Maryland Patient Safety Center s. Call for Solutions 2018

Transcription

1 Maryland Patient Safety Center s Call for Solutions 2018 Organization: Fort Washington Medical Center Fort Washington Medical Center (FWMC) is located in a tight-knit community, on the outskirts of Washington, DC, in Fort Washington, Maryland. In 1991, Fort Washington Medical Center became an acute care hospital with 37-beds, and it is the youngest hospital in the Maryland healthcare system. The hospital serves 43,000+ patients every year and staffed by a group of physicians, nurses, and other medical professionals that care about the community. Solution Title: Sepsis, Connecting the Data for Process Improvement Program/Project Description, including Goals: What was the problem to solve? On October 1, 2015, the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) launched a Sepsis Core Measure requirement for all U.S. hospitals. Core measure performance is an integral part of TJC Accreditation and is publicly reported by CMS. Standards for satisfactory compliance are often 96% or higher (Bennett, 2016). The CMS Sepsis Core Measure involves minimum sets of actions required by 3-hour and 6-hour time points after a patient reaches severe sepsis or septic shock. Although public reporting of the measure was not projected to begin until late 2016, FWMC began this initiative in October 2015 with disappointing results. As FWMC had identified that sepsis was the second highest cause of the hospital s mortality rate, it was subsequently established that improved compliance with sepsis core measure was a priority. The problem to solve was how to improve our sepsis core measure performance rate. How was it identified? The world-wide initiative and goals of the Surviving Sepsis Campaign (SSC) spearheaded the utilization of bundles, which simplified the complexities for the care of patients with severe Page 1 of 11

2 sepsis. A bundle is a selected set of elements of care that, when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone. ( The CMS sepsis bundle reflects the Surviving Sepsis Campaign recommendations and requires hospitals to complete several interventions within three hours of a patient presenting with sepsis, then several more within six hours. To get credit for meeting the measure, hospitals must achieve 100% compliance with all bundle elements, essentially an all-or-nothing requirement. Although, the bundles helped to provide a framework for the care of the suspected sepsis patient, the specifics of the failed elements were not easily identifiable. Data submission through the core measures vendor would only say if a sepsis case passed or failed, without pinpointing which component did not meet compliance. In order to improve compliance with Sepsis Core Measure performance, it was imperative that we had the capabilities of identifying which components lead to the failure of the sepsis case. What baseline data existed? The performance data for Sepsis core measure, October through December 2015, is outlined in below table (Item A). The data compares FWMC s performance with Best in Class performing hospitals as well as with all hospitals in the vendor s pool. FWMC scored an average of 10% for this time period, which was significantly below the averages for hospital wide pool and best performer hospitals at 34.9% and 70.5% respectively. Item A Month/Year FWMC Performance Project Wide Overall Performance Best In Class Minimum Performance Oct % 34.3% 58.8% Nov % 35.2% 58.3% Dec % 35.3% 65.6% Q Average 10.0% 34.9% 70.5% What were the goals- how would you know if you were successful? Page 2 of 11

3 The ultimate measure of success would be determined by consistently meeting the Sepsis Core Measure Top Performer minimum performance benchmark, as released by Core Measures vendor Press Ganey. A hospital internal measure of success would be an upward trend in our Sepsis Scorecard, which displays the monthly and quarterly rate for Sepsis core measure compliance. Another measure of success would be a decrease in percentage of cases failed due to specific contributing cause, as a result, of implementation of practice changes. Process: What methodology or process was used to develop the Solution? FWMC used the Plan Do Check Act (PDCA) methodology, which is a problem-solving model to continually improve processes. Solution: What Solution was developed? Through the PDCA process, it was determined that a deeper analysis was required to identify the individual elements of the sepsis core measure in order to determine what specific areas needed a remedy. How was it implemented? It was very frustrating in the beginning because existing core measures were more objective and only required a met or not met response. On the other hand, the Sepsis core measure required clinical analytics or expertise to differentiate between the stages of sepsis (SIRS, Sepsis, Severe Sepsis or Septic Shock). At times, it was difficult to understand the expectations of the elements with so many nuances to meet each component. In addition, the sepsis core measure was indepth and more judgement that is clinical was required to abstract various data points. If you failed one component then you failed the entire measure, which was overwhelming and discouraging to focus on the final score without knowing the specifics of the failure. Step 1: Focused Chart Audits Chart audits can sometimes conjure up negative feelings but in the quality and performance improvement world, they serve many beneficial purposes. Chart audits are frequently used as part of a quality improvement initiative and aids to find deficits in clinical processes that do not Page 3 of 11

4 work well, in order to fix it. Focused chart audits were completed monthly on 100% of the sepsis-related cases. The chart audits focused on gathering clinical information related to each specific component of the sepsis measure. Step 2: Quality Performance Improvement Sepsis Worksheet The data gathered from the chart audits were placed in a customized spreadsheet, Quality Performance Improvement Sepsis Worksheet, (Item B). The spreadsheet was designed based on dissecting the 3-hour and 6-hour bundles into their individual core measure components. Item B By utilizing the populated spreadsheet, we were able to clearly identify successes and areas for focus improvement (Item C). The spreadsheet was also designed to populate an automatic compliance percentage for each element and an overall compliance score for the month to include actual versus potential sepsis cases. The actual score (included cases) was determined only by the cases that met the core measure requirements for severe sepsis. Conversely, the potential score included all sepsis cases (excluded and included) and helped to hold ourselves to a higher standard in meeting the requirements. An excluded case is a sepsis case that did not advance to severe sepsis (organ dysfunction) but may have presented with SIRS or Sepsis or both. Furthermore, data were also gathered on which clinical department was responsible for a missed opportunity for success. This information allowed responsible parties to take ownership and to guide focus actions and educational opportunities for improvement. Page 4 of 11

5 Item C Step 3: Prioritization The development and use of the Quality Performance Improvement Sepsis Worksheet (Item C) indicated the areas on which to target education and actions for improvement. The top three identified areas of noncompliance were: 1. No collection of 2 nd lactate 2. Administrations of antibiotics 3. Collection of Blood Cultures Step 4: Process Mapping Once the top three (3) areas for improvement were identified, each record was further investigated to the specific cause of the individual failure, where the failure generated, and how the failure occurred. Example: Blood Culture process was found to be multifactorial: Provider not ordering the blood culture Timeliness for blood culture to be drawn Method in which lab received the blood culture order (STAT vs routine) Electronic Medical Record (EMR) glitches, i.e., the order was entered but not received by lab Step 5: Action Plan for Process Improvement Each identified cause for failure triggered an action plan for improvement and sustainability. The action plans included but were not limited to the following: Multidisciplinary Team Formation: In order to attempt to meet the Sepsis Core Measure requirement, every discipline plays an integral role towards its success. Each team member or department plays a vital part in meeting this measure, as if one area fails Page 5 of 11

6 to meet the standard, then we fail the core measure in its entirety. In January 2016, a true multi-disciplinary Sepsis Team was developed to review the data and to identify the scope of the problem using an on-going cycle for process management. Staff Education: It was important for providers, nursing staff and lab to be educated on the stages of sepsis. An educational flyer (Item D) was developed and the staff were provided with badge-buddies to serve as a quick reference. Item D Provider Sepsis Order Sets: A foundation for the management of sepsis cases was created through the development of an electronic Sepsis Order Set for providers (Item E). Item E Page 6 of 11

7 Measurable Outcomes: What are the results of implementing the Solution? Provide qualitative and/or quantitative results to data. (Please include graphs, charts or tools). Item F In 15/18 months from Apr 2016 to Sep 2017, FWMC compliance rate with CMS Sepsis core measure was higher than project wide average. Comparison outlined in below table. (Item F) Month/Year FWMC Sepsis Performance Project Wide Sepsis Overall Performance Best In Class Sepsis Minimum Performance Oct % 34% 58.8% Nov % 35% 58.3% Dec % 35% 65.6% Jan % 37% 62% Feb % 42% 69% Mar % 42% 69% Apr % 43% 71% May % 46% 72% Jun % 47% 71% Jul % 40% 69% Aug % 40% 65% Sep % 41% 71% Oct % 43% 68% Nov % 44% 73% Dec % 46% 74% Jan % 50% 79% Feb % 48% 79% Mar % 49% 75% Apr % 49% 78% May % 52% 79% Jun % 52% 79% Jul % 52% 77% Aug % 54% 82% Sep % 57% 85% Page 7 of 11

8 Item G In 4/9 months from Jan-Sep 2017, FWMC compliance with CMS Sepsis core measure was included in Best of Class performers. Compliance outlined in below graph. (Item G) Comparative Report: Best in Class Facility: Interval of Analysis: Month Discharge Dates: 10/01/2015 to 09/30/2017 Measure: SEP-1 Measure Description: Sepsis Item H FWMC sepsis core measure compliance has trended upward in 2017 and with the exception of July 2017, has been consistently at 60% or above. This is indicative of marked improvement over compliance in 2016 Comparative analysis of 2017 with 2016 outlined in below graph (Item H) Page 8 of 11

9 Sustainability: What measures are being taken to ensure that results can be sustained and spread? With continuation of the multi-disciplinary team approach, we are sustaining our efforts for improvement through continuous communication, sharing of data and its analytics, to produce an upward trend with this life-saving core measure. Core Measures vendor Press Ganey now provides a drill down report on reasons for measure failure that provides the information previously obtained through focused chart audits, which makes the continual examination of reasons for failure feasible. This project served to highlight that some of our ancillary systems required focus and the improvements achieved to improve sepsis core measure compliance also result in improved outcomes in other areas. Role of Collaboration and Leadership: What role did teamwork and collaboration play in the Solution? What partners and participants were involved? Was the organization s leadership engaged and did they share the vision for success? How was leadership support demonstrated? This initiative could not work without collaborative teamwork between hospital staff and medical providers in conjunction with the support of Executive Leadership. The Chief Medical Officer, Chief Nursing Officer and Medical Staff President were highly engaged and supportive of the progress and outcomes of this initiative. The multi-disciplinary team was physician chaired and facilitated by Performance Improvement department. It included Emergency Medicine providers as well as Hospitalists, along with representatives from Nursing, Lab, Infection Prevention, Education, Informatics and Information Technology departments. Other departments, such as pharmacy, were included on an as needed basis. We were fortunate because the team members were vested in success as evidenced by active participation and full attendance at team meetings. Distributed to all providers are the updates to the Specifications Manual for National Hospital Inpatient Quality Measures. It is important for them to have this information as it guides them on the changes and the clinical practice requirements that equate to compliance. Innovation: Page 9 of 11

10 What makes this Solution innovative? What are its unique attributes? When dealing with complex processes with many nuances and layers, sometimes the best approach for improvement is to keep it simple. As we brainstormed on how to approach improving on the sepsis measure, we relied on the tried and true PDCA methodology and a drill down approach to each component until a root cause was revealed. The innovation came through the development of a customized Quality Performance Improvement Sepsis Worksheet, which clearly displayed what was working versus what was not working. In addition, the worksheet was simple enough for all stakeholders to utilize. For example, the ER provider would reference the tool to focus individual provider education. Culture of Safety: What impact did the solution have on the culture of safety within the organization? The culture of safety within health care is an essential component of preventing or reducing errors and improving overall health care quality (AHRQ, 2017). The Sepsis Team supports the collaboration across ranks and disciplines to seek solutions to patient safety problems. In addition, there is an organizational commitment of resources to address safety concerns. Adopting the High Reliability Organization (HRO) principles, the Sepsis Team does not ignore any failure, no matter how small, because any deviation from the expected result could lead to an untoward outcome. Additionally, it is important to focus on how things could fail, even if they have not. The use of the PDCA methodology prevents us from not acknowledging the complexities of a problem, but assists in identifying the root cause of a problem. Patient and Family Integration: How did the solution include the patient and family? The integration of the patient and family into this initiative is demonstrated with the application of the plan of care, which is a means of communicating and organizing the clinical interventions. The Sepsis Core Measure supports evidence-based practice through the use of the sepsis bundles, which guides the plan of care for sepsis-related cases. FWMC recognizes an opportunity to engage patients and families in sepsis awareness. Currently, there are plans to distribute an informational Sepsis Fact Sheet to patients and families. The goal is to equip the Page 10 of 11

11 patient with the knowledge to self-identify symptoms of infection or sepsis and when to seek medical attention. Related Tools and Resources 1. Item B: Quality Performance Improvement Sepsis Worksheet 2. Item D: Sepsis Education Badge Buddy 3. Item E: Provider Sepsis Order Set 4. Item F: Table FWMC Sepsis Core Measure Compliance Comparison with Project Wide Average and Best In Class performers 5. Item G: Graph FWMC Sepsis Core Measure compliance Comparison with Best In Class 6. Item H: Graph FWMC Sepsis Core Measure compliance comparative analysis 2016, Bennett, K. (2016, September 09). The Sepsis Core Measure. Retrieved November 10, 2017, from 8. Bundles. (n.d.). Retrieved November 10, 2017, from 9. Wells, A. and Gannon, D. (2013) Sepsis Worksheet. Retrieved March 2016, from Culture of Safety. (n.d.). Retrieved November 11, 2017, from Contact Person: Peg Cocimano, RN Title: Performance Improvement Coordinator Phone: Page 11 of 11