Quarterly Medical Staff Breakfast Quality Update

March 30, 2016

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

Clinical Quality Scorecard

Patient Experience Scorecard

0

10

20

30

40

50

60

70

80

90

100

Pro

po

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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

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erc

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tile

Unit

Central Line Device Utilization Ratio By Unit

Q3

Q4

Jan

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

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ays

Month

House-Wide CLABSI Rate 2014 - Present

SIR

Rate

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

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

Did you know ?

• We are in top decile in GYN, vascular, and orthopedics ?

• Did you know we are in 10th decile rank for pneumonia ?

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

Did you know ? We are outliers for SSI procedures in New York State 3 years in a row…

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

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

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

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.

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%

Sepsis CMS SEP1 Reevaluation smartphrase or “dot phrase”:

.sepsisreevaluation

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.

Peer Review Structure:

Peer Review: Quality Improvement Themes/Trends.