mha: strategic qualityweb.mhanet.com/lnlwuw3-4-15.pdf · 2015-10-22 · reactive proactive . key...
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MHA: Strategic Quality What’s Up Wednesday | Lunch and Learn Your clinical quality, process improvement resource
Jessica Rowden, RN, BSN, MHA
Clinical Quality Improvement Manager
March Topics of Interest
Refresher: Data/Website
Patient Safety Month Spotlight
Collecting total harms
Transparency at the unit level
Hospital Spotlight – Saint Francis Medical Center
Transparency Update
HEN 2.0 Update
Upcoming Events
2015 Missouri Quality Outcome Measures
Refresher
Quality Collections
www.hidianalyticadvantage.com
– MOHEN – if you have not uploaded your data, touchbase with me
– HIDI is able to upload data from other HEN cohorts into Quality Collections for continuation of tracking; touchbase with me
SQI Website: http://web.mhanet.com/strategic-quality/
Patient Safety Month Center for Patient Safety Update
Tina Hilmas, RN BSN
888/935-8272, ext. 222
March is Patient Safety Awareness Month
Patient Safety Awareness week
March 8-14, 2015
http://www.centerforpatientsafety.org/category/patient-safety-awareness-month/
What is Patient Safety?
Buzzword that is difficult to define
“Patient Safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care deliver. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events”
March is Patient Safety Awareness Month
http://www.npsf.org
Annual Conference: “Safe Care is Our Focus, 24 hours a day, 7 days a week, 365 days a year”
March 13, 2015
Crowne Plaza, Bridgeton, MO
http://www.centerforpatientsafety.org/2015conference
Share with us what you’re doing for Patient Safety Awareness Week!
Transparently Tracking Harms Approach & Impact
Safety of Hospitals Compared with Other Hazardous Industries
Engaging Staff in Safety
Daily identification of potential safety risks, opportunities for system failures, at-risk behaviors, raised awareness
Utilize huddles
Leadership presence on units – you have to ask the questions!
In the moment solutions and implementation
Huddles
DEBRIEF – an underutilized tool
– Real-time discussion
– Immediate fix
– Items to turf to the PI team
– Platform to spread the lessons learned-quickly-to fix the system
Don’t forget…
Communication – key to success
Engage stakeholders – not just the “normal” ones
Finance
Coding/abstracters
PR/marketing
Patient & Family
Count All Harms
Create a performance improvement measurement system to track and reduce all-cause harm
Use consistent, standardized measures if possible—but don’t get lost in the measure!!
“What really matters…is the harm that patients suffer — some of it due to errors, but most of it resulting from flawed systems within which highly skilled providers operate.” --IHI
This is about people…
Improving Harm Rates (/ Discharge)
HACs Baseline
Time Period
Baseline
Rate
Target
Rate
Current Rate
[time period –
last 3 months]
Improvement
Status (scale)
ADE 1/1/11 – 12/31/11 .0001 .0000 .0000 Ideal
CAUTI 1/1/11 – 12/31/11 .0029 .0017 .0022 Progress
CLABSI 1/1/11 – 12/31/11 .0011 .0007 .0010 Progress
EED 1/1/11 – 12/31/11 .0011 .0007 .0000 Ideal
OB 1/1/11 – 12/31/11 .0002 .0001 .0010 Opportunity
Falls 1/1/11 – 12/31/11 .0043 .0026 .0050 Opportunity
PU 1/1/11 – 12/31/11 .0001 .0000 .0000 Ideal
SSI 1/1/11 – 12/31/11 .0003 .0002 .0008 Opportunity
VAP 1/1/11 – 12/31/11 .0000 .0000 .0000 Ideal
VTE 12/1/11 – 12/31/11 .0001 .0000 .0010 Opportunity
Total 1/1/11 – 12/31/11 .0101 .0060 .0110 Opportunity
Readmissions 1/1/11 – 12/31/11 .1096 .0877 .1312 Opportunity
13
What does this mean to staff??
How does this information drive improvement? How do you know?
Put a Face on the Data
• Total harm is compelling data with an emotional impact
• Creates urgency to do what is right
• Has applicability to every person
• No rates, No denominators…ONLY numerators
“When organizations stop looking at harm rates and denominators, and begin to focus on only the numerators or numbers of patients harmed, this changes the focus of the staff from data to people and it becomes a personal crusade to keep those numbers to a minimum.”
—Cathleen Krsek, MSN, MBA, RN, FAAN Senior Director, UHC
25
30
35
40
45
50
55
60
HARM
S/1
,000 P
ATIE
NT D
AYS
Missouri Total Harm Per 1,000 Patient Days Baseline Goal MO
Reduced Total Harm by 22.7 harms/1,000 patients
15
For every 1,000 patients, 35 are harmed in Missouri
Be Transparent
In a HIPAA protected area (unit break room), post unit
harms at the patient level
Harms this Month:
Harms this Year:
Hospital Spotlight Saint Francis Medical Center
3/4/2015
MEWS (Modified Early Warning System)
Denise Ernst, RN, BSN, CCRN, CSC, CMC
Manager, CICU & Chairperson of Code Blue Committee
Saint Francis Medical Center
• 284 – bed facility
• Located in Cape Girardeau, Missouri
• Catholic Healthcare Provider
• Mission:
“To provide a ministry of healing and wellness
inspired by our Christian philosophy and values.”
• Serves more than 650,000 people throughout
Missouri, Illinois, Kentucky, Tennessee, Arkansas
What is MEWS? (Modified Early Warning System)
• A scoring system that assists in the identification of high risk patients based on changes in vital signs and oxygen saturation levels.
• Identifies patients likely to deteriorate so additional steps can be implemented to avert further decline.
MEWS Implementation Goals
• Decrease the number of unplanned transfers to the intensive care units.
• Decrease the number of cardio-respiratory arrests outside of the ICU setting.
• Earlier discussion with patient and families of Designation of Code Status and/or Palliative Care and Advanced Directives.
• Provide assessment and intervention education for nursing and respiratory therapy staff members.
• Promote critical thinking skills for nursing and respiratory therapy staff members.
MEWS Implementation
• The implementation of MEWS should increase the number of
RRT’s, promoting earlier recognition and intervention, and
therefore, decrease the number of Code Blues.
Evidenced Based Studies indicate early recognition and intervention
saves lives
Too Late
Reactive
Proactive
Key Points
• MEWS scores are a tool to bring attention to vital signs of deterioration
• Physiological deterioration usually precedes critical illness
• It is important to recognize and intervene when patients have abnormal vital signs
• Early effective intervention can improve patient outcome and use of intensive care resources
• Abnormal early warning scores trigger a call to Rapid Response Teams, who are there to help manage deteriorating patients.
Avoid the Panic Mode
How It Works • BASED ON VITAL SIGN PARAMETERS
• Heart Rate
• Blood pressure
• Respiratory Rate
• Temperature
• Oxygen Saturation
SCORING
• Each parameter is given a score
• Normal parameters = 0
• Abnormal parameters = 1,2,or 3
• Detects early signs of deterioration so changes can be acted upon appropriately.
MEWS Scoring Parameters 3 2 1 0 1 2 3
Pulse Rate
(bpm) <40 40-50 51-100 101-110 111-129 >130
Respiratory
Rate <9 9-14 15-20 21-29 >/= 30
Temperature <35.1 35.1-36 36.1-38 38.1-38.5 >38.5
Systolic BP <71 71-80 81-100 101-199 >/= 200
O2 Sat <84 84-87 88-92 93-100
Example of automatic scoring of MEWS
Treatment Guidelines
What We Did • Assembled a Multidisciplinary Workgroup
• Identified Pilot areas by analyzing the Code Blue /RRT data specifically the
number per pt day by unit/department
• Identified a process to alert staff involved for critical MEWS scores
• Developed a timeline for implementation
• Developed a Newsletter to be distributed to patient care areas about the pilot
• In the process of developing a detailed education plan for all staff involved in the
pilot. (RN’s, NA’s, RT’s, ICU RN’s, Telemetry RN’s and Supervisors)
• Discussed workflow changes that will affect the staff involved in the pilot
• Used evidenced based research to validate the tool and provided that information
to our physician champions
Goals of the MEWS Pilot
Clinical Goals of MEWS pilot:
• Reduce number of Code Blues outside of the ICU
• Reduce (LOS) Mortality by earlier assessment and
intervention based on MEWS scoring
• Increase number of Rapid Responses (RRT’s)
Non-Clinical Goals of MEWS pilot:
• Determine impact on Staff
• Determine patient population triggering the Alerts
• Determine peak days and times of the alerts
• Determine if the alerts impact LOS/Cost
Expectations • Accurate, timely, and real-time documentation of
complete set of vital signs is the key to success.
• Increase in the number of RRT’s with increase in the
workload of the ICU staff.
• Reduction in number of Code Blues outside of ICU.
• Reduction in LOS resulting in less cost for the
patients and organization.
• Reduction in unplanned transfers to the ICU.
• Increase in bedside monitoring.
• Calling a Rapid Response (RRT) even if the patient
LOOKS GOOD for MEWS greater than 5.
RRT vs Code Blue
34 3/4/2015
10 6
13 10 16
7 7 11 5 6 6
2
51 51 42 45
69
52
137
197
115 111
64
98
0
20
40
60
80
100
120
140
160
180
200
1Q12 2Q12 3Q12 4Q12 1Q13 2Q13 3Q13 4Q13 1Q14 2Q14 3Q14 4Q14
RRT vs Code Blue
# OF CODES OUTSIDE ICU EXCLUDING ER # OF RRT EPISODES
Linear (# OF CODES OUTSIDE ICU EXCLUDING ER) Linear (# OF RRT EPISODES)
Lessons Learned
• After RCA on in-house STEMI not meeting 90 min PCI goal, RRT
activation occurred for any patient with CP
• Alarm fatigue with increase in RRT’s due to CP
Identified need
for additional
program to
support
Progressive
Care Nurses
with chest pain
patients:
RACER!
RACER TEAM • Core Team:
* PCU Charge Nurse
* Telemetry Room Nurse on PCU
* Primary Nurse for the patient
• CICU nurse: notified by this team as needed
for additional expertise and assistance.
• Used on the Progressive Care Unit only.
• RRTs to continue to be called on all other
inpatient areas for patients with chest pain.
.
36 3/4/2015
RACER PROCESS
Charge & Telemetry Nurse Assess with Primary
Nurse
Start Chest Pain ProtocolO2, NTG, stat ECG
May Consult CICU Nurse for ECG Interpretation
Telemetry Nurse informs Charge above and brings
ECG machine
Primary Nurse will push Telemetry Room button
on Responder 5
Fax or take ECG and old ECGs for comparison
ST
Rapid Response Called STEMI Activation
ST
RACER DATA 2014
38 3/4/2015
RACER Team implementation prevented 577 RRT’s
in one year!
Staff had more appropriate responses to RRTs!
Sharing Best Practices
“Transforming Cardiac Outcomes:
Implementation of the “RACER” TEAM” will be presented at the National
Association of Clinical Nurse Specialists by:
Barbara DeRossett, RN, MSN, ACNS-BC
Clinical Nurse Specialist
Progressive Care Unit (PCU)
Lisa Job, RN, MSN, ACNS-BC
Clinical Nurse Specialist
Cardiac Intensive Care Unit (CICU)
Summary
• MEWS program significantly decreased
Codes outside ICU.
• RRTs increased to a level that caused a lack
of response (alarm fatigue), this lead to
development of RACER program.
• Ongoing evaluation of MEWS/RRTs/Code
Blues are needed to improve patient outcomes
and support staff critical thinking/decision
making.
Questions??
Transparency Initiative Update
Transparency Launch
On Tuesday, February 17th MHA launched phase one of the price and quality transparency initiative
Objective
To support Missouri’s hospitals in continuing to provide safe, timely, effective, efficient and patient-centered care by sharing best practices
Where is the Data Stored?
The state aggregate price and quality data will be posted on MHA’s website, Focus on Hospitals.
Which Measures Are Included?
Twenty-one claims-based measures have been selected to highlight Missouri’s health care quality strategy
How Can I Validate?
Concurrent to the release of state-aggregate data, hospitals will be able to access their hospital-specific quality data via HIDI Analytic Advantage® for internal review
Resources
MHA has developed a tutorial to assist quality staff with accessing and understanding their quality data
Transparency Timeline
Summer 2015- Data Use Agreements with non-marketing clause dissemination
January 2016- Hospital-Specific Dashboard release (for hospitals who sign
DUA)
Upcoming Education
Missouri Quality Transparency Update
Tuesday, April 7. Noon-1 p.m.
Register here
Missouri Quality Measure Coding
Tuesday, April 21. 10-11 a.m.
Registration will be forthcoming
Questions?
Dana Downing
Director of Quality Program Development
573\893-3700, ext. 1314
HEN 2.0 Update
99 site visits in 2014 to date
Health Literacy Missouri consultation to 12 hospitals
Hospital Survey on Patient Safety Culture through CPS offered to 36 hospitals
Previous HEN Project Value-Added Benefits
71 hospitals applied for 2014 Educational Funding
2014: $213,000
2013: $162,500
Total: $375,500
Data stipends were given in 2014
Total: $279,000
53
Webinars, conference calls, virtual education and in-person meetings
All 10 topics
Cross-cutting topics
78 total in 2014
1,115 participants
Reimbursement/waived fees for MHA sponsored education
2013-2014 covered expense for 54 participants to Infection Control Conference
Previous HEN Project Capacity, Collaboration, & Engagement
966 IHI Open School courses completed
Improvement Leader Fellowship: 47 attended
Purdue Medication Safety Course: 16 attended
National Patient Safety Foundation curriculum: 68 attended, 59 courses completed
Travel reimbursement to safety and quality education events
54
HEN 2.0 Overview
Who’s involved: CMS’ goal to include as many or more hospitals as were in HEN
General goal: Reduce all cause preventable harm by 40 percent and readmissions by 20 percent
Timeframe: 12 months
Topics: 10 required, others optional
Will pursue reduction of all cause preventable harm
Official Request for Proposal from CMS can be found here
Missouri HEN 2.0 Overview
HEN work will align with MHA’s quality strategy
No fee for participation in our cohort
Hands-on improvement support
National- and MHA-led site visits
Coaching support to hospital leads
Utilization of HEN funds to offer support, stipends and educational funding dollars for items such as certifications, educational offerings and other national seminars
Missouri HEN 2.0 Overview
Four key emphases across all topics:
Leadership engagement
Unit-based improvement efforts
Physician leadership
Patient and family engagement
Plan to continue to build and sustain capacity on quality improvement, patient and family engagement and work on regional collaborative efforts to improve care coordination
Missouri HEN 2.0 Overview
Focus is to offer value without overwhelming our members
Data-driven approach to improvement that requires consistent data submission
Data collection, reporting and use
Education related to accurate data collection and submission
Guidance and training regarding data reporting
Advice on how to leverage data to drive change
Offer support to our hospitals for data and reports
HEN 2.0 Overview
10 core topics (all applicable topics are required) Adverse Drug Events
Adult population: opioid, anticoagulation, glycemic mgmt.
Pediatric population: opioids and two add’l measures
Both
CAUTI
All hospital settings with focus on avoiding placement of catheters in ER and hospital
CLABSI
All hospital settings
Injuries from falls and immobility
OB adverse events
EED, OB hemorrhage, preeclampsia
Pressure Ulcers
SSI
Multiple classes of surgeries
VTE
All surgical settings
VAE
Including IVAC and VAC
Readmissions
HEN 2.0 Overview
Optional/additional topics
Severe Sepsis and Septic Shock
Hospital Culture of Safety that fully integrates patient safety with worker safety
Iatrogenic Delirium
C. diff including antibiotic stewardship
Undue Exposure to Radiation
Airway Safety
Failure to Rescue
HEN 2.0 Overview
CMS Emphases
Objective measurement of 10 core topics
Coordination of effort with government and contracted personnel
Hosting in-person and virtual training sessions
Coordination with QINs, ACOs, Area Agencies on Aging, others
Inclusion of pediatric hospitals and measures
Emphasis on disparity reduction
HEN 2.0 Hospital Expectations
…at this time, vague
Work on all applicable core set of topics plus any additional relevant topics (e.g., sepsis, culture of safety)
We anticipate CMS will require all hospitals to work on ADE, CAUTI, Falls, PrU, VTE and Readmissions
Submit monthly data in alignment with the commonly reported, nationally standardized measures
Agree to allow their de-identified hospital level data to be submitted to CMS
HEN 2.0 Hospital Expectations
Once the project is awarded and begins, have your CEO sign a commitment that they will work on the aims of the PfP, especially CAUTI and readmissions
Have your QI lead co-sign the commitment
Participate in webinars and in-person meetings and utilize the tools and resources available to them to drive improvement in all target areas
Upcoming Events
March – Patient Safety Month
Mar. 13, CPS Patient Safety Conference in St. Louis
Mar. 25, from 11 to 11:30 a.m. – HIDI/Data Webinar (register, then dial 855/427-9512)
Mar. 25, from Noon to 1 p.m. – MHA Clinical Quality Webinar - "Safety Across the Board" Part 2 (register, then dial 855/427-9512)
April
April 1, from Noon to 1 p.m. - Lunch & Learn: What's Up Wednesday (register, then dial 855/427-9512)
Upcoming Events, April & May
MHA Spring Regional Quality Workshop – Readmissions and Care Coordination: Aim Towards Outcomes
April 14 - Marriott West, 660 Maryville Centre Dr, St. Louis (Register)
April 15 - Drury Lodge, 104 Vantage Dr, Cape Girardeau (Register)
April 17 - Comfort Inn, 1821 N. Missouri, Macon (Register)
April 22 - Hilton Garden Inn, 19677 East Jackson Dr, Independence (Register)
April 24 - Hilton Garden Inn, 4155 South Nature Center Way, Springfield (Register)
Still need speakers – especially for the Cape Girardeau and Springfield workshops; thank you to those who have already volunteered!
May 20, 21 – Quality 101 Conference, Hilton Garden Inn, Columbia
Visit our website for additional events and links
7 Things to Start Next Week
If you haven’t yet, sign up for the CPS Safety Conference, MHA April Regional Workshop in your area and the Quality 101 Conference and forward to all those in your organization who would find these learning sessions beneficial
Formalize process for huddles and debriefs; reduce variation of steps among units
Make staff leaders of system design and process improvement
Get started on a change project. Make sure you are working on important issues – what matters to patients and families
Be transparent – start telling patient stories
Review your organization’s transparency data
Discuss your organization’s HEN commitment with your CEO and leadership team
MHA:SQI - http://web.mhanet.com/strategic-quality/
Leslie Porth, PhD-C, MPH, R.N.
Division Vice President for Strategic Quality Improvement
Triple Aim
Population Health
Oversight of division (Quality Improvement, Quality Works,
Emergency Preparedness)
MONL
Alison Williams, R.N., BSN, MBA-HCM
Vice President of Clinical Quality Improvement
Dana Downing, B.S., MBA-H, CPHQ
Director of Quality Program Development
Patient and family engagement
National quality measures
Quality outcome transparency
Electronic clinical quality measures
MBQIP grant lead
MOAHQ
Jessica Rowden, R.N., BSN, MHA
Clinical Quality Improvement Manager
Clinical quality SME
Data management and analytics
HEN/AHRQ grant projects
TeamSTEPPS
Host of WUW|LNL
MOAHQ
MONL
Cheryl Eads
Executive Assistant of Quality Improvement
Provides support to the SQI team
Coordinates webinars, conference calls and meetings
Distributes correspondence and communication
Assists in maintaining reports
[email protected] 573/893-3700x1305
[email protected] 573/893-3700x1326
[email protected] 573/893-3700x1314
[email protected] 573/893-3700x1391
[email protected] 573/893-3700x1382
Clinical quality SME
Oversight of Quality Improvement
Grant management
Collaboratives management
MONL
MOAHQ
Resources are tight…what can we do
Visit Missouri Health Matters
Take action and be heard
Support Medicaid expansion