Quality Matters. Quality & Performance Improvement

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1 Quality Matters First, do no harm it s a defining mandate for those who devote their lives to caring for others health. Recent studies have shown, however, that approximately 100,000 patients nationwide die unnecessarily in healthcare institutions. Several national organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services, the Agency for Health Care Research in Quality (AHRQ) and the National Quality Forum, are a few that have responded by establishing standards of care and by giving healthcare organizations quality measurement tools. At Inova, we have taken up the call to evaluate and improve our care at every level, using the best hospitals in the nation as our benchmarks. A component of this effort involves transparency with both internal and external stakeholders. This report is the first publication to share our progress with all members of the Inova community. So, how did Inova do? Overall, we had a dramatic improvement in 2011 as compared to 2009 and 2010, and those improvements have continued in the first six months of We are continuing to accelerate our improvement by adopting nationally-accepted standardized best practices. This report will highlight those best practices, both in our quality results and in the success stories that follow. One measure you will see in the following report is something we call perfect care. We use this term to indicate that a patient has received 100 percent of the steps in the process of care for a given condition. In other words, patients received the correct treatment and prophylaxis at the proper time and got the information and advice they needed to maintain and improve their health after discharge. Consistent, high-quality care perfect care is what drives us at Inova. I hope this report inspires each of us at Inova to achieve even higher levels of excellence throughout the rest of 2012 as we continue to deliver leading edge, best in class healthcare throughout the region. Sincerely yours, Loring S. Flint, MD EVP and Chief Medical Officer Deneen Richmond, RN, MHA Vice President, Performance Improvement & Outcomes inova.org

2 Quality Matters: Mid-year 2012 Inova Quality Report Overview In 1998, the Institute of Medicine published To Err Is Human, which highlighted that over 100,000 patients nationwide die unnecessarily in healthcare institutions. This report continues to be referenced today and has led to increasing interest in evaluating health care providers and in measuring their care against nationally-recognized standards. Stakeholders including clinical professionals, health care provider organizations, state hospital associations, and health care consumers want to know how well a given hospital follows evidence-based guidelines for certain clinical conditions. In response to this burgeoning interest in quality measurement, there are a number of national measures that can be used as a gauge on the quality and safety of hospital care. This report summarizes Inova s performance on these national measures, as well as profiles of four quality improvement teams. Section 1 delineates Inova s performance on four core measure sets for adults: acute myocardial infarction (AMI), heart failure (HF), pneumonia (PNU), and surgical care improvement (SCIP). It also includes Inova Fairfax Hospital s performance on children s asthma care, which is the only core measure set exclusively focused on pediatrics. Section 1 also defines each component in the process of care for the five core measures. This year s performance targets were determined by external benchmarks as well as Inova s year-over-year performance. Section 2 summarizes data on patient mortality. Section 3 covers patient harm performance, including patient safety indicators, hospital acquired conditions, and serious reportable events. Section 4 summarizes data on patient experience. Section 5 has profiles of the 2011 Iams quality award winners and demonstrates how four Inova teams created innovative programs that had a measurable impact on patient care quality. This section will expand as we continue to add outstanding examples from our performance improvement project teams.

3 Section 1: Core Measures Performance Perfect Care Inova aims to complete all of the appropriate core measure components for each patient in line with the national standards developed by CMS. When it all comes together, and patients receive every component, that s what we strive for, we call it perfect care. More than anything else, perfect care requires consistency. Every step must be taken -- every time, with every patient. This section explains each core measure and provides annual summary data for each hospital. Inova s system-wide goal for 2012 is to achieve perfect care in 95 percent of patients. Perfect care is an all-or-nothing measure. In other words, if the hospital does not complete every component correctly, that patient does not count toward the perfect care totals. Note: if a patient is assessed for a core measure component but does not receive it because it was medically inappropriate for that individual that core measure component is not counted as a perfect care failure. In 2010, 90 percent of patients received perfect care. In 2011, we improved our performance significantly 92 percent of patients received perfect care (see Chart 1). Across the system, we met or exceeded our 93% target in 7 out of 12 months of In the first six months of 2012, 95% of patients have received perfect care, right at our target for this year. Higher is better

4 Perfect Care for Acute Myocardial Infarction (AMI)/Heart Attack In 2011, all Inova hospitals exceeded the goal: more than 93 percent of patients received perfect care for AMI, and some hospitals achieved perfect care in as many as 98 percent of AMI cases (see Chart 2). In addition, each of the hospitals improved its performance relative to During the first six months of 2012, we have continued to improve, with 98 percent of AMI patients receiving perfect care. At Inova Fair Oaks Hospital, 100 percent of the AMI patients have received perfect care in Higher is better

5 Perfect Care for Heart Failure (HF) The percentage of patients receiving heart failure perfect care has increased from 92 percent in 2011 to 94 percent in the first six months of Inova Fairfax Hospital and Inova Loudoun Hospital achieved 99 percent perfect care for heart failure in the first six months of (see Chart 3). Higher is better

6 Perfect Care for Pneumonia (PNU) All five Inova hospitals have improved their pneumonia perfect care percentages in the first six months of The system-wide percentage has increased from 92 percent in 2011 to 98 percent in Inova Fair Oaks Hospital has maintained 100 percent perfect care during the first six months of (see Chart 4). Higher is better

7 Perfect Care for Surgical Care Improvement Project (SCIP) Four of the five Inova hospitals have improved their 2012 percentages of perfect care for surgical patients. Across the system, SCIP perfect care percentages improved from 91 percent in 2011 to 94 percent in the first six months of 2012 (see Chart 5). Higher is better In addition to the perfect care indicators, Inova also monitors our performance on all of the individual core measure indicators, which is summarized below.

8 Acute Myocardial Infarction (AMI)/Heart Attack The AMI core measure is composed of four 1 sets of data, tracking the percentage of AMI patients who: Are given aspirin on discharge Receive percutaneous coronary intervention (PCI) to remove the blockages that cause heart attack within 90 minutes of arrival (also known as door-to-balloon time) Receive counseling on smoking cessation Are prescribed a statin at discharge to lower cholesterol Table 1: Acute Myocardial Infarction 2 Heart Failure (HF) The core measures for HF have three 3 components that measure the percentage of patients who: Receive an evaluation of how well their heart s left chamber is pumping (assessment for left ventricular systolic dysfunction, or LVSD) Are given an ACE inhibitor or ARB, medications that treat heart attack, heart failure, or decreased heart function Are given written discharge instructions or other educational material that covers activity level, diet, discharge medications, follow-up appointments, weight monitoring, and steps to take if symptoms worsen. 1 As of January, 2012, CMS revised the AMI core measure to include fewer sets of data. Three of the components (aspirin on arrival, ACEI/ARB, and beta blocker at discharge) are now voluntary rather than required. One component, smoking cessation counseling, has been eliminated from the AMI core measure. As a result of the CMS changes, we are not reporting 2012 results for these measures and they will not be included in future quality reports data is for 1 st six months 3 As of January, 2012, CMS retired smoking cessation counseling from the HF core measure. As a result, we are not reporting 2012 results for this measure and it will not be included in future quality reports.

9 Table 2: Heart Failure 4 Pneumonia The two 5 components of the pneumonia core measure track the percentage of patients who: Have an initial emergency room blood culture performed prior to the administration of the first hospital dose of antibiotics to determine which antibiotic will work best Are given the most appropriate antibiotics for the patient s specific infection Table 3: Pneumonia 6 Surgical Care Improvement Program (SCIP) data is for 1 st six months 5 As of January, 2012, CMS revised the pneumonia core measure to include fewer sets of data. The two immunization measures (flu and pneumococcal vaccine) are now part of a separate measure set and will no longer be included in PNU. Two other components, smoking cessation counseling and initial antibiotics within six hours of arrival, have been eliminated from the PNU core measure. As a result of these changes, we are not reporting 2012 results for these measures and they will not be included in future quality reports data is for 1 st six months

10 There are nine 7 components to the SCIP core measure, which fall into three categories: steps taken to prevent blood clots, steps taken to prevent infections, and steps taken to manage cardiac medications patients are taking. To prevent blood clots, we track the percentage of surgery patients: Whose doctors ordered treatments to prevent blood clots after certain types of surgeries, and Who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery. To prevent infections, we collect data on the percentage of surgery patients: Who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection, Who were given the right kind of antibiotic to help prevent infection, Whose preventive antibiotics were stopped at the right time (within 24 hours after surgery), Whose blood sugar (blood glucose) was kept under good control in the days right after surgery, Whose urinary catheters were removed within 2 days after surgery to reduce the risk of infection, and Whose body temperatures were managed during surgery. We also track measures to manage cardiac medication during surgery, including the percentage of surgery patients who were taking heart drugs called beta blockers before coming to the hospital and were kept on the beta blockers during the period just before and after their surgery Table 4: Surgical Care Improvement Program 8 7 As of January, 2012, CMS revised the SCIP core measure and made the appropriate hair removal component voluntary rather than required. As a result of these changes, we are not reporting 2012 results for this measure and it will not be included in future quality reports data is for 1 st six months

11 Children s Asthma Care Children s Asthma Care To assess the quality of children s asthma care, we collect data in three areas: The percentage of children who received reliever medication while hospitalized for asthma, The percentage of children who received systemic corticosteroid medication (oral and IV medication that reduces inflammation and controls symptoms) while hospitalized for asthma, and The percentage of children and their caregivers who received a home management plan of care document while hospitalized for asthma. Table 5: Children s Asthma 8 Improvement Focus for Core Measures For all of the individual indicators as well as for perfect care, we have a number of strategies to improve. We are continuing to provide education and tools, such as order sets, to our physicians, nurses and other caregivers to help them identify the core measure patient populations, prompt them to provide all evidence-based care and to assist them in documenting valid reasons when the care being measured is medically inappropriate for a particular patient. We also have staff who round on the core measure patients on a daily basis to ensure that the right care is being ordered and given. We closely examine the reasons for every case that is not compliant with the core measures so that we can continue to improve our processes and systems for delivering perfect care.

12 Section 2: Patient Mortality Performance Severity Adjusted Mortality Rates Hospital mortality rates measure the percentage of people who die while in the hospital. One way to tell whether a hospital is doing a good job is to find out whether patients admitted to the hospital have mortality rates that are lower (better) than the expected rate for a given condition, the same as expected, or higher (worse) than the expected. In order to paint a more accurate picture of how mortality rates reflect quality, many hospitals use risk adjusted or severity adjusted mortality rates. Severity adjusted mortality rates take into account a person s age, medical condition, and other risk factors that may increase the likelihood of death. A score of 1.0 indicates that there is no difference between the hospital s actual mortality rate and the expected mortality rate. A score that is less than 1.0 means that there were fewer deaths than expected based on patients medical condition and risk profile. A score greater than 1.0 means that there were more deaths than expected. Inova s system-wide mortality goal is to get to achieve severity adjusted mortality rates in the top quartile (i.e., performance at the level of the top 25th percentile of hospitals) by 2013, which is a mortality rate of During the first six months of 2012, we are meeting our top quartile mortality performance goal system-wide. Inova Fair Oaks Hospital and Inova Loudoun Hospital have also achieved top quartile performance. Individual hospital scores are depicted in Chart 6 (next page).

13 Lower is better Improvement Focus for Mortality Our clinical leaders review all deaths throughout the Inova hospitals. We also had a consultant review a significant number of the medical records of patients who died to evaluate the documentation and billing accuracy. As we have reviewed the deaths, we have not found any concerning trends in care across the wide number of diseases treated. However we have identified opportunities to improve the precision of the documentation (e.g., patient risk factors) and coding, thus that is where we are focusing our improvement efforts.

14 Section 3: Patient Harm Performance AHRQ PSI Composite The Agency for Healthcare Research and Quality (AHRQ) is a federal agency dedicated to improving healthcare quality, safety, efficiency, and effectiveness. AHRQ has established 17 patient safety indicators (PSI) to track potentially preventable hospital complications and adverse events following surgeries, procedures, and childbirth. Examples include postoperative sepsis, central venous catheter-related bloodstream infection, and obstetric trauma. PSI data can help hospitals identify potential adverse events that might need further study, decrease the incidence of adverse events and in-hospital complications using administrative data found in the typical discharge record, and recognize and avoid potential patient harm or patient safety events. We benchmark our PSI results against a national group of about 700 hospitals. Inova s goal for 2012 is to have at least 64% (7) of the 11 PSIs that are included in AHRQ s PSI composite in the top quartile. During the first six months of 2012, we are meeting this goal system-wide. Inova Fair Oaks Hospital, Inova Loudoun Hospital and Inova Mount Vernon Hospital are also meeting this goal. Each hospital s data is listed in Chart 7. Higher is better

15 Hospital Acquired Conditions Beginning in 2008, CMS began to penalize hospitals for hospital acquired conditions (HAC). A HAC is a medical condition that was not present when the patient was admitted to the hospital. Rather, the patient acquired the condition at the hospital, usually as the result of the hospital s failure to follow evidence-based guidelines for care. As Chart 8 shows, Inova has achieved significant percent reductions in HACs system wide over the last three years. For the first six months of this year, we have had a 70 percent reduction in HACs system wide compared to Lower is better Serious Reportable Events As part of its mission to promote patient safety, the National Quality Forum (NQF) developed a list of serious reportable events (SRE). An SRE is an adverse event in which a patient suffers death or serious harm because of an error that is usually preventable. They include injuries that occurred during the patient s care (not due to the patient s disease) as well as harm that occurs because a healthcare worker did not follow standard care or institutional protocols. During the first six months of this year, Inova hospitals have decreased SREs by 59 percent system wide, as compared to Currently, all five individual hospitals have SREs in the single digits. Inova Fairfax Hospital deserves particular mention. As the largest Inova hospital, and the only tertiary care center, Inova Fairfax Hospital typically has a higher overall number

16 of SREs due to the volume and complexity of cases. It should be noted that Inova Fairfax Hospital has reduced its SREs by 30 percent so far this year. Chart 9 shows each hospital s number of SREs. Lower is better Improvement Focus for Harm Indicators As with the mortality cases, Inova s quality and clinical leaders review all cases of patient harm and we have also looked for common themes across the system. In some cases, we have identified opportunities to change the way we deliver care. For example, we significantly decreased patient falls with injury by using different tools to better assess which patients are at risk for falls, and by enhancing and standardizing the actions we take to prevent any serious injury from falls. These actions include things such as better educating our patients and their families on steps they can take to prevent falls, to using bed alarms and floor mats, to using alternative medications with fewer side effects such as dizziness that might increase the chance of a patient falling. In other cases, again similar to our mortality improvement strategy, we have identified the need to improve the precision of the documentation and coding. This helps to more accurately distinguish between a complication compared to an expected risk or clinical finding.

17 Section 4: Patient Experience Inova measures our patients perception about their experience using a national, standardized survey referred to as the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS). The HCAHPS survey was developed by the Centers for Medicare and Medicaid Services (CMS) to accomplish three goals: 1) Collect comparable data on hospitals based on care topics of importance to consumers 2) Create incentives for hospitals to improve their quality of care through public reporting of the survey results 3) Drive informed consumer choice by providing transparency around the quality of hospital care The HCAHPS survey focuses on eight key topics: Communication with doctors Communication with nurses Responsiveness of hospital staff Pain management Communication about medicines Discharge information Hospital environment of care Hospital overall rating. HCAHPS measures the patients perception regarding the frequency that care activities occurred on an always to never scale. For the overall rating, patients are asked to rate the hospital on a 0 to 10 scale, with 0 being the worst hospital and 10 being the best. The HCAHPS results are reported using top box scores, which are defined as the best available survey response (e.g., percent Always; or the percent of 9 and 10 responses). Table 6: HCAHPS Top Box Scores data is for the 1 st six months.

18 Inova s goal for 2012 is to achieve the 75th percentile in the overall rating question, which would be 73% of patients surveyed rating the hospital a 9 or a 10. Inova Fairfax Hospital is close with 72% and the other hospitals have made improvements since Improvement Focus for Patient Experience Inova is committed to creating excellent patient experiences. We have adopted a service promise to our patients and visitors that we will anticipate their needs and provide personalized care with humility and openness We seek every opportunity to meet the unique needs of each person we are privileged to serve every time, every touch. To honor that promise, we are refining, and in some cases re-engineering, our culture and operational processes. We are also collaborating with organizations that have reputations for superior service so that we can learn and adopt best practices.

19 Section 5: Inova Quality Success Stories The quality awards are named for Franklin P. Iams, who was instrumental in founding Inova and who championed excellence in performance and service. The following four programs, which won 2011 Iams awards, are examples of what we at Inova can do when we focus on excellence: Program title: Coaches, Get in the Game! Contemplating joint replacement surgery can be daunting for patients: preparation takes time, recovery can be tough, and patients worry about whether they can handle the process on their own. The patient-centered outcomes team for joint replacement noticed that patients who had a friend or family member by their side throughout the process seemed to do better. They set out to quantify, then replicate, the results. When they tracked the outcomes for patients who had a strong support system, they found that they did in fact do better much better. Patients with coaches got out of bed and walked sooner, had a shorter hospital stay, felt more confident and ready to continue their recovery at home, and were more satisfied with their overall surgical experience. In addition, more patients were able to go home after surgery rather than to a skilled nursing facility.

20 The joint replacement team designed the Coaches: Get in the Game! program to encourage everyone planning to have joint replacement surgery to have a coach a close friend or family member who would be there with them through the process. The team publicized the program and designed brochures for coaches that explained their important role as part of the patient s healthcare team. The program encouraged coaches to attend the pre-operation class, be there on the day of surgery, and the last physical therapy session before discharge. By formalizing this social support role, and by identifying the three points at which a coach was most beneficial, this program helps patients and their coaches get the most benefit. Having a coach on the patient s team is proving to be a win for everyone.

21 Program title: Babies Without (Bad) Bugs! The Babies Without (Bad) Bugs Team was charged with the task of reducing central line associated blood stream infections (CLABSI) in the NICU. CLABSI are hospital acquired, often serious infections, and they pose a particular threat to newborns since their immune systems are immature. Although the NICU had received accolades for steadily reducing infection rates over the past decade, the team set a goal of reducing the CLABSI rate to 0. In previous years, NICU staff had taken many steps to reduce infection, from hand hygiene with no jewelry or artificial nails to a closed medication system, standardized education, and a variety of other specific protocols. In 2011, the NICU continued all of these measures but also drilled down through each individual past case of CLABSI to determine possible causes that could be corrected. The NICU has had a CLABSI rate of 0 throughout The unit received the Joint Commission Gold Seal of Approval in August, 2011, due in part to this program s results. Each individual NICU staff member and practitioner take great pride in this achievement. It has also become a source of ensuring care, as many have been overheard to remark that they don t want to be the one to cause the days since a CLABSI count to start all over again. The NICU team s successful drive to eliminate CLABSIs is motivated by one thing: the desire to protect Inova s most fragile patients.

22 Program title: Wake Up and Breathe Nearly 30 percent of critically ill patients rely on mechanical ventilation due to underlying respiratory failure. Powerful sedatives, paralytics and/or analgesics are used to alleviate the discomfort, anxiety and pain associated with breathing tubes and mechanical ventilators. The team s mission was to reduce the duration of mechanical ventilation without compromising patient safety or comfort. The team developed a protocol they coined Wake Up and Breathe with the objective of reducing the length of time patients stay on a ventilator (ventilator length of stay, or VLOS). The Wake Up and Breathe protocol addresses two processes, the management of the sedation and that of the ventilator. Sedatives affect the process of discontinuing ventilatory support, but the two processes are often not coordinated. This protocol brings the respiratory and pain management concerns together, allowing the patient s team to optimize sedation levels and let patients demonstrate that they are ready to breathe on their own. Wake Up and Breathe helped improve the quality of care for patients requiring mechanical ventilation by using the appropriate levels of sedation to assure patient comfort and safety and by providing daily breathing trials to allow for timely ventilator withdrawal. This program has resulted in shorter VLOS times, which correlate to a shorter overall hospital stay for patients and better one-year survival rates. In 2008, pre-protocol VLOS averaged 6.6 to 7.1 days. After implementing this program and conducting follow-up interventions, the department brought VLOS to a historic low of 5.2 days in During the last quarter of 2011, the department broke the 5-day barrier (4.9).

23 Project title: D2B: A Sustained Heartfelt Improvement Time is tissue. Minutes are muscle. Whatever catchy phrase comes to mind, the point is the same: for patients suffering an ST-elevation myocardial infarction (STEMI), every minute that passes means more damage to the heart muscle. When STEMI patients receive coronary angioplasty to open the blocked artery in less than 90 minutes from first medical contact, they have the best chance to return to a near-normal quality of life. Because first medical contact is often made in the field, at a doctor s office, or at an urgent care center, patients often have less than 90 minutes remaining when they actually arrive at the emergency department (ED). Inova s goal is to treat the patient with emergency coronary angioplasty and possible coronary stents (also known as percutaneous coronary intervention, or PCI) in less than 60 minutes from the time they arrive at in the ED of a PCI-capable facility. This is called door-to-balloon time, or D2B. The multi-disciplinay Green Team is comprised of Inova s ED and cath lab interventionalists, nurse leaders, and technicians; other ED medical directors and nurse leaders; first responder agencies; ground and air inter-facility transport agencies; Inova s cardiac access line leaders; and administrative leaders. The team focused on reducing the amount of time it took for the patient to undergo PCI from the moment the patient enters the ED. In 2011, Inova teams consistently met and exceeded the AHA s D2B goals. For STEMI patients who present in the ED of a PCI center, the Green Team has decreased the median D2B time from 65 min to 53 min, with 69 percent of the patients meeting less than 60 minutes D2B. Minutes Chart 13: Patients Presenting to Inova Fairfax Hospital ED Median Door to Balloon Times Q Q Q Q Median Door to Balloon Times

24 For STEMI cases transferred from other sites, the team has increased of the percentage of cases D2B time less than 90 minutes from 38 percent to 67 percent, with a median time of 89 minutes. Over the course of this initiative, the team learned that when data and patient results are provided in a team framework, it can inspire individual participants to work to improve their part in the process. For example, EMT teams compete to get patients to the ED in the least amount of time, and interventional cardiologists moved to empower ED physicians with the ability to activate the cath lab team. These actions save minutes and, ultimately, save lives.