent of documentation improvement. Post implementation, documentation improvement allowed coders to capture more relevant, and thus more accurate, electronic health record data to identify an average of 15.7% more diagnoses per patient. The improvements in documentation quality and accuracy drove an average of 4 patients per month to higher diagnosis-related group levels. When looking at yearly revenue enhancement, these changes added up to almost $250 000 a year. The improved stroke documentation practices also altered Vizient ROM and SOI values. Post intervention, ROM increased by 6.44% while SOI increased by 5.85%. These results show that documentation improvement initiatives truly can help providers and health systems drive reim-bursement and quality measure improvement from the ground up. In the newest iteration of our project, we are sharing and applying identified documentation best prac-tices across the health system with our community hospi-tal affiliates. Furthermore, we have used the revamped data platform to identify other high opportunity subspe-cialty areas such as surgical brain tumor care, neuro-inflammatory, and neurodegenerative processes.

Pre-Hospital Acute Services Team (PHAST): Shaping Health System Admission Patterns

Keith Dombrowski, MD, Wes Dickson, BS IE, Carey Unger, MHA, and Neel Kapadia, MD, MBADuke University Health System

Background. With a growing average daily census, alarm-ing bed utilization rate, and increased elective surgical volumes, the Duke University Health System neurosci-ence service line needed to develop a reliable and system-atic process to direct the flow of admissions to the correct care teams throughout the entire organization. The service line was frequently unable to accommodate outside-hos-pital transfer requests because of bed constraints and com-munication flow issues. Simultaneously, lower acuity cases were being accepted to the flagship University Hospital, often without systematic thought or consider-ation that those cases may not need the resources of a large academic medical center. As a result, an important col-laboration formed between the University Hospital, 2 sis-ter hospitals, transfer center, and neuroscience service line to create an algorithm-driven multihospital triage and pre-hospital care system called PHAST (Pre-Hospital Acute Services Team). This multidisciplinary group of physi-cians, administrators, and analysts from across the health system worked together to foster cross-functional think-ing and to develop transfer center admission algorithms.

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The algorithms were developed to facilitate the flow of neuroscience patients to the most appropriate hospitals and care teams within the Duke University Health System. We strongly believe that the algorithms and administrative framework that created them can be used in similar health systems to optimize patient flow, maximize care resources, and provide the best possible care to each patient. Intervention Detail. Duke’s growing neuroscience service line has put pressure on care teams and resources through-out the organization. Over the past 4 years, the neurosci-ence intensive care unit’s bed utilization rate has steadily increased by 33% in average daily census. Likewise, the neuroscience stepdown floor has experienced a 10% increase in average census. The neuroscience general floor has experienced an 11% increase in average census as well. A component of this increased activity comes from a growing number of outside hospital transfer requests. Currently, there are an average of 150 neurosci-ence transfer requests per month. This number is 25% higher than it was 3 years ago. The data made it clear that new and innovative ways of thinking were necessary to accommodate patient care needs. Shortly thereafter, the team used transfer center data to identify groups of lower acuity patients who could potentially be directed to Duke Regional, a smaller community hospital, where appropri-ate clinical resources and more compliant bed capacity were available. The team found that their service line was accepting roughly 150 patients per year who could have received appropriate, high-quality care at Duke Regional. This cohort was made up of patients with less medically complex conditions, including certain subtypes of isch-emic stroke, uncomplicated seizures, and other general neurology conditions. The data fostered collaborative dis-cussions and strategic thinking, which helped with the cre-ation of multiple algorithms that soon started systematically reshaping neuroscience demand across the Duke Health enterprise. Outcomes and Impact. After assembling the team and thoroughly exploring the data, multiple algo-rithms were generated to more efficiently direct the flow of Duke Health neuroscience transfer center admissions. The transfer center is currently using these algorithms every single day to identify and route neuroscience patients to appropriate care teams. One of the algorithms routes lower acuity stroke and general neurology patients to Duke Regional Hospital. The program has success-fully routed more than 200 patients to Duke Regional so far, with the average climbing to 20 patients per month. This has given immediate and much-needed relief to the University Hospital care teams who have been strug-gling with a rising average daily census and high bed utilization rates. These results also have allowed Duke Regional to strengthen growing neurohospitalist and stroke programs. A second algorithm rapidly transfers mechanical thrombectomy ischemic stroke candidates to

neurointerventional radiology and surgical care teams at Duke University and Duke Raleigh hospitals. Health sys-tem thrombectomy volumes have climbed to more than 10 procedures per month as a result of this streamlined pro-cess. A third algorithm creates a “fast track” for emer-gency neurosurgical patients with conditions such as aneurysmal subarachnoid hemorrhages and brain tumors. The transfer center staff who apply these algorithms have been trained with visual diagrams, active rounding, data reviews, and monthly updates. The team of physicians, administrators, and analysts who developed the algo-rithms continue to refine logic and review outcome data through regular bimonthly meetings. Overall, this initia-tive has given Duke’s neuroscience service line the ability to shape patient admission patterns that previously were thought to be fixed and unchangeable, allowing them to maximize resources and provide care in a more efficient manner.

Clostridium difficile: A Hardwired Approach—Assessment and Management of Loose Stools

Carmen M. Faulkner-Fennell, PharmD, BCPS (AQ-ID), and Lorie Bolding, BSN, RNGreenville Health System

Background. Greenville Memorial Hospital (GMH) rec-ognized an opportunity to improve patient outcomes and positively impact value-based purchasing reimbursement by focusing on and reducing facility-associated Clostridium difficile (C difficile) lab ID events. We cre-ated a multipronged action plan facilitated by a multidis-ciplinary work group led by infection prevention and the Antimicrobial Stewardship Program (ASP). The work group included quality management, physicians, nursing, microbiology, pharmacy, and environmental services (EVS). ASP reviewed all facility-associated C difficile cases to determine if they represented true infection or colonization. Mandatory education focusing on C diffi-cile infection (CDI) signs and symptoms, diarrhea defini-tion and alternative causative factors, and appropriate ordering of the C difficile polymerase chain reaction (PCR) test was developed and disseminated to all clini-cians. To reinforce education, a C difficile test best prac-tice alert (BPA) was developed in the electronic health record (EHR) that screens the profile for reasons why testing may not be indicated including: laxative adminis-tration in the past 48 hours, less than 3 loose stool occur-rences in the past 24 hours, tube feed initiation or rate change in the past 48 hours, negative C difficile PCR within the past 7 days or positive within the past 30 days. If any criteria are met, BPA alerts clinicians to the

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reason(s) why testing may not be indicated and provides an opportunity to either discontinue testing or proceed with required documentation of the override. The C dif-ficile test is ordered if BPA criteria are not met. When C difficile testing is ordered, an additional BPA fires to place the patient on preemptive contact-enteric isolation. Nursing education was provided regarding appropriate isolation, hand hygiene, daily environmental cleaning, and standardized stool documentation. Additional proto-cols for microbiology stool rejection and EHR notifica-tion to EVS for terminal cleaning and ultraviolet (UV) light disinfection upon discharge or transfer were imple-mented. The GMH multimodal approach relies heavily on EHR utilization; however, the components can be amended and strategically applied at any health care facility. Intervention Detail. The GMH facility-associated C difficile rate during fiscal year (FY) 2016 was 9.97 per 10 000 patient days, which was concerning given the morbidity and mortality associated with true disease. This rate was above the third quartile of the Vizient Hospital Improvement Innovation Network (HIIN) benchmarks (hospitals > 551 beds). During the prelimi-nary stages of the GMH action plan development, the ASP pharmacist identified 58% of C difficile lab ID events in adult patients were colonization, not true CDI. Education was designed based on trends found in the case reviews and a BPA was developed to hardwire proper uti-lization of C difficile testing. BPA performance is assessed monthly and updates are made to make the alert more clinically relevant. Important process changes include incorporation of the Bristol Stool Scale to standardize stool documentation by nursing and eliminating the BPA patient areas where it should not fire to decrease clinician alert fatigue. Nursing unit-level compliance with the C difficile action plan is disseminated by the infection pre-ventionist and includes hand hygiene, unit CDI rates, and case review results. Case review findings are discussed at multidisciplinary unit meetings and allow the units to identify opportunities to improve. Other components of the C difficile action plan include utilization of soap and water rather than sanitizer though our electronic monitor-ing system, and terminal cleaning and UV disinfection of rooms. Outcomes and Impact. C difficile reduction is an organizational priority for which leadership and frontline staff are held equally accountable. Overall compliance with the multifaceted C difficile action plan resulted in a reduction in our facility-associated C difficile rate from 9.97 (FY 2016) to 7.5 (FY 2017) per 10 000 patient days, resulting in 46 fewer events. The reduced number conser-vatively represents a cost savings of $360 000 ($7800 per case). Our FY 2018 C difficile rate through March is 5.75 per 10 000 patient days, which is below the Vizient HIIN C difficile benchmark median. Other benefits to the orga-nization include a reduction in the number of C difficile

lab tests performed, a reduction in colonized patients tested, improvement in the nursing assessment and docu-mentation of loose stools, consistent terminal UV disin-fection of patient rooms, and improved hand hygiene compliance. Efforts to reduce our facility-associated C difficile rates are ongoing. In addition to process improve-ments for BPA, C difficile lab testing is being further refined to better identify toxigenic strains and standard-ized treatment algorithms are being developed. This proj-ect successfully demonstrated that a multidisciplinary approach brings everyone to the table and results in high-level engagement, which is needed to address complex clinical issues.

Identifying Malnutrition: The Registered Dietitian’s Role in Coding and Reimbursement

Kelly Fedder, RD, LD, CNSC, Abby Watkins, RD, LD, Whitney Duddey, MHA, RD, LD, Jeremy Riser, MPH, and Andrew Kelly, MSUniversity of Kentucky Healthcare

Background. It is estimated that 20% to 50% of hospital-ized adult patients are malnourished. Malnutrition in the hospital setting increases length of stay, fall risk, develop-ment of pressure ulcers, infection rates, and use of resources. Proper identification, documentation, and cod-ing of malnutrition are necessary to obtain appropriate diagnosis-related group (DRG) categorization and accu-rate reimbursement for the condition. Registered dietitians (RDs) across the country are implementing nutrition-focused physical exams (NFPE) through guidelines pro-vided by the American Society of Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics to correctly identify and stratify degree of malnutrition. Failing to capture a malnutrition diagnosis could leave thousands of reimbursement dollars unclaimed. The pur-pose of this study was to examine the effects of dietitian-led NFPEs on malnutrition diagnosing and hospital reimbursement within the University of Kentucky Healthcare (UKHC) system. Intervention Detail. Data were collected by UKHC data management analysts uti-lizing an electronic medical record, patient management system, and diagnosis coding system. Adult inpatient admissions were reviewed from October 1, 2016, through January 31, 2018. Data were segregated into pre- and post-intervention time periods: October 1, 2016, through March 31, 2017, and August 1, 2017, through January 31, 2018, respectively. The use of 4 malnutrition International Classification of Diseases, Tenth Revision (ICD-10) codes was analyzed: E43—Unspecified severe protein-calorie malnutrition, E44.0—Moderate protein-calorie malnutri-tion, E44.1—Mild protein-calorie malnutrition, and

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E-46—Unspecified protein-calorie malnutrition. To obtain financial outcomes, UKHC-specific DRG weighted multipliers for Medicare, Medicaid, and other payer groups for fiscal year 2017 were used. The assumption was made that there was no seasonal impact on rates of malnourished admissions. Adult inpatient RDs were trained on the NFPE process in January 2017. In February 2017, the electronic nutrition evaluation note was updated to include this assessment. In April 2017, RDs initiated formal documentation of malnutrition. In August 2017, the clinical documentation integrity (CDI) team was edu-cated on this process. This study received Institutional Review Board approval through the University of Kentucky Office of Research Integrity. Outcomes and Impact. It is estimated that 14% of the adult inpatient pop-ulation within the UKHC system is malnourished. Total diagnosing of malnutrition increased by 50% (pre: n = 1675, post: n = 2517). A decreased trend in the use of unspecified malnutrition was seen, with an increased trend in the use of all severity specific categories. Post interven-tion, 60% of patients who screened positive for malnutri-tion by the dietitian were subsequently coded with the same diagnosis by the physician. The number of visits where adding malnutrition impacted the weight of the DRG increased by 110% (pre: n = 147, post: n = 309). This equated to an estimated increase in overall reim-bursement of $822 644 over 6 months (78% increase from baseline). Implementing dietitian-led NFPEs, updating the nutrition evaluation note, and educating the CDI team led to an increase in malnutrition diagnosing, improved diagnosis specificity, and increased reimbursement. These outcomes demonstrate that the RD is a valuable asset to the medical team. Accurately identifying, documenting, and coding malnutrition can increase hospital reimburse-ment and available resources to treat malnourished patients. Continued communication and education between dietitians, physicians, and the CDI team is neces-sary to achieve optimal reimbursement.

A Multidisciplinary Team-Based Approach to Reducing Sepsis Mortality

Catherine Huck, MS, BSMT, CIC, Kristen Smith, MPP, BA, and Rebecca Armbruster, DO, MS, FACOIJeanes Hospital

Background. Faced with a sepsis mortality index that was continually outside of expected range, our multidisci-plinary team of key stakeholders organized to systemati-cally tackle sepsis. Our 2-phased plan included implementation of a sepsis early warning system, fol-lowed by implementation of a sepsis pathway. Recognizing

sepsis as a primary driver of our mortality rate, our institu-tion’s performance improvement (PI) plan included a sig-nificant reduction in sepsis mortality rate as a primary goal. Approximately 85% of our patients (seen in our emergency department [ED]) were diagnosed with sepsis that was present on admission (POA), while the remaining 15% of cases were identified in-house and transferred to the critical care unit, often after the patient had progressed to severe sepsis or shock. Our institution lacked a stan-dardized, multidisciplinary approach to address this urgent, critical patient condition. The collaborative efforts of our multidisciplinary sepsis team—engaged physician champions (internal medicine, ED, infectious diseases and pulmonary critical care), nursing (ED, inpatient, criti-cal care), clinical documentation improvement, health information management, information technology (IT), laboratory, infection control, and PI staff—were key to our success in meeting and sustaining our goal. Initial steps included conducting a gap analysis of best practices. Utilizing the Plan-Do-Study-Act model, our improvement plan was divided into 2 major tactics: (1) instituting an early warning scoring system to be used consistently in the ED and inpatient medical/surgical and critical care units; and (2) developing and implementing a sepsis path-way. In addition to serving as a systematic approach for adhering to all steps in the sepsis bundle, the pathway also served as a great communication tool used by our nursing and physician staff; a handoff tool used by clinicians between care areas; and a monitoring tool for assessment of compliance. Teamwork also led to developing a stan-dard of practice for repeat lactate levels and a consensus document for recommended antibiotics for different sources of sepsis. Intervention Detail. In the fourth quarter of 2014, our institution’s sepsis mortality index (observed/expected ratio) was 1.3 compared to a target of 0.45. This placed our rank at 86 compared to the other 116 commu-nity hospitals in the Vizient database. Phase 1: Sepsis early warning system (EWS)—Our institution adapted the principles of an EWS based on the Vitalpac Early Warning Score (ViEWS) early warning score methodology for detecting adult inpatient deterioration. (1) EWS quick-reference guides for the ED and inpatient units, using an aggregate weighted vital sign score, were adapted from another institution’s model. (2) Within several months, with the help of our IT colleagues, the EWS calculations also were programmed into our inpatient electronic medi-cal record (EMR), with accompanying alerts for the nurs-ing staff for action steps to take, based on the aggregate EWS score. Manual calculations continue in our ED, which uses a separate EMR. Compliance with EWS score calculations was monitored daily with timely staff feed-back. Phase 2: Sepsis pathway—Once the sepsis EWS was hardwired, members of our interdisciplinary sepsis team developed a pathway that helped meet 3 major

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purposes: (1) to remind staff of the key process steps that correlate to the Centers for Medicare & Medicaid Services’ sepsis core measure (SEP-1) bundle; (2) to account for documentation of patient assessment and treatment deliv-ered; and (3) to serve as a handoff communication tool between nurses and physicians and between treatment areas when patients were transferred from one level of care to the next. Once a patient met the EWS alert score or systemic inflammatory response syndrome criteria, the pathway was started. The sepsis team, which met monthly, addressed compliance rates related to each measure of the bundle. As in phase 1, team members became owners of specific process improvement action plans and were key to providing role-based education and just-in-time feed-back to frontline staff. Outcomes and Impact. By the third quarter of 2017, after many cycles of improvement and quarter-to-quarter reductions, our institution’s sepsis mor-tality index was reduced from 1.3 to 0.51. This equated to a 60.8% improvement in our sepsis observed mortality rate and $614 928 in annualized cost avoided. Sepsis POA lives saved between 2016 and 2017 were 14, which equated to $238 000 in estimated cost savings. We imple-mented our ED and inpatient EWS in September 2015 after role-based staff education. Our compliance rate for calculating the EWS score in the ED (a manual process) was sustained at 95% or greater in 2017, with an average of 98.6% for the year. Automation in the inpatient EMR supported consistency in calculation and documentation calculation of the EWS and approved standard of practice, based on the EWS. In January 2016, our institution’s com-pliance rate for adherence to the SEP-1 bundle was 20%. By December 2017, our rate increased to 66.7%. With greater adherence to the sepsis pathway, we anticipate ongoing improvement in our compliance rate. Ongoing performance monitoring, just-in-time role-based feedback to our frontline staff, and an engaged group of stakehold-ers led to efficiencies in our meetings. The time that our interdisciplinary team spends in our face-to-face monthly meetings was reduced over time from 90 minutes in January 2016 to just under 60 minutes in January 2018. This interdisciplinary team-based improvement strategy serves as a model for our other improvement teams.

Unit Safety Huddle: A Powerful Leadership Strategy to Demonstrate a Commitment to Organizational Learning and the Drive to Zero Harm

Annette Gagnon, RN, MS, Patrick Gardner, MD, David Goldberg, MD, Debra McCann, RN, MSN/MBA, HC, NE, BC, CCRN, and Shelly Waala, MSHA, BSN, RN, NE-BCFroedtert Health

Background. Aiming for zero preventable harm events, we recognized our response to these events lacked organi-zational nimbleness. Our reviews were retrospective and rarely included clinical leaders and staff. Executives accountable for quality performance were not part of the review and lacked insight into process failures that pre-vented sustained quality. In response, we developed a stra-tegic framework incorporating tactics critical toward building a culture of safety and high reliability. Central to this foundational framework are executive leadership-led unit safety huddles that include frontline staff and are completed within 48 hours of an event. Intervention Detail. We lacked structure and processes to achieve pre-ventable harm. We did not use zero harm language. Our data displayed as a scorecard was not directional; it indi-cated a problem but did not show its magnitude or proba-ble causes. We were quick to implement best practice but slow to identify and correct process barriers. Our analysis of performance failures was typically 30+ days post event and siloed. We developed a framework to align the divi-sion from board of directors to frontline staff in the urgency to achieve zero harm. It includes the goal of reducing patient harm events by 20% each year to achieve zero harm by 2020, data displays designed for a zero harm journey, and performance improvement (PI) teams and executive-led unit safety huddles (USH) for events such as hospital-acquired infections (HAIs) and hospital-acquired pressure injuries (HAPIs). The USH, the corner-stone of the framework, is scheduled within 48 hours of the event and is attended by leaders and staff from the clinical areas involved, a subject matter expert (SME) as indicated by the event, and the hospital’s chief medical officer, chief nursing officer or nursing executive, and quality. The executive leaders open the huddle by rein-forcing the goals, unit and organizational learning, identi-fication of tactics to prevent a similar event reaching another patient, and thanking the staff for their engage-ment in these efforts. In 30 minutes, the team reviews the event using templates that are completed in advance by the SME and the unit. They then identify failure points and easily implemented improvement tactics. When the team identifies failure points and improvement tactics with division-wide implications, they assign them to the appropriate PI team. Outcomes and Impact. We were suc-cessful at engaging executive and unit leaders, staff, and SME in the USH process. We conducted a USH for each HAI and HAPI event. A total of 60% took place within 3 days of the event and 81% within 5 days. We completed all USH within 30 minutes and believe this was related to our SME and unit staff completing the USH templates prior to the huddle. The tightly managed time supported achieving good attendance by our executive leaders and unit staff. An executive leader attended 100% and 2 or 3 attended 72% of the huddles. Our unit point-of-care staff

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attended 74% of the huddles. Most important, we have made the care we deliver to our patients safer. We imple-mented several divisional improvements and our targeted events decreased 54%. Examples of improvements are the development of criteria and training for the use of urinary catheters for difficult insertion and an external female catheter, redesign of a C difficile testing algorithm, and pressure injury prevention bundle tool. We recommend others consider the USH. It is easily deployed and it sup-ports learning from every patient harm event and contin-ued performance improvement toward the achievement of zero preventable harm.

VTE Prophylaxis Doses: An Offer You Really Shouldn’t Refuse

Maja G. Gift, MHA, BS, Pharm, Laura Haubner, MD, Maresa Glass, PharmD, BCPS, BCCP, and Sarah Hein, PharmDTampa General Hospital

Background. The patient’s role in preventing venous thromboembolism (VTE) is crucial. Prophylaxis orders are useless if the patient refuses to receive them and even 1 missed dose can increase the risk of VTE significantly. Baseline data showed that 11% of ordered doses were missed; of those, 67% were refusals. Intervention Detail. An interdisciplinary team, including medical, nursing, and pharmacy, set out to reduce the number of VTE pro-phylaxis dose refusals, and thereby reduce the rate of pre-ventable VTEs as measured by the VTE Patient Safety Indicator (PSI)-12. Outcomes and Impact: Through focused pharmacist and nurse interventions, the percent-age of missed doses decreased from 11% to 9.6%, with a 43% reduction of refused doses. The PSI-12 rate decreased from 15.8 to 7.5 VTEs per 1000 discharges. Review of missed VTE doses was incorporated into nurse and pharmacist workflow.

Extracorporeal Membrane Oxygenation: Addressing Mortality, Length of Stay, and Central Line–Associated Bloodstream Infections

Eric Hadhazy, MS, Jack Boyd, MD, Corrine Pogemiller, PA, Charlene Kell, RN, Paul Shuttleworth, CCP, Maia Bucoy-Duque, RN, Norman Rizk, MD, Charles Hill, MD, Tammy Schaffner, RN, Gundeep Dhillon, MD, Jeffrey Teuteberg, MD, Yasuhiro Shudo, MD, and John Shepard, MHAStanford Health Care

Background. Stanford Health Care’s (SHC) cardiotho-racic surgery department had increasing surgical volume and rising complexity of cases from fiscal year (FY) 2015 to FY 2017 leading to more patients initiated on extracor-poreal membrane oxygenation (ECMO). Venovenous (VV ECMO) and venoarterial (VA ECMO) have both expanded as treatment options for organ recovery or bridge to transplantation. Despite the inherent high mor-tality rate associated with ECMO, we wanted to compare our patient outcomes to similar academic medical cen-ters. By using the Vizient Clinical Data Base/Resource Manager (CDB/RM) and the Report Builder tool, we were able to benchmark SHC to other like institutions and assess our mortality index, length of stay (LOS) index, case volume, and case mix index (CMI). Additionally, we wanted to improve our central line–associated blood-stream infection (CLABSI) rate, specifically for patients in our cardiovascular intensive care unit (CVICU). Intervention Detail. Using the Vizient CDB/RM and Report Builder tool, we created a report to benchmark our performance. We used patient outcomes grouped by hos-pital/hospital systems and used our FY (September-August) data to benchmark with other Association of American Medical Colleges teaching hospitals as selected in the hospital profiler. We added advanced restrictions of any procedure to include only ECMO cases using International Classification of Diseases, Ninth Revision (ICD-9) (3965) and Tenth Revision (ICD-10) (5A15223). We filtered by ECMO case volume/year >49, and sorted by mortality index, LOS index and CMI. SHC ECMO case volume (VV + VA) increased from 25, 62, and 92 for FYs 2015, 2016, and 2017, respectively. The mortal-ity index during this same period was 1.48, 1.88, and 1.85, and LOS index was 1.19, 1.74, and 1.37, respec-tively. SHC CMI was the top 1% (19.97) of all bench-marked hospitals. However, the mortality index and LOS index did not adequately reflect the increased resources allocated to these patients given the observed deaths and LOS remained higher than expected values. We created a multidisciplinary team deemed the ECMO Task Force to reduce observed mortality, LOS, and decrease CLABSI in the CVICU. Key stakeholders included the chief medi-cal officer, cardiac surgeons, CVICU intensivists, perfu-sionists, advanced practice providers, nursing, social work, case management, palliative care and ethics, infec-tion prevention, and critical care quality. The ECMO task force met weekly to discuss every patient recently can-nulated for ECMO, and cases where ECMO was consid-ered, initiated, or withdrawn. Transfer cases were reviewed in detail for clinical acceptance criteria and we established a new ECMO policy to include a palliative care consult within 72 hours of cannulation. Additionally, we optimized an ECMO order set in our electronic health record and reinforced best practices to reduce CLABSI.

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Outcomes and Impact. SHC ECMO case volume (VV + VA) in FY 2018 year to date (YTD) includes patients dis-charged from September 2017 to July 2018 (n = 44). Mortality index is 1.20 and LOS index is 1.16. ECMO patients with protracted LOS >29 days have decreased from 26 cases in FY 2017 to 5 cases YTD in FY 2018, an 80.8% decrease. Additionally, there were 31 CLABSI cases reportable in our CVICU last year. For FY 2018 YTD there have been 5 CLABSI in the CVICU, an 83.9% reduction. These improvements in patient outcomes have come following the creation and sustainment of the mul-tidisciplinary ECMO task force, which has not only improved measurable care to patients, but also has fos-tered a more inclusive and collaborative environment for staff in the CVICU.

The Power of Focusing on Strengths of Interventions

Timothy E. Klatt, MD, and Siddhartha Singh, MDFroedtert and Medical College of Wisconsin

Background. For the past 3 years, our institution has earned a top 5 finish in the Vizient Award for Superior Performance in Quality and Accountability. Even so, we recognized that this metric includes only a portion of the care that we deliver. We sought to improve the safety of the entirety of our care and our safety culture. We also wanted to build on our 2015-2017 Specialty Metrics Program, presented at the 2017 Vizient Clinical Connections Summit, through which our providers and personnel developed teams and basic process improve-ment skills through partnership on quality improvement projects of their choosing. In response to serious adverse and patient safety events, our safety department tradition-ally facilitated action plans focused on education and reinforcement of rules and policies. Although these inter-ventions are essential, they led to short-lived improve-ments at best. These improvements were rapidly undone by the frequent turnover of care team members and the constant influx of new personnel required by our rapid growth. People simply had too much to remember—especially our residents who rotate through multiple insti-tutions with different workflows. In May 2017, a new medical director for patient safety was appointed and tasked with working with administration to improve the safety of the entirety of our care and our safety culture by: (1) pursuing high-reliability responses to safety events, like those our system implements for items within the Vizient Quality and Accountability scorecard; and (2) developing stronger, enduring, more visible systems improvements to ensure that each of our patients receives

the safest and best possible care. Intervention Detail. We developed a customized strength of interventions tool that ranks interventions from least to most effective: (1) education—information provided to individuals and groups; (2) rules and policies—reinforce education and desired behaviors; (3) reminders and checklists—make key information readily available; (4) redundancies—incorporate duplicate steps/add individual(s) to force additional checks; (5) standardizations and protocols—reduce complexity and meritless variation; (6) automa-tion and computerization—computers used to reduce sources of errors/perform checks; (7) forcing functions—hard stops requiring final verification; and (8) fail safes/constraints—design makes it nearly impossible to err without significant effort. The safety department adopted this tool as its guiding focus. On July 1, 2017, we began challenging the teams gathered to address safety events to brainstorm and implement the strongest possible inter-ventions. After this date, action plans limited to education or rules and policies interventions were only reluctantly accepted. Nearly all improvements were achieved via the Plan-Do-Study-Act cycle, a basic tool recently dissemi-nated throughout our organization via our Specialty Metrics Program. We measured the impact of focusing on the strength of interventions tool by comparing work between January 1, 2016, to December 1, 2016 (base-line), and that completed July 1, 2017, to July 1, 2018. July 1, 2017 was chosen to start the study period because of the leadership transition. Every action item imple-mented via 2016 action planning sessions was included. Items were considered “implemented” only after sus-tained, measured improvement. Because some work con-tinues from the July 1, 2017, to June 30, 2018 time period, these action-planning items were evaluated in 2 ways: (1) implemented interventions; and (2) both implemented interventions and those on track for implementation. Only those interventions facilitated by safety were included. Interventions identified and implemented inde-pendently by local units were excluded. The safety department consisted of 1 medical director, 1 director, and 8 patient safety specialists throughout both time peri-ods. Outcomes and Impact. After emphasizing the strength of interventions tool, a higher percentage of action plans included strong interventions (stronger than education or reinforcing policies): 6/25 before versus 72/76 after, P < .001. Action plans contained more strong interventions per action plan for both implemented inter-ventions, 0.32 before versus 0.79 after (P = .037), and implemented and intended interventions, 0.32 versus 1.36 after (P < .001). Specific interventions implemented and intended, in descending order of strength, before (after): fail safes: 1 (6), forcing functions: 0 (2), automa-tions: 0 (9), standardizations: 4 (60), redundancies: 2 (10), and reminders: 1 (16). Policy changes and education

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remained key elements of nearly every action plan before and after the intervention. Challenging teams to aim for the strongest possible interventions expanded our reviews to include the entirety of the involved systems. This pro-duced several multi-department solutions and fostered ongoing partnerships within our relatively siloed organi-zation. These stronger interventions are also highly visi-ble, making it easier for patients, personnel, and providers to witness their colleagues’ and our organization’s com-mitment to patient safety. The number, visibility, and suc-cess of these stronger interventions have encouraged providers and personnel, possibly explaining why 3 times as many action planning sessions occurred after the change. Most of our stronger interventions were stan-dardizations. Our providers and personnel found that simplifying complex systems of care delivery, especially by removing meritless variation and dependence on indi-viduals’ memories, helps them work better instead of harder. Focusing on the strength of interventions tool pro-duced a rapid and marked improvement in the quality and sustainability of safety’s work without the need to change personnel or expand their skill sets. This focus also set an example for local units pursing interventions, energized our pursuit of a culture of safety and made it easier for everyone to deliver and receive the best possible care.

Effect of Educational and Personalized Interventions on Health Care Provider Behavior

Alyssa G. Lorzano, MPH, Ann Bingham, MD, and L. Michele Noles, MDOregon Health & Science University

Background. Effective patient management demands that health care providers have the systems and resources to help modify their practice. With increasing patient com-plexity, production pressure, and competing priorities, many physicians find it difficult to incorporate published recommendations into their practice in a timely and con-sistent manner. This is reflected by the many studies that demonstrate the slow pace at which many beneficial advances are incorporated into medical practice. Today, lectures, conferences, email, and printed materials remain the primary methods to provide the latest education and alter physician behavior. Perioperative and postoperative hyperglycemia in general surgery patients with and with-out diabetes has been associated with a nearly 2-fold higher risk of infection, in-hospital mortality, and opera-tive complications. Despite these observations, glycemic monitoring and control are often overlooked. One study reported that glucose monitoring occurred in only 59% of hospitalized patients, and only 54% of those patients with

elevated glucose received insulin therapy. At Oregon Health & Science University’s (OHSU) department of anesthesiology and perioperative medicine, we have approximately 56 adult anesthesia attendings, 51 certified registered nurse anesthetists, and 55 trainees each year. In 2016, our providers cared for approximately 2000 adult surgical inpatients at risk for perioperative hyperglyce-mia. In an effort to reduce hyperglycemia in our periop-erative patients, our goal was to improve our recognition and treatment of hyperglycemia in our adult surgical inpatients. We also used this opportunity to observe changes in provider behavior following educational out-reach and again when education is combined with indi-vidualized feedback. Intervention Detail. We instituted standardized perioperative glycemic management guide-lines for anesthesia providers to follow. These guidelines incorporate identification of patients at risk for hypergly-cemia as well as standardization of treatment parameters. Intraoperatively, a glucose level should be checked in all patients who are at risk for hyperglycemia. “At risk” is defined as those patients who have a history of diabetes, have abnormal glucose levels in the last 90 days, are 45 years old or older, and have no glucose labs in the last 90 days, or those who are 18 years old or older and have a body mass index >25 and have no previous glucose lab data. Before incorporating education and individualized feedback, we ensured that our systems would support the desired change. This included (1) removing barriers to compliance—ensuring that each operating room had a glucose meter and that our staff were trained to use it; and (2) utilizing visual icons to help identify patients who were at risk for hyperglycemia. Initial departmental edu-cation was given during anesthesiology grand rounds in August 2016. Compliance was measured for 6 months after grand rounds. Chart audits and individual feedback began on February 2017 and continued until February 2018. Both compliance after grand rounds and compli-ance after grand rounds plus individual feedback were compared to baseline data collected 6 months before any intervention. Outcomes and Impact. Baseline data were collected from February 2016 through July 2016. There were 998 surgical cases that were included in our baseline group. Grand rounds data were collected from August 2016 through January 2017. There were 1001 surgical cases were included. Grand rounds plus individual feed-back data were collected from February 2017 through February 2018. There were 2043 surgical cases included. Initial investigation using trial limits showed an apparent shift in the average after August 2016 and after February 2017. Prior to any intervention, our process was stable with a mean compliance of 83% (lower control limit [LCL]: 75%, upper control limit [UCL]: 92%). After grand rounds, there was an upward shift in average com-pliance to 94% (LCL: 89%, UCL: 100%). The process

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was stable, except for one signal of special cause in January 2017, when compliance fell below control limits at 77. After incorporating individualized feedback, there was an upward shift in mean compliance to 96% (LCL: 92%, UCL: 100%). The process has remained stable with a mean compliance of 96% (LCL: 92%, UCL: 100%) over the following 12 months. Effective patient manage-ment demands that health care providers have the sys-tems and resources to help modify their practice. Education, as the only intervention to change, changes behavior. However, it is unclear if education alone can sustain change. Sustainable change can be achieved by standardizing processes, reducing barriers, educating, and providing a mechanism for consistent feedback.

It Takes a Village—The Road to PSI2 (Patient Safety Indicator Improvement)

Erin J. Burgess, PMP, and Lawrence K. Mandelkehr, CPHQ, MBAUNC Health Care System-University of North Carolina

Background. UNC Hospitals reduced their number of Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) by more than 50% in 12 months through partnerships with key quality partners, focused interventions coordinated by service-based physician–nursing leaders supported by quality coaches, a pre-bill audit process, and service- and unit-specific reporting based on Vizient Clinical Data Base data. Intervention Detail. We took a multifaceted approach to reducing the volume of patient harms. (1) Physician service leader infrastructure: We partnered service-based physician leaders with nurse managers to prioritize and improve patient care processes and safety, patient experience, and documentation and coding. These leaders are supported by quality coaches, care managers, and resources such as epidemiology and health information management as needed. (2) Pre-bill audit: Our pre-bill process begins with health information management’s “SMART” soft-ware identifying potential PSIs and includes reviews by a lead coder, a quality nurse reviewer, and physician before the potential coding issues are sent to the patient’s physi-cian as a coding query. (3) Quality coaches: Coaches are assigned to all service lines to provide facilitation, educa-tion, and data interpretation/analysis support. (4) Daily and monthly reporting: A variety of PSI-related reports are distributed each month, including daily venous throm-boembolism prophylaxis compliance reports and monthly PSI unit/organization dashboards. (5) Senior leadership commitment: Held clinical leaders accountable, built quality improvement capacity by expanding the coaching program, and encouraged collaboration across nursing,

epidemiology, medical staff, health information manage-ment, information systems, and perioperative services. Participated in our guiding coalition/steering group. Outcomes and Impact. We reduced the number of selected PSIs by 52% during fiscal year 2017. Our number of PSIs decreased from 365 during our baseline period to 161 during the performance period. Although not on the poster, we further reduced our count of PSIs by another 37% in fiscal year 2018. We improved our ranking com-pared to approximately 100 academic medical center peers from 89th in 2015 to 5th in 2018. Our most impor-tant impact is to the dozens of patients who did not suffer a complication. We succeeded in engaging physicians, nurses, and others in our improvement efforts and identi-fied champions for the next phases of the PSI reduction and other programs. We developed robust reports that have since combined with readmission, infection, and sepsis data into a monthly service quality reporting bun-dle which has improved both focus and satisfaction of our clinical leaders.

The Doctor Is In: Deploying a Centralized Physician to Grow Access to Inpatient Care

Matthias J. Merkel, MD, PhD, James Heilman, MD, MBA, Susan Yoder, RN, Jennifer Packer, MSN, RN, CENP, CEN, Carl Eriksson, MD, MPH, Katie Ellero, MHSA, and Joe Ness, MHA, RPhOregon Health & Science University

Background. Physician engagement in daily capacity and access operations is challenging. The lack of struc-ture commonly opens the door for siloed approaches by individual physicians. We identified the need to have a physician as an essential member of our daily operations teams to increase system-level decision making and shared medical decision making in real time, 24/7. The physician on duty (POD) position was created as a mis-sion-critical, non-relative value unit (RVU)-producing position reporting directly to our chief medical capacity officer (CMCO) and chief medical transfer officer (CMTO). The 14 POD members were recruited out of all areas of our clinical faculty plan (ie, emergency med-icine, critical care, anesthesiology, surgery, medicine, pediatrics), selecting individuals known to be system thinkers with at least 2 years of faculty experience. Each POD member is an active clinical faculty member and contributes on average a 0.1 full-time equivalent of their clinical work to the POD role. The CMCO and CMTO developed a 4-hour training course for the POD, which was mandatory prior to being scheduled for the first POD shift. The training included Emergency Medical

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Treatment and Active Labor Act orientation, ethical principles of triage decision making, logistics of clinical operations, and role definitions of each member of the daily operation team. We also established a clear path-way to allow real-time escalation. The POD is included in daily operational huddles in both our adult and pedi-atric areas representing the physician voice. The POD role was introduced to the clinical chairs and faculty at large with easy access via a designated cell phone num-ber. Daily routines include touch points with our admin-istrator on duty and bed flow manager, emergency room physician, Transfer Center staff, system partner hospi-tals, intensive care unit (ICU) physicians, pediatric teams, and perioperative services. The POD success-fully created a unified platform that is increasingly used by clinical faculty and has contributed to improved access and expedited inpatient flow. Intervention Detail. The impact of the POD Program was assessed by daily tracking of interventions that have been grouped into the following categories: transfer triage (to our aca-demic medical center [AMC] or partner hospitals), boarders (emergency department [ED], ICU, interhospi-tal transfers), delays in care escalation, quality and safety, and service disputes. All interventions are tracked in a logbook and categorized by the POD on call. Outcomes and Impact. In the first 17 weeks since estab-lishing a 24/7 POD role in our health care system, the POD engaged in 237 interventions (an average of 13.9 interventions/week) and facilitated 42 transfers to our AMC (an average of 2.5 transfers/week), and 24 trans-fers to our partner hospitals (an average of 1.4 transfers/week). This exceeded the predicted impact of 1 transfer to the AMC/week projected prior to implementation. On a daily average, the POD screens 7 ED boarders (accepted for inpatient admission at the AMC), 9 ICU boarders (waiting for placement in acute/intermediate care environment) and 10 transfer boarders (accepted for transfer to AMC waiting for bed assignment) for possible placement in partner hospitals. The POD allows us to modify our standard work in real time and make patient-centric decisions supported by the system needs at a given time. This includes overriding closed service line principles in the ICUs (adult and pediatric) in col-laboration with ICU medical directors, facilitating tran-sition from inpatient to outpatient care, providing medical triage for placement priority in our ED, and transfer center wait lists in close collaboration with accepting and referring physicians. The success of the program highlights the benefits of colocation and coop-eration between system-based nursing administrators and physicians. Using a multidisciplinary group of phy-sicians allowed rapid learning from each individual’s specialty area and formed an effective physician team to supplement our daily operations team.

Advance Care Planning Program

Kimberly S. Glassman, PhD, RN, NEA-BC, FAAN, Tom Sedgwick, MSSW, LCSW, CCM, Kevin Hauck, MD, MPH, and Christine Wilkins, PhD, LCSWNYU Langone Health

Background. The Advance Care Planning (ACP) Program was launched in 2014 to improve advance care planning for our patients across the continuum of care. Historically, ACP has typically occurred in crisis, during an acute inpatient episode. Even when an advance directive such as a health care proxy form was completed, it did not reflect a thorough conversation involving the health care agent. As a result, important decisions often were left to individuals with little or no knowledge of the patient’s end-of-life wishes. Similarly, documentation of patients’ wishes was fragmented, as there was little coordination between the inpatient and ambulatory settings. Also, the New York State Medical Orders for Life Sustaining Treatment (MOLST) form was seldom used, and there was not a central area in the electronic medical record to document and retrieve advance care planning efforts. The mission of the ACP Program is to promote enterprise-wide advance care planning in which patients’ health care preferences are discussed, documented, and honored by families, friends, and the health care community. The vision is that advance care planning becomes the standard of care for all patients system wide. Intervention Detail. Since the inception of the ACP Program, the following interventions occurred: the electronic version of MOLST (eMOLST) was integrated into Epic and approved as the standard document for do not resuscitate (DNR); code status orders changed to cardiopulmonary resuscitation (CPR)/DNR, eliminating the limited resuscitation option and mirroring MOLST; the ACP Navigator was devel-oped in Epic as a multifunctional location for document-ing and retrieving ACP; staff were trained in the Respecting Choices First Steps (FS) and Advanced Steps (AS) ACP Programs; implementation of AS ACP Program in heart failure, Cancer Center, and inpatient areas; cre-ation of educational materials on ACP, advance direc-tives, CPR, and breathing options; ACP web presence; ACP group sessions; and educated staff on ACP billing codes 99497 and 99498. Outcomes and Impact. The ACP Program was launched in 2015 and there has since been considerable growth across the organization. Advance care planning note completion for inpatients with an answer of “No” to the mandatory surprise question (“Would you be surprised if this patient died in the next 6 months?”) increased from 7% in 2016, to 17% in calen-dar year 2017, to 31% through September 2018. Advance care planning note completion for inpatients with a

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disposition of “hospice” or “expired” increased from 16% in 2016 to 29% in calendar year 2017, to 53% through September 2018. Similarly, eMOLST comple-tion for inpatients with an answer of “No” to the manda-tory surprise question increased from 3% in 2016, to 10% in calendar year 2017, to 25% through September 2018. eMOLST completion for inpatients with a disposition of “hospice” or “expired” increased from 5% in 2016 to 12% in calendar year 2017, and was at 33% through September 2018. When looking at the frequency of com-pleted ACP notes and eMOLST forms from program ini-tiation to date, there has been a significant increase in documentation. For example, from July 2016 through December 2016, 458 ACP notes were completed, yet 2311 ACP notes were completed for 2017, and 4064 ACP notes were completed from January 2018 through September 2018. Similarly, from August 2016 through December 2016, 40 eMOLST forms were completed, yet 679 eMOLSTs were completed from January 2017 through December 2017, and 1482 eMOLST were com-pleted from January 2018 through September 2018. The increase in documentation exemplifies the organization’s efforts to document and honor patients’ wishes at the end of life and the commitment to providing high-quality care through patient engagement.

Why Costs Matter: Improving Clinical Efficiency and Driving Down Case Costs in Surgery

Balaji Narayanan, MS, Six Sigma Black Belt, Kellie R. Brown, MD, Jamie R. Silkey, PA-C, MHA, and Jennifer R. Brown, RN, MSN, CNORFroedtert Health

Background. Preference cards provide the basis for operational, financial, and business decisions in the operating room (OR). Lack of a standardized manage-ment process led to incomplete case carts, delayed on-time starts, interruptions during the case leading to overall reduction in utilization, and increased expenses. Intervention Detail:

•• Designed a phased approach to cleanup, mainte-nance, optimization process, and ensuing education

•• Displayed and discussed supply cost and clinical outcomes transparently

•• Shared results from data collected on OR disrup-tions attributed to cards

•• Surveyed card design and routine for ongoing maintenance

Outcomes and Impact:

•• A 25% reduction in total cards in circulation•• A total of $240 603 in expense reduction for 276

“top-decile” cards over 6 months•• Increased surgical volume and operating room uti-

lization by 4%•• Improved on-time starts for first cases by 10.35%•• Positive changes in engagement and ownership

Stakeholder Involvement in Mortality Reduction

Erin Stapleton, RN, MHA, Douglas Obogo, BS, MPH, N. Scott Litofsky, MD, Premkumar Nattanmai Chandrasekaran, Brandi R. French, MD, Vicky Ferris, RN, CIC, Cindy Hestir, RN, MSN, Karen R. Cox, RN, PhD, Kathryn Qualls, PharmD, BCPS, Madihah Hepburn, MD, Kristen Marshall, RN, and Laura Qi, MDUniversity of Missouri Healthcare

Background. Academic medical centers accept referrals for care of our most challenging and acute cases. Regardless of severity, we strive to deliver excellent care and continually improve with each case. In fiscal year 2014, the neurosciences service line ranked below the 50th percentile for morality ratio with Vizient data. In fis-cal year 2015, the neurosciences service line leadership implemented a multidisciplinary, collaborative case review approach to assess improvement opportunities with each patient. The overarching question is always, “What would we do differently if we could do it all over again?” Intervention Detail. Stakeholders include a fac-ulty of experts who review every case and identify best practices as well as facilitate implementation of effective strategies to improve care. The theory of change is that teams learn faster and are more effective in implementing and spreading improvement ideas and assessing their own progress when collaborating with other teams. The World Health Organization’s model of stakeholder engagement further supports this theory. Our process is summarized in the following 6-steps. (1) Key features of each mortality case are summarized prior to the weekly team meeting. (2) The team reviews each case prior to convening together to discuss viewpoints and concerns. (3) Lessons learned and improvement opportunities are categorized by themes with follow-up action items gener-ated and assigned with a completion date. (4) At the start of each weekly meeting previous task assignments are presented and recommendations presented. (5) Trends are

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monitored using quality improvement methodologies and interventions initiated based on the results of the findings. (6) Interventions are monitored using the Plan-Do-Study-Act improvement methodology and feedback presented in subsequent meetings. The process measures include multidisciplinary attendance rate and the number of fol-low-up action items that were completed. Review find-ings were grouped into themes and the frequency of incidence was trended. Mortality ratio was the outcome measure, and performance was benchmarked against other academic medical centers using the Vizient Clinical Data Base. Outcomes and Impact. Based on the trends, several qualitative results were identified. These include the following: we were not getting credit for how sick our patients were as a result of poor documentation; noted delay in hospice transition; and treatment goals were not always explicitly stated prior to transfer from outside hospitals. Pre intervention the observed to expected mor-tality ratio was 1.2; post intervention this decreased to 0.68, which represents a 43% reduction. These results show the value of stakeholder involvement in mortality reduction. Stakeholders are more likely to engage in and sustain change processes when they identify problems and come up with their own solutions. Improving and saving lives takes a village; therefore, having an engaged multidisciplinary team who reviews mortality events is crucial.

Reducing Narcotic Use, Complications, and Resource Utilization Among Surgical Hip and Femur Fracture Patients

Karin Madsen Drescher, MD, Sheila C. Blogg, MSN, BSN, BA, Jamie Avdeev, MS, and Kathryn Lauer, MDMedical College of Wisconsin

Background. The Centers for Medicare & Medicaid Services proposed a bundled payment model for surgi-cal hip and femur fracture treatment (SHFFT), hoping to improve quality of care and decrease cost. Although the government program canceled plans requiring certain hospitals to participate in the original proposed payment model, Froedtert & The Medical College of Wisconsin (F&MCW) were inspired to improve care for the emer-gent surgical hip and femur fracture population. An interdisciplinary project team was assembled, including clinical and hospital leadership staff. After several facil-itated sessions led by process improvement experts, the team completed a map of current state processes, pain points, and improvement opportunities. The scope cap-tured patient arrival at the emergency department (ED)

through hospital discharge. Opportunities identified for improvement included appropriate pain management regimen; reducing risk of surgical, postoperative, and respiratory complications; appropriate admissions to intensive care units; improved care coordination, medi-cal optimization, and preparedness for surgery. Improvements with the aforementioned opportunities led to transformation in the delivery of care resulting in a more efficient use of health care resources, and improved outcomes and patient experience. While designing the future state for the SHFFT clinical path-way, all team members empathetically placed the patient at the core of all proposed improvements, rather than around the current system’s design. This unique approach is fairly new to health care and is becoming more prevalent as programs and payment models are being designed around patient-centered measures. Key components of the clinical pathway include administra-tion of regional blocks immediately upon arrival at the ED, enhanced recovery after surgery nutritional supple-ments preoperatively, early postoperative ambulation, less opioid use, and standardized medical management and communication methods. The clinical pathway launched March 1, 2017, and performance is monitored monthly by the multidisciplinary team and efforts are in place to continually refine the process for long-term sustainability. Intervention Detail. Data had been ana-lyzed measuring F&MCW’s performance compared to academic medical centers (AMCs). Efficiency, patient-centered, and clinical effectiveness measures were ana-lyzed using the Vizient Clinical Data Base/Resource Manager in conjunction with the hospital’s electronic medical record for specific process measures, and inter-nal billing database for cost. In calendar year 2016, patients admitted to F&MCW with a hip or femur frac-ture identified by Medicare Severity Diagnosis-Related Groups 480-482, reported an average length of stay (LOS) of 5.96 days (N = 243, LOS index = 1.01). The LOS index is calculated using an observed to expected ratio, applying the 2016 Vizient AMC risk model. When comparing calendar year 2016 performance with Vizient AMC members, F&MCW’s average LOS was 5.59 days (LOS index = 1.04); top decile performance reported 4.81 days (LOS index = 0.81). F&MCW is recognized by Vizient as a top-performing AMC; the project team is striving to sustain top decile performance with major episodes of care. Achieving top decile performance with LOS index (0.81) will save 282 inpatient days and yield a direct cost savings of $255 774 annually (average direct cost/day = $907). Of the AMC cohort, the aver-age direct cost index was 1.01, the top decile was 0.95, while F&MCW reported 1.18. When soliciting anec-dotal feedback from the clinical team, intensive care

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unit (ICU) admissions, high-cost medications, LOS, and management of avoidable complications were identified as major cost drivers. For ICU admissions, F&MCW reports a higher rate compared to the AMC cohort, 11.52% versus 8.83%, supporting the clinical team’s hypothesis. Complications such as respiratory failure result in unplanned ICU admissions requiring intense medical management, leading to higher cost for both the patient and the hospital. Calendar year 2016 baseline analysis motivated executive sponsorship, clinical lead-ers, and performance improvement team members to develop a clinical pathway that minimizes financial risk and improves the quality of care, prescribing value to the hip and femur fracture patient population. Outcomes and Impact. After March 1, 2017, outcomes improved and performance is trending in the positive direction. Two patient samples were compared to evaluate improvements: patients admitted with a hip or femur fracture prior to launch of the clinical pathway (January 1, 2016, to February 28, 2017, N = 285) and patients who completed the pathway during hospitalization (March 1, 2017, to December 31, 2017, N = 214). The pathway is triggered immediately upon patient arrival at the ED via electronic page to the entire care team. The regional anesthesia team is triaged to the ED and places a regional nerve block to manage the patient’s pain with minimal narcotics. The amount of opioids and narcotics administered during a single episode decreased by 0.72% morphine milliequivalents post implementation. The orthopedic, anesthesiology, and internal medicine providers also are alerted via the protocol activation page and collaborate with one another to coordinate a care plan for preoperative, intraoperative, and postop-erative care. Effective preoperative management reduces time optimizing the patient for the operating room and avoids surgery cancellations. Clinical leaders from nursing, physical therapy, nutrition services, surgi-cal services, emergency medicine, anesthesiology, med-icine, and orthopedics designed a process using the electronic record to collaborate. Clinical criteria for pre-operative optimization and postoperative management were developed to avoid delays to the operating room or cancellations; create transparency in each care plan; and identify scheduling barriers, appropriate ICU admis-sions, and LOS reduction. Post implementation, LOS index decreased by 0.03 (0.95 vs 0.92) and by 0.42 days (6.46 vs 6.04 days). ICU admissions have decreased by 3.7% (12.6% vs 8.9%) and the surgical patients are entering the operating room within 24 hours of arriving at the ED. Anecdotal evidence from the care team describes improvement in pain, earlier ambulation and bowel movements, and enhanced nutrition intake. Overall, the care is more orchestrated.

Ambulatory Pharmacy Electronic Consults: The Right Prescription in Our Evolving Health Care Environment

Elizabeth A. Koczera, PharmD, BCACP, Namone S. Pike, PharmD, and Megan M. Colgan, BADartmouth Hitchcock Medical Center

Background. Electronic consults were introduced at Dartmouth-Hitchcock as part of the Center for Medicare & Medicaid Innovation Coordinating Optimal Referral Experiences project in 2015. Since their initiation, 36 specialties have chosen to participate in this care model. We have several uncommon specialties participating, including ambulatory pharmacy. Ambulatory pharmacy consults can help improve patient care and reduce overall health care costs in a dramatic way. This specialty’s main focus—to provide patient care that optimizes the use of medication and promotes health, wellness, and disease prevention—is perfectly aligned with a high-value care model. We will demonstrate how ambulatory pharmacy electronic consults deliver on all 4 components of the Quadruple Aim: improving population health, increasing patient satisfaction, reducing per-capita health care spending, and improving clinician/care team satisfaction. Intervention Detail. To evaluate the impact of ambulatory pharmacy electronic consults, we retrospectively reviewed a total of 159 consults sent to ambulatory phar-macy between April 2017 and November 2017. This review consisted of deriving medication-related ques-tions in each consult and assessing whether they were informational or were recommendations to improve care. Recommendations accepted by primary care providers (PCPs) were used to calculate cost avoidance utilizing the nationally accepted formula developed at the US Department of Veterans Affairs referenced in the 2002 article published in the American Journal of Health-System Pharmacy.1 Patient satisfaction was assessed through a qualitative phone survey focusing on patients for whom the pharmacists’ recommendations were “accepted” by the PCP. Care team experience and satis-faction, both PCP and specialty, were assessed through online surveys between January 2017 and October 2017 and a recent online survey of the ambulatory pharmacists was conducted to evaluate pharmacist satisfaction. Outcomes and Impact. Ambulatory pharmacy receives an average of 28 consults per month—the highest requested electronic consult specialty by PCPs on a monthly basis—in comparison to the other 36 specialties. Our preliminary data show that 328 medication-related questions were derived from a total of 159 consults sent to ambulatory pharmacy between April 2017 and November 2017. Of

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the medication-related questions, 33% were informa-tional and 49% were recommendations to improve care. The latter category had a 93% acceptance rate by PCPs. Utilizing the nationally accepted formula developed at the US Department of Veterans Affairs, our preliminary findings with 8 months of data show that for the 149 “accepted” ambulatory pharmacy recommendations, more than $75 000 was saved in cost avoidance. The greatest dollars saved fell into the categories of “prevent or manage an adverse drug event” and “drug interac-tions.” We reached out by phone to 47 patients, with 18 agreeing to participate in the survey and 23 not being able to be reached. Of the 18 patients who agreed, 7 patients were aware a consult had been submitted. Findings show that 91% of patients were satisfied with the outcome of the consult and 44% of patients saw an impact on their health or experienced cost savings as a direct result. Results from care team experience and satisfaction sur-veys indicated that 94% of PCPs were satisfied with their ambulatory pharmacy electronic consult response. A recent online survey of the ambulatory pharmacists was conducted and all pharmacists stated they found their electronic consult experience satisfying.

1. Lee AJ, Boro MS, Knapp KK, Meier JL, Korman NE. Clinical and economic outcomes of pharma-cist recommendations in a Veterans Affairs medi-cal center. Am J Health Syst Pharm. 2002;59: 2070-2077.

Man Versus Machine: A Comparison of Chart-Abstracted Core Measures and Electronic Clinical Quality Measures (eCQM)

Ellen F. Robinson, PT, Maria G. Leal, RN, and Anneliese M. Schleyer, MDHarborview Medical Center

Background. Measurement of the quality of care pro-vided in hospitals has been reported through the Core Measures programs. Chart abstraction is considered the gold standard for collection of these data. The Meaningful Use Program provides incentives to hospitals with elec-tronic health records that can report on specific electronic quality measures (eCQM) without manual chart review. As hospitals begin publicly reporting eCQM performance it is critical that outcomes are accurately represented. We compared the results and performance between the 2 sys-tems and categorized discrepancies to measure the qual-ity of our chart abstraction and improve eCQM data capture. Intervention Detail. Source files from each sys-tem were pulled into tables in a database and merged to compare outcomes. Patient-level outcomes for each of

the 4 measures were evaluated for the total population of stroke cases for a 9-month period. Results were desig-nated as pass, fail, or exclusion. Cases were categorized as a match or a review through queries. The overall match rate between systems was 92% comparing 2172 records. The unmatched cases were categorized as follows: sys-tem reporting (32%), specification variance (30%), clini-cal data entry (19%), billing/coding (15%), with chart abstraction opportunities as the lowest variance (3%). Outcomes and Impact. In conclusion, eCQM reports can provide relevant information to clinical teams for improvement opportunities and can provide a system for tracking the quality of manual chart abstraction by acting as a comparative source for performance. The eCQM reports also can be utilized by quality teams to improve efficiency through reduced manual chart abstraction. This project prepares our hospital to shift focus from manual to electronic abstraction and ensures accurate reporting of quality performance as the eCQM program becomes more rigorously audited and publicly reported.

Impact of Drug Cost Awareness on Medication Utilization by Anesthesia Providers

Jessica Mullin, PharmD, BCPS, Calvin Motika, MD, Gregory Filatoff, MD, and Scott Pappada, PhDThe University of Toledo Medical Center

Background. Health care costs account for 18% of the US gross domestic product and are projected to grow to 20% by 2025. At the University of Toledo Medical Center, approximately 6% of the hospital’s budget is spent on inpatient and outpatient medications. Approximately 70% of the inpatient pharmacy budget is spent on medications. Studies evaluating various strategies to decrease medica-tion costs have had conflicting results. A systematic review of physician awareness of drug prices found that physicians were able to estimate the price of a medication within 25% less than one third of the time. It also showed that doctors tend to underestimate the cost of expensive drugs and overestimate the cost of less expensive alterna-tives. Finally, the review indicated that physicians want cost information and feel it would impact their prescrib-ing, but that the information is not accessible. At our insti-tution, cost savings initiatives have been encouraged within each department. This has increased interest in drug costs and often, physicians are surprised at the cost of medications and their alternatives. We received anecdotal reports of physicians changing their prescribing practices after being made aware of drug costs. This study aims to evaluate the impact of improving cost awareness to anes-thesia providers. Intervention Detail. At the University of

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Toledo Medical Center, anesthesia providers obtain the majority of their medications in trays that are used for a single patient case. Trays are returned to the pharmacy after use for charging and restocking. This was a single-center, prospective study that looked at pre- and postinter-vention data. Anesthesia drug utilization data was collected from all surgeries performed at the University of Toledo Medical Center from February 1 through April 30, 2017, and also for the month of June 2017. February served as a baseline with no intervention. In March and April, forms were distributed in the anesthesia drug trays that included drug prices. The forms were removed in May, which served as a washout period. Data from June were collected to assess for sustained effects. Average price of medications per case and overall utilization was collected. Medications with similar indications and sig-nificant price differences were matched 1:1 and a χ2 test was used to compare use between months. Outcomes and Impact. Over the study period, 3899 operative cases were assessed for drug cost and utilization. Average cost of medications was $68.88 per case in February, $57.36 per case in March, $60.35 per case in April, and $56.54 per case in June. Overall, when compared to the baseline month, there was a decrease in medication costs of approximately $12 000 in March, $8000 in April, and $11 000 in June. To perform statistical analysis over mul-tiple months, we paired medications that are available in the anesthesia medication tray, have similar indications, and have a significant price difference. There was a sig-nificant shift for using metoprolol instead of esmolol in March and June (P = .03, March; P = .08, April; P = .01, June). There was a significant shift for using vecuronium instead of rocuronium in April and June (P = .21, March; P = .001, April; P = .02, June). There also was a signifi-cant shift in use of a less expensive lidocaine product in March and June (P = .001, March; P = .06, April; P = .01, June). We also observed a 25% decrease in ephedrine use during all of the intervention months. When made aware of drug prices, anesthesia providers decreased use of expensive medications and chose less expensive alter-natives. Our findings indicated that the choice and presen-tation of drugs in our anesthesia trays have a large impact on utilization. We have initiated a multidisciplinary group of pharmacists and anesthesia providers who periodically review medications in the drug trays. We also review data on waste and shortages to balance medication availability and cost containment. Drug prices are displayed and updated periodically to better inform providers of medica-tion cost. This experience of increasing cost awareness can be applied to multiple areas in the hospital setting by bringing awareness of expenses associated with supplies, labor, and waste. In our study, we notified end users at the point of use, which has the advantage of allowing autono-mous decision making.

Modeling Observation/Inpatient Status Determination Pathways: “Getting It Right” for Everyone

Grant Sinson, MD, Julie Kolinski, MD, and Siddhartha Singh, MD, MSMedical College of Wisconsin

Background. Competing interests of patients, hospitals, and third-party-payors can pull in divergent directions when determining both the admission and continued care observation/inpatient status of hospitalized patients. Practically, this manifests itself in demands, such as “decrease our observation numbers,” “justify a new inpa-tient floor or an observation unit,” or “answer a patient’s desire to be admitted only as an ‘inpatient.’” Attempts to address any of these problems individually can have unin-tended consequences on other aspects of the organization with one “fix” actually hurting another outcome. These variables also can be difficult to even discuss if adminis-trators and providers find themselves speaking in unclear language, especially at a large academic hospital with more than 500 beds. Examples of differing patient descrip-tors include “bedded outpatients,” “observation patients in inpatient beds,” “obs unit patients,” or “outpatient for recovery.” Intervention Detail. To better visualize the pathways available to patients and highlight decision-making opportunities during their stay, we developed the Kolinski/Sinson Observation (KSO) pathway model. Between 2500 and 3000 patients per month provide input to the model: they represent admissions through proce-dural departments, transfers, and the emergency depart-ment. Outflow is defined as hospital discharge to home or another institution. Patterns of patient flow are represented in both their physical location and their admission status. Specific decision-making points define changes in status and patient flow. These decision points are impacted by payor criteria, provider judgement and documentation, patient needs, and the utilization review process. Stopping points along the admission are quantified with patient data and optimal pathways identified. Once constructed, the patient movement ratios (PMRs) are utilized to guide pro-cess changes and administrative decisions. Outcomes and Impact. The KSO pathway model provides clarity and guidance for communication and changes in administra-tive processes. Our experience in applying these princi-ples in numerous ongoing process improvement projects will be discussed. The KSO model also guides planning for future observation unit size needs. Modeling has sup-ported programmatic change for laparoscopic cholecys-tectomy patients to transition to home via the observation unit. Additionally, efforts within cardiology have focused on reducing the percentage of time that their inpatient unit beds are occupied by observation-designated patients.

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KSO modeling has identified subpopulations of patients for whom changes in process can move toward this goal. In an additional example, we evaluated our patient popu-lation who are initially admitted with outpatient status and intervened to optimize our utilization review procedures. In doing so, the conversion rate to inpatient status for this group increased from 28% to 36%. This was the result of a more timely/accurate process and was administratively viewed as positive. However, application of the KSO model and PMRs demonstrated a disproportionate number of these converted patients were initially admit-ted to our observation unit; upon changing to inpatient status a second in-house patient transfer was then required. Eliminating these transfers provided a target to increase both efficiency and patient satisfaction by addressing admission criteria to the observation unit. In all these examples, we also have found the model to be a useful reference when bringing administration and providers to the table to discuss care management pro-cess improvement.

Collaborative Coalition for Collective Community Health Impact

Muthusamy Anandkumar, MD, MBA, Srinivas Polineni, BS, Jacqueline Sullivan, PhD, RN, and Esmaeil Porsa, MD, MBA, MPH, CCHP-AParkland Health & Hospital System

Background. Parkland Health & Hospital System (Parkland), a public safety net entity, serves a large vul-nerable population of uninsured patients. Many of these patients with complex health and social needs frequently use emergency departments (EDs) as portals of care. In addressing Parkland’s mission to improve health and well-being within the community, Parkland leaders across several departments embarked on initiatives providing “better, smarter, healthier” care for high ED utilizer patients that resulted in reduction in unnecessary ED vis-its and admissions at the acute care point of service. These groups included complex care within the ED, value-based care (vCare) in primary care clinics, and Faith Health Initiative in the community. Using a Care Optimization and Standardization Initiative performance improvement methodology, programmatic accomplish-ments and individualized patient-centered care improve-ments were initially achieved. As these multidisciplinary teams proceeded to advance, they recognized opportuni-ties to strengthen intraorganizational collaboration for intensifying each program’s uniquely distinct approaches while collectively leveraging resources to further impact health and well-being in the community. This inspired

inauguration of the High ED Utilizer Affinity Group, including the original high ED utilizer groups, along with Parkland’s behavioral health department and Community Health Institute. The affinity group meets monthly and engages in dynamic bidirectional collaboration. As the affinity group’s progress accelerated, leaders recognized further opportunities for advancing interorganizational collaboration with other health care systems and commu-nity-based organizations (CBOs) to collectively leverage interorganizational resources within an integrated net-work of health and social services for the highly vulner-able across Dallas County. This collaborative coalition encompasses dynamic navigation involving health ser-vice delivery across multiple health care organizations as well as CBO coordination addressing homelessness, food insecurity, and post-incarceration community reentry. The coalition is launching innovative multifaceted initia-tives expected to significantly impact community health upstream, advancing population health where it begins rather than waiting for downstream detection of disease and chronic illness. Intervention Detail. Quantitative: Using pretest/posttest methods, Health Care Driven Measures will be subjected to analysis across organiza-tions participating in this coalition including: access to care, same-day clinic visits, ED visits, observation stays, hospital admissions, hospital readmissions, patient/fam-ily experience, and total cost of care. In addition to con-sidering the Health Care Driven Measures identified, a normalized ratio based on consideration of “opportunity” ED visits was developed in Parkland’s vCare Program and has been favorably reviewed by the Centers for Medicare & Medicaid Services in June 2017. This ED visits per patient per month ratio will be utilized as a pro-gram evaluation outcome measure across Parkland High ED Utilizer Affinity Group participants and will be shared with all participating coalition health care systems for consideration. Multi-organizational data regarding vol-umes and characteristics of ED visits will be analyzed across all participating coalition health care organizations using a Regional Master Patient Index (REMPI) limited data set available from the Dallas-Fort Worth Hospital Council (DFWHC) Data Registry. Given that the ultimate purpose of this coalition is to improve the health and well-being of the Dallas County community, the Regional Health Partnership 9: Community Needs Assessment (CNA) (2018) is being utilized as a baseline assessment of the community’s overall health, with longitudinal tracking on an annual basis to determine improvements in measures within CNA strategic priority domains: capac-ity/access, chronic disease, care coordination/preventive care (including ED utilization), behavioral health (includ-ing mental health and substance use disorder), and infant/maternal health. Qualitative: In addition to quantitative data, consideration of individual case studies/exemplars

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will provide rich contextual information as well as, most importantly, furnish insight into the “voice of the patient.” These case exemplars will be studied at the individual level as well as subjected to further qualitative analyses using the grounded theory method of content analysis to identify common categories and themes to further inform development of patient-centered interventions. Outcomes and Impact. Quantitative analysis of Health Care Driven Measures is being conducted using pretest/posttest meth-ods to demonstrate the collective impact of Parkland’s High ED Utilizer Affinity Group including complex care, vCare, and Faith Health Initiative. Parkland is proposing multi-organizational analysis of these data among partici-pating coalition members. The initial vCare patient cohort, enrolled in January 2017, demonstrated proven success with high-impact outcomes. This patient cohort (n = 15) had an aggregate baseline of 1.68 ED visits per patient per month ratio (June-December 2016). By May 2017, significant improvement in this cohort was demon-strated with 0.67 ED visits per patient per month ratio—a statistically significant reduction of 1.01. To date, more than 96 patients have enrolled in vCare. Data for the sec-ond vCare patient cohort (April-August 2017) is under-going analysis. Preliminary results indicate an even lower baseline preintervention ED visits per patient per month ratio with significant reduction in the postintervention ratio. Preliminary results of REMPI DFWHC Registry data indicate that a discrete subpopulation of patients (n = 80) are the highest ED utilizers (>30 ED visits during 12 months) receiving ED services across 2 to 3 DFWHC health care organizations. This recent information pro-vides even greater impetus for advancement of the coali-tion. Although preliminary results are quite compelling, further data sharing across health care organizations awaits finalization of a memorandum of understanding. Comprehensive analysis of Regional Health Partnership 9: CNA (2018) is being conducted. Early results are pro-found, indicating that excessive alcohol consumption occurred in 17% of the total adult population in Dallas County in 2018. Detailed CNA analysis is being pro-vided as the coalition’s baseline measurement. Qualitative analysis of individual and group-level patient case study data is being conducted for both baseline and postintervention analysis. Results will be provided dur-ing future presentations.

It Takes a Village: Developing Preferred Partnerships for Post-Acute Care

Cheryl L. Talbert, MSW, LCSW, and Nancy J. Maggard, RN, MSN, BC-NEUniversity of Kentucky HealthCare

Background. As health care needs continue to increase in complexity, multiple layers of resources (both medical

and social) are required to safely transition patients to the appropriate level of care. Health care organizations must successfully navigate through internal and external forces and encourage collaboration among multidisciplinary teams and community resources for successful discharge planning and partnership alignment. Intervention Detail. High-risk patients have complicated clinical and nonclin-ical needs, often leading to unnecessary utilization. Handling the needs of these patients in a traditional prac-tice can be time-consuming and appropriate support resources may not be available. The top 5% to 10% high-est-risk patients typically have multiple chronic illnesses and complex psychosocial needs. University of Kentucky HealthCare (UKHC) patients experience high utilization needs (high case mix index ranging from 2.14 to 7.79). Prior to the implementation of the partnerships, acute rehabilitation opportunity days were up almost 40% (approximately 600 days); nearly 1 in 5 Medicare patients discharged from the hospital—approximately 2.6 million seniors—are readmitted within 30 days at a cost of more than $26 billon every year. UKHC established a partner-ship with the Kentucky Appalachian Transitions Services (KATS), a public–private partnership charged with reduc-ing hospital readmissions by 20%, with length of stay (LOS), acute admission, Charlson comorbidity index, and number of emergency department visits within 6 months (LACE) scores of 16 or greater. Outcomes and Impact. As a result of the Preferred Partnership Program, UKHC LOS index has ranged from 0.97 to 1.10 (target, 1.03) and zero 30-day readmission for patients with LACE scores ≥16. Opportunity days (potential reduction in LOS) have ranged from a high of 623 to a low of 137 for skilled nursing facilities; a high of 514 to a low of 131 for acute rehab. Although data have improved, it is still a work in progress. UKHC continues to face challenges related to LOS with the increased number of patients requiring intravenous antibiotics who have a history of substance abuse and homeless patients. A new focused initiative is in the planning phase for a medical respite program in partnership with the KATS program.

Getting Disagreeable Surgeons to Agree

Kelli J. Kurtovic, BS, MS, LSSBB, and Caitlin M. Daley, BS, MS, SSBBDuke University Health System

Background. Prostatectomies and nephrectomies were identified as having high cost per case variation, length of stay (LOS) indices, direct cost indices, and readmission rates. Using Vizient to compare Duke to the 2015 U.S. News & World Report “best hospitals for urology” showed an LOS index of 1.11 versus 1.07 for prostatec-tomy and 1.25 versus 0.95 for nephrectomy; a direct cost index of 0.99 versus 0.94 and 1.24 versus 0.95; a 30-day

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readmission rate of 3.13% versus 2.75% for prostatec-tomy, and 10.38% versus 3.76% for nephrectomy. Duke’s internal cost data showed significant cost variation between surgeons driven by LOS and surgical services. Surgeon-to-surgeon median cost delta was $5200 for prostatectomies and radical nephrectomies. This was the first time the surgeons had seen their own aggregate LOS and cost data or that of their internal or external peers. These data were used to fuel their desire to change. Qualitative data were collected through interviews with nurses who routinely care for these patients. They revealed that they must remember 7 different ways to care for these patients because surgeries are performed by 7 different surgeons with 7 different treatment pathways. This was a major source of frustration for the nurses. It also created inefficiencies for residents as well as the need for several versions of patient education materials. Detailed analysis of Duke’s cost data showed that surgi-cal services cost variation was driven by the surgical approach (lap/robotic/open) and the level of learner assisting on the case. These were not things that this proj-ect team could change; therefore, the team did not focus on these. LOS variation was related in part to variation in surgeon practice patterns; thus, the team’s focus was on standardization from preoperative through discharge, with goals of reducing LOS, readmissions, and narcotic usage. Intervention Detail. The chief medical officer with the urology division chief and the assistant chief nursing officer with nursing leadership identified surgeon and nurse co-leaders for a cross-functional team. They were paired with an engineer/Six Sigma Black Belt. The engi-neer interviewed about 50 stakeholders to identify areas of practice variation and created a survey for surgeons to document current practices. Seven surgeons completed surveys. This was their first time learning their col-leagues’ practices patterns. A librarian searched for best practices for each treatment step. Survey responses were combined and surgeons met as a group during a series of 4 meetings. For treatment steps for which evidence existed, the group discussed the evidence and how it could be incorporated into their practices. Where no evi-dence existed, the group decided whether there was anec-dotal evidence to support 1 treatment method. If so, they agreed on 1 method. If not, differing methods prevailed. Meetings were scheduled at times convenient for sur-geons, were face-to-face as well as virtual to ensure max-imum participation, and were facilitated by the unbiased engineer. Because this group of surgeons is known for wide practice variation, it was important that each treat-ment step be discussed and that each surgeon verbally give agreement that he or she would follow the agree-ments. In cases of hesitation, the issue was discussed until a firm agreement was reached. After the series of meet-ings, final agreements were sent to all surgeons. They were again asked to acknowledge their agreement via

email. Standardized practices were built into preoperative and postoperative order sets. Technical services met with each surgeon prior to order set implementation to set up the order sets as favorites in their electronic medical record (EMR). Usage is reported monthly. The surgeon co-lead follows up with surgeons not using the order sets. Outcomes and Impact. Structured query language code was written to extract data automatically from the EMR. Metric visualizations were built in Tableau and are filter-able by discharge date, current procedural terminology, surgeon, unit, and anesthesia type. Tableau files are pub-lished on an internal website. Surgeons, anesthesiolo-gists, and nursing leadership have access to filter the data and print and paste it into documents. Process metrics include preoperative/postoperative order set usage. Additionally, metrics were built around treatment steps for those methods for which surgeons agreed on a single method so that we can track whether the agreements are being upheld. These include bowel prep, pain manage-ment, and diet. Metrics also are reported for nurse-driven components of care such as number of times and distance patients ambulate, and use of care plans and discharge education templates. For prostatectomy, preoperative order set usage has gone from 0% to 72% and postopera-tive order set usage from 0% to 100%. For nephrectomy, preoperative order set usage has gone from 0% to 50% and postoperative order set usage from 0% to 88%. For prostatectomy, the average LOS (ALOS) decreased from 1.61 to 1.42 days (−11.8%) after implementation, the LOS index decreased from 0.91 to 0.81 (−11.0%), and 30-day readmissions decreased from 4.7% to 3.2% (−32.0%). For nephrectomy, ALOS decreased from 4.58 to 4.35 days (−5.0%), the LOS index decreased from 1.19 to 1.15 (−3.4%), and the readmit rate decreased from 6.6% to 5.4% (−18.2%). Key takeaways: Data are power-ful and many surgeons are competitive. Use data to moti-vate surgeons to make improvements to processes and outcomes. There should be a physician champion for treatment standardization projects and having a neutral party facilitate agreement among providers can be help-ful. Do not assume providers know the details of the prac-tices of their peers. Do not assume providers know the outcomes of their patients as a population (ie, ALOS, LOS index, readmission rates). Many providers remem-ber the outliers, not the norm.

Umbilical Cord Blood Cultures

Lisa D. McGee, DNP, APRN, CCNS, CKC, and Courtney H. Weekley, MSN, APRN, RNC-OB, ACNS-BCUK HealthCare

Background. Neonates in the neonatal intensive care unit (NICU) at University of Kentucky HealthCare (UKHC)

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were receiving more than 1 venipuncture upon admis-sion, leading to an increase in blood loss to the neonate and an increase in nursing time. The UKHC Maternal and Neonatal Shared Governance Council recognized that venipunctures and blood loss in very low birth weight (VLBW) neonates (those who weigh less than 1500 grams) also cause stress, which can cause an increase in rates of intraventricular hemorrhage (IVH). The literature reflects that drawing specimens from the umbilical cord can limit or avoid a major phlebotomy event for the neo-nate. Literature also supports that sepsis can be accurately diagnosed for the infant by obtaining umbilical cord blood cultures (UCBC). The council set a goal to decrease to 1 venipuncture and 1 milliliter of blood loss for VLBW neonates. Intervention Detail. UKHC developed a proto-col for labor and delivery nurses to obtain UCBCs from VLBW neonates, and supply kits were made to stream-line the specimen collection process. Nurses were edu-cated about the protocol, process, and workflow surrounding it. The protocol was implemented in February 2016. The first 2 quantitative measures used were UCBC collection occurrence rates and contamination rates, which allowed monthly tracking related to compliance with the protocol and helped focus efforts for improve-ment. Two additional quantitative measures added were the number of venipunctures infants received upon admission to the NICU and IVH rates. These measures were used to compare the identified population of neo-nates to the other neonates in the NICU. Outcomes and Impact. UKHC saw improvement in all quantitative mea-sures. The UCBC occurrence rate has continued to trend upward and has been maintained at or above 75% for more than 6 months. The UCBC contamination rate for 2016 and 2017 combined has remained low, at 6%. Every neonate in the defined population has received 1 less venipuncture upon admission to the NICU as a result of UCBC being collected. Intraventricular hemorrhage rates for neonates who received UCBCs were lower in both 2016 and 2017 compared to other neonates in the NICU who weighed less than 1500 grams. This practice has made an impact on the care of these tiny babies, as even 1 milliliter of blood saved makes a difference.

Making It SWIFT: Automating Processes to Identify Patients in Need of Social Work Services

Nicole R. Silva, LICSW, and Nidia Williams, PhD, MBB, CPHQ, FNAHQLifespan

Background. Identifying patients in need of clinical social work interventions can be inefficient and labor intensive.

Intervention Detail. At Lifespan, we developed the Lifespan Social Work Intervention Facilitation Tool (L-SWIFT) to facilitate timely screening and prioritiza-tion of patients in need of clinical social work consulta-tion and/or intervention. This tool is embedded within our electronic health record and integrated into social work documentation workflows. Using L-SWIFT, manual case-finding processes for social work consultation were eliminated and replaced with a criteria-based scoring algorithm aimed at identifying and prioritizing patients in need of social work evaluation/services. Outcomes and Impact. Following implementation, the total proportion of patients seen by a social worker for a formal consult increased 200%. In addition to doubling the total number of patients receiving a consult, the number of hours between admission to inpatient and inpatient social work consult was reduced by 36.8% four months after imple-mentation. The number of hours between emergency department admission and social work consult increased following implementation of L-SWIFT because we learned that for specific patient populations with assigned social workers (seen following admission), the use of L-SWIFT was unnecessary.

To Infinity and Beyond: Integration and Transformation of a Health System

Julia A. Bossie, MSN, RN, CEN, CNL, Freda G. Lyon, DNP, MSN, RN, NE-BC, LeeAnna Spiva, PhD, RN, Jill Case-Wirth, MHA, BSN, RN, Gerald Hobbs, DNP, APRN, ACNS-BC, and Weslee Wells, DNP, MPH, APRN, ACNS-BC, CNS-CP, CNORWellStar Health System

Background. Our integration journey commenced when a 5-hospital system initiated a merger/acquisition of 6 hospitals, which transformed WellStar into an 11-hos-pital system, the largest health care system in the state of Georgia. Government regulation and reimbursement pressures drive hospitals to implement efficiencies that will lead to higher quality care, improved access, and lower costs. Our 10 emergency departments (EDs) serve 682 000 patients annually with high-risk popula-tions and it was paramount that our quality of care for each individual who sought care from WellStar Health System was the same, regardless of population or loca-tion. Intervention Detail. Uniform assessment tools were developed and completed. As expected, there was variation in workflows, processes, and policies that required standardization to ensure the safety of our patients across all facilities. On April 1, 2016, we

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became one WellStar and over the next 4 months bed-side nurses, physicians, pharmacists, security, biomedi-cal engineering, and leaders took on integration-related roles and responsibilities with the goal to minimize changes to operations and to limit interruptions to patient care. One year later, we sought to describe methods/strategies used during integration; provide current state analysis using clinical practice assessment data; and discuss next steps. Nurses collaborated to cre-ate and establish guiding principles, governance struc-ture, roles and responsibilities, issue escalation process, and work plans to guide team efforts. Our next steps included specialty-specific, standardized, evidence-based practice (EBP) tools created to assess clinical practice. Lean methods were used, which allowed teams to identify waste in processes that could be elimi-nated. Action plans/time lines were developed to imple-ment improvements and EBP. More than 400 action items were identified in critical care, perioperative, and emergency services. Data were analyzed using SPSS 24 software. Clinical practice data were collapsed into cat-egories with 22 themes identified and validated with leaders. Outcomes and Impact. Outcomes of teamwork, communication, and countless hours to plan for an effective transition included closing 330 operational items. Nursing and information technology created and deployed command centers for post support. We are a 20 000 plus team supporting 11 inpatient hospitals, 240 medical offices, and 19 freestanding diagnostic/imag-ing centers. Stabilization included prioritization, inven-tory, and closure of 243 clinical operational items. More than 90% of action items have been resolved, with policies/practice integration being the most com-mon item remaining, followed by information technol-ogy and throughput enhancements. On February 25, 2018, we went live with a standard electronic health record across the 6 new facilities. This large initiative took many phases of planning and putting out fires with technology and practice gaps that were discovered before and after go live. The fire hose urgency contin-ues, and new opportunities are discovered every day. The nursing practice team assesses these needs and cre-ates a plan to mitigate complications and collaborates with frontline teams at facilities to implement safety and quality strategies. Reconciling policies and proce-dures and merging ED practices on the basis of EBP is underway. More than 75% of ED policies have been adopted by 9 of the 10 EDs. Next steps include standard hospital policy adoption and building teams to review quality and safety practices to improve overall care and patient outcomes. WellStar Health System is on the journey to becoming a highly reliable organization and we look forward to planning and implementing EBPs instead of reacting to crises.

Where’s the Evidence? Putting Manufacturer Claims to the Test

Gina A. D’Agostino, RN, MSN, CPC, Paula Jurewicz, RN, MS, Ray Liu, MS, MBA, and Yue (Sally) Yin, BSYale New Haven Health; Vizient (Liu, Yin)

Background. The coronary stent market continues to evolve with new products introduced each year by vari-ous manufacturers. In this competitive context, manufac-turers use product claims to highlight the technological benefits and superiority of their own stents. The extent to which these claims are supported by scientific, clinical evidence, and the quality of available evidence varies. In some cases, there is limited or no evidence to confirm manufacturer claims. In others, evidence may be over-shadowed by conflicts of interest, such as direct manufac-turer funding. In this case study, published scientific evidence is used to test coronary stent manufacturers’ product claims to assess if the claims are supported by the evidence. Intervention Detail. For our analysis, we selected stents approved by the Food and Drug Administration for the US market between January 2014 and January 2018. Product claims for each stent were determined from the respective manufacturers’ official websites. To identify the relevant clinical evidence, a comprehensive literature search with the use of multiple search engines was performed (including PubMed, Google Scholar, ResearchGate, and Cochrane Library). With the support of a machine-assisted tool called EvidenceEngine, each paper was classified with an evi-dence quality score and an evidence direction score. The evidence quality is determined based on the paper’s study design, population size, publication date, peer-reviewed status, and potential for conflict of interest. The evidence direction is determined based on a sentiment analysis of the study’s conclusion relative to the claim being tested. The overall results are compiled using evidence quality as a weighting factor. Outcomes and Impact. A total of 30 product claims were identified from manufacturer web-sites. A literature search based on these 30 claims yielded 67 unique studies for evaluation. About half (16) of the identified claims were determined to be supported by the evidence. More than a quarter (8) were unverifiable and one fifth (6) of the manufacturer claims were outright refuted by the evidence. More than half (37) of the indi-vidual studies were found to have some type of conflict of interest, with more than a quarter (19) having received direct funding from the manufacturer. Therefore, clinical practitioners should be cautious when interpreting manu-facturer-stated claims without a comprehensive view of the respective evidence. Furthermore, when specific claims are not supported, the practitioner may need to

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evaluate each study in order to reveal negative safety or efficacy outcomes and their potential etiology. It is worth noting that evaluating the validity of manufacturer claims does not tell us whether the respective stent itself is clini-cally effective or superior—it only tells us whether or not the marketed claims can be supported. Applying a sys-tematic approach enables a quantitative, objective, and repeatable method by which to evaluate each manufac-turer claim. As manufacturers compete to gain the atten-tion of their potential customers, the ability to systematically differentiate between well-supported claims and poorly supported claims becomes increas-ingly important. Additionally, for each claim, a compre-hensive landscape view of the evidence quality and direction can reveal essential insights for health systems to make the most informed and clinically sound decisions regarding medical devices.

Clinical Benefits? Robotic-Assisted Prostatectomies Versus Traditional Techniques

Gina A. D’Agostino, RN, MSN, CPC, Paula Jurewicz, RN, MS, Ray Liu, MS, MBA, and Yue (Sally) Yin, BSYale New Haven Health; Vizient (Liu, Yin)

Background. It is estimated that almost 90% of all prosta-tectomies today are performed robotically. These proce-dures have come at a high cost for hospitals, with each robot requiring approximately $2 million in capital investment, along with an additional $3000 to $6000 in operational costs per surgery compared to the traditional laparoscopic approach. Despite the high costs and wide-spread adoption of robotic-assisted prostatectomies, the evidence of their effectiveness compared to nonrobotic approaches is rather mixed. Therefore, a systematic eval-uation is needed to more clearly understand the evidence landscape behind the application of this technology. In this analysis, the relevant studies comparing robotic-assisted radical and simple prostatectomies (RARP and RASP, respectively) to laparoscopic radical and simple prostatectomies (LRP and LSP) and traditional open radi-cal and simple prostatectomies (ORP and OSP) are com-pared. Intervention Detail. A comprehensive literature search of multiple databases (namely PubMed, Google Scholar, ResearchGate, and Cochrane Library) was per-formed for digitally accessible full-text articles and abstracts published between 2011 and 2018. Studies com-paring robotic-assisted prostatectomies with laparoscopic and/or open surgeries were included. With the support of a tool called EvidenceEngine, the studies were collected and analyzed based on their evidence direction and evi-dence quality. The evidence quality is quantified into a score based on the factors of study design, population

size, potential conflict of interest, publication date, and peer-review status. The evidence direction is determined based on a sentiment analysis of the study’s conclusion. An analysis of the clinical outcome results was then per-formed considering the following head-to-head compari-sons: RARP versus LRP, RARP versus ORP, RASP versus LSP, and RASP versus OSP. These results were then compiled with each study’s conclusion weighted by its evidence quality to arrive at an overall score (OS) for each head-to-head comparison. Outcomes and Impact. The evidence comparing RARP and LRP resulted in an OS of 4.2/10 in support of the robotic technique, with benefits that include functional outcomes (higher urinary continence and potency), lower blood loss and transfu-sion rate, and shorter length of hospital stay (LOS). In the comparison between RARP and ORP, the OS was 2.7/10 in weak support of the robotic technique, with benefits of lower blood loss and transfusion rates, shorter LOS, and faster recovery of functional outcomes, but longer opera-tion times. In the comparison between RASP and LSP, the OS of -0.1/10 in opposition to the robotic technique reveals that there is no meaningful difference between the 2 approaches. Finally, the evidence on RASP versus OSP indicated an OS of 4.0/10 in support of the robotic-assisted approach, with lower transfusion prevalence and shorter LOS, but longer operation times. Although robotic-assisted surgeries have numerous potential bene-fits over traditional techniques, a systematic and quanti-fied evaluation of the evidence surrounding these surgeries reveals unique insights that are very valuable for health system decision making. The wide distribution of the study conclusions indicate that the benefits of the robotic-assisted approach over traditional techniques are not necessarily clear-cut. In order to make an evidence-based evaluation, it is important for clinical practitioners to examine the evidence both holistically and individu-ally to ensure an objective and unbiased result. This anal-ysis shows that having a comprehensive view of the evidence landscape using a systematic approach is imper-ative. The systematic analytical approach applied here helps bring objectivity, comprehensiveness, and replica-bility to evidence analysis and interpretation, thereby providing clinicians with a more accurate and truthful understanding of what the evidence reveals.

Additional Power Huddle and Panel SessionsSuccess: Improving and Transforming End-of-Life CareKatherine A. Hochman, MD, FHM, MBA; Michelle Ulrich; William Winfree, MHA; NYU Langone HealthFrank M. Volpicelli, MD; NYU Langone Hospital–BrooklynNicole Adler, MD, FACP, FHM; Manhattan Campus NYULH, and NYU Winthrop

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Population Health: Collaboration to Achieve High-Reliability Team-Based CareJennifer Raum, MD, MBA, FACP; Molly Clark, PharmD, MHA; Sanford HealthNote: The Population Health: Collaboration to Achieve High-Reliability Team-Based Care panel presentation was presented in collaboration with Houston Methodist West Hospital.Improving the Value of Transcatheter Aortic Valve Replacement: A Health System PerspectiveBraden W. Batkoff, MD, FACC, MMM; Bob Hunter, MA, MBA; Providence Spokane Heart InstituteWithout Culture, Strategy Doesn’t Even Get Invited to LunchBob Page; Tammy Peterman, MS, RN, FAAN; The University of Kansas Health SystemFriend or Foe: The PEER Approach to Creating Value Within the Multihospital Pharmacy EnterpriseSteve Rough, MS, RPh, FASHP; University of Wisconsin HealthDan Schenkat, PharmD, MS; University of North Carolina Medical CenterAligning Strategy and Operations Using Lean Management SystemsJustin Farren, MBA; Yuma Regional Medical CenterVascular Access Stewardship: Enhancing Patient Safety One (Less) Line at a TimeNicole Adler, MD, FACP, FHM; Manhattan Campus NYULH, and NYU WinthropKatherine A. Hochman, MD, FHM, MBA; NYU Langone HealthDiscover How a “Total Health” Approach to Care Improves Patient and Community HealthJohn Vu; Kaiser PermanenteEvidence-Based Approach: Reduce 30-Day Readmissions for Congestive Heart Failure PatientsJames W. Ingerson, MSN, RN, CNL; WellStar Paulding HospitalConnecting Patients to Hospice Care in the Emergency DepartmentJillian Hauser, MIE; Momen M. Wahidi, MD, MBA; Duke University Health SystemHealth Care Disparities and Closing the Gap in Pneumonia ReadmissionsWendy Renedo, RN, BSN; Larry Weems II, MD; Novant HealthHumanizing the Chart: Becoming More Responsive to Patient NeedsBradley H. Crotty, MD, MPH; Inception Health and Froedtert & The Medical College of WisconsinImproving Opioid Safety With Behavioral Economic Theory—How to Use the “Nudge”Adam J. Bursua, PharmD, BCPS; UI HealthThe Big Read: Improving Attitude Toward End-of-Life Care

Brian P. Bosworth, MD, FACG; NYU Langone Health’s Tisch HospitalKatherine A. Hochman, MD, FHM, MBA; NYU Langone HealthJourney to Workforce Empowerment: A “Meaningful” Culture ChangeShannon B. Stewart; Judy Yankey; New Hanover Regional Medical CenterTop of License Pharmacy Work in the Ambulatory SettingDoug Marx, DO; Chris Sanders, PharmD, MHA; Froedtert & The Medical College of Wisconsin

Additional Vizient SolutionsInformation, Execution, and Management With Clinical InsightJosh Martin, Tina Stevens, Lori Jensen, RN; North Mississippi Health Services; Vizient (Jensen) [Vizient Solution: Vizient Advisory Services]Proven! The Clinically Integrated Supply Chain Governance Model in ActionCambria Kang, MD; Kaiser Permanente [Vizient Solution: Vizient Member Business Ventures]

Additional Poster PresentationsContinuous Improvement in a Colorectal ERAS Population: A Multidisciplinary ApproachRobin Anderson, BSN, RN; Caitlin Daley, MS; Duke University Health System“We Need More Clinic Space!” Moffitt Cancer CenterSusan Avon, MIS, PMP; Jodi Conway, MPA; Moffitt Cancer CenterConsidering Sepsis Earlier: Improving Sepsis Recognition and Management in the EDJohn Lanphere, MBA; Aekta Andrea Miglani, MD; University of Rochester Medical Center/Strong Memorial HospitalTelestroke at Scale: Not Just for For-Profit OrganizationsZach Griffin, MBA, MHA, FACHE; Providence St. Joseph HealthData-Driven Antimicrobial Stewardship: Improving Outcomes, Changing Culture, and Saving MillionsNick Bennett, PharmD, BCPS; Sarah Boyd, MD; R. Erin Johnson, MS; Saint Luke’s Health SystemImproving Screening Rates for Diabetes Mellitus Among High-Risk PatientsFernanda C. G. Polubriaginof, MD, PhD; David K. Vawdrey, PhD; NewYork-Presbyterian HospitalImproved Patient Satisfaction and Engagement: A Patient-Centered Appointment Reminder SystemJake Moore, MBA; Neha Patel, MD, MS; University of Pennsylvania Health System

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If the Glove Fits: Hospital-Wide Universal Gloving—Improved Hand Hygiene and Reduced C Difficile Infection RatesLynne Brown, MBA, RN; Paritosh Prasad, MD, DTM&H; University of Rochester Medical CenterGet the PICTR: A PDSA on A3 ThinkingJean M. Lakin; Whitney Walters, BSE, MSE; Michigan MedicineNo Short Cuts and No Silver Bullets: The Journey to Achieve Sustained and Significant Reduction in 30-Day Readmissions Across an Academic Health SystemWendy Stulac Motzel; Siddhartha Singh, MD, MS; Froedtert & The Medical College of WisconsinEnhanced Recovery for Colorectal Surgery and Cystectomy: Improving Outcomes and Patient and Family-Centered CareRoy Soto, MD; Oakland University William Beaumont School of MedicineBreaking Well: A Model for Balanced Breakthrough Therapy Evaluation and ImplementationPhilip J. Trapskin, PharmD, BCPS; UW HealthAll Quality Is Local: Accountable Care Teams as the Foundation for High Reliability

Michael Walsh; Samuel Zielke, MS IE; Froedtert HospitalThe Enhanced Interdisciplinary Care Team: A Novel Approach to Facilitating Challenging DispositionsAmarpreet Bains, MD; Deserie Duran; Lorna Lee-Riley, LMSW, CCM; NYU Langone Hospital–BrooklynImplementation of a Hemophilia Management Program Improves Clinical OutcomesGiles W. Slocum, PharmD; Thomas A. Webb; Rush University Medical CenterThe Journey to Patient-Centeredness: A Marathon, Not a SprintGaurav Jain, MD; The University of Alabama at BirminghamDisproportionately High Readmission Rates Among Weekend Discharges: A Reversible PhenomenonJoseph Song, MD; Washington University School of Medicine in St. LouisManaging Acute Agitation: The Evolution of a New ExpertChristine Buth, MHA, BSN, NE-BC; Froedtert & The Medical College of WisconsinMelissa Gregor, MSN, RN; Jessica Thomey, MSN, RN, NE-BC; Froedtert Hospital