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Quarterly Medical Staff Breakfast Quality Update
March 30, 2016
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State of Quality
• Clinical GPA … Trinity average
• $1.9M loss in Inpatient Prospective Payment System (IPPS)
– Value Based Purchasing/Readmissions/HACs
• Hospital Safety Score = “C”
• Consumer Reports Safety Score of 49%
– Leads Syracuse Market for Consumer Reports
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Clinical Quality Scorecard
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Patient Experience Scorecard
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0
10
20
30
40
50
60
70
80
90
100
Pro
po
rtio
n P
erc
en
tile
Unit
Urine Catheter Device Utilization Ratio by Unit
Q3
Q4
Jan
0
10
20
30
40
50
60
70
80
90
100
Pro
po
rtio
n P
erc
en
tile
Unit
Central Line Device Utilization Ratio By Unit
Q3
Q4
Jan
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0.32
0.61
0.92
0.82
2.40
1.60
2.10
0.58
1.00
1.41
1.68
2.33
1.30
1.63
1.00
0.33
0.99
0.00
1.01
1.28
1.60
0.67
2.28
1.93
1.73
1.86
0.83
1.53
1.27
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0.00
0.50
1.00
1.50
2.00
2.50
3.00
Jan -14
Feb -14
Mar- 14
Apr -14
May- 14
Jun -14
Jul -14
Aug -14
Sep -14
Oct -14
Nov -14
Dec -14
Jan -15
Feb -15
Mar- 15
Apr -15
May-15
Jun -15
Jul -15
Aug -15
Sep -15
Oct -15
Nov -15
Dec -15
Jan -16
CA
UTI
pe
r 1
00
0 D
evi
ce D
ays
Month
House-Wide CAUTI Rate 2014 - present
SIR
Rate
0.56
0.93
1.31
1.08
0.00
0.33
1.20
1.08
1.30
1.06
0.34
1.42
0.72 0.69
0.36
1.00
1.37
0.76
0.35
1.31
0.97
1.37
2.34 2.41
1.33
1.19
0.36
2.74
1.79
0
0.2
0.4
0.6
0.8
1
1.2
1.4
0.00
0.50
1.00
1.50
2.00
2.50
3.00
Jan -14
Feb -14
Mar- 14
Apr -14
May- 14
Jun -14
Jul -14
Aug -14
Sep -14
Oct -14
Nov -14
Dec -14
Jan -15
Feb -15
Mar- 15
Apr -15
May- 15
Jun -15
Jul -15
Aug -15
Sep -15
Oct -15
Nov -15
Dec -15
Jan -16
CA
UTI
pe
r 1
00
0 D
evi
ce D
ays
Month
House-Wide CLABSI Rate 2014 - Present
SIR
Rate
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Catheter Associated UTI - Strategy
• Criteria for insertion • Catheter removal
– Nurse-driven protocol – Daily reminder to providers – Alternative urinary devices (male
external catheters & female urinals)
Key Takeaway: Foleys should not be used for convenience but instead by evidence based criteria
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CLABSI - Strategy
• Line strategy: – VAT (vascular access team) floors and providers/nurses units
• Midline catheter
• US-guided PIV (peripheral IV)
• PICC line (peripherally inserted central catheter)
• Daily Assessment & Early Removal
• Peripheral blood cultures – Central line cx increases false positive CLABSI
Key Takeaway: Consider alternative devices when ordering venous access
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Did you know ?
• We are in top decile in GYN, vascular, and orthopedics ?
• Did you know we are in 10th decile rank for pneumonia ?
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How can you help ?
Q: Do you give the expectation of getting out of bed the day of surgery ? Q: Do you encourage your patients to get out of bed to eat and ambulate ? Q: Do you encourage your patients to brush their teeth ?
HABIT
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Did you know ? We are outliers for SSI procedures in New York State 3 years in a row…
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0.00
2.00
4.00
6.00
8.00
10.00
12.00
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Rat
e p
er
10
00
Pt-
Ins
day
s Severe Hypoglycemic Episodes (<50mg/dL)
Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol
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0.00
2.00
4.00
6.00
8.00
10.00
12.00
May
-14
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Rat
e p
er
10
00
Pt-
Ins
day
s Severe Hypoglycemic Episodes (<50mg/dL)
Initiation Hypoglycemia Response Team and Pharmacy Lantus Protocol
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0
5
10
15
20
25M
ay-1
4
Jun
-14
Jul-
14
Au
g-1
4
Sep
-14
Oct
-14
No
v-1
4
Dec
-14
Jan
-15
Feb
-15
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
Dec
-15
Jan
-16
Feb
-16
Pe
rce
nt
Pat
ien
ts
Recognition and Documentation, and Sepsis Mortality 5/1/14-2/29/16
Inpatients with Sepsis
Documentation and CDI Education
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SEP-1: CMS Core Measure Oct, 2015
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION † :
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate ≥4mmol/L
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid
resuscitation) to maintain a mean arterial pressure (MAP) ≥65mmHg
6. In the event of persistent hypotension after initial fluid administration
(MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume
status and tissue perfusion and document findings.
7. Re-measure lactate if initial lactate elevated.
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sepsis 3-hour & 6-hour Bundle Compliance Core Measure OFIs
ED
ICU
M/S
0% 0% N/A 0% 0% N/A 0%
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Sepsis CMS SEP1 Reevaluation smartphrase or “dot phrase”:
.sepsisreevaluation
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Peer Review Process:
Quality Improvement NOT Quality Assurance.
Multidisciplinary review structure.
Review is intended to find areas for patient care improvement through process and system focused review NOT point fingers or blame.
Reporting structure is set up to improve care and quality throughout organization.
Structured to maintain Confidentiality and Non discoverability.
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Peer Review Structure:
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Peer Review: Quality Improvement Themes/Trends.