Greetings from Michelle & Katie QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE

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1 IN THIS ISSUE: Create Raving Fans of Your Idea P. 1 Where is our waste? P. 1 Sepsis Update P. 3 Quality Updates P. 4 APeX quality tips P.5 Division Incentive Metrics P. 6 Focus Group Findings P. 2 The Post Monthly Quality Improvement Newsletter FOR THE Division of Hospital Medicine September 2012 Issue 21 Greetings from Michelle & Katie QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE Welcome to the 21st edition of the Quality Post. In this issue, we feature the results of our DHM patient focus group. We also provide you with updates in Sepsis, APeX, Discharge Safety and Lean. Enjoy! Where is our Waste? The health care system squanders $750 billion a year, 30 cents of every medical dollar, through unneeded care, byzantine paperwork, fraud and other waste, the Institute of Medicine revealed this month. The report came from an 18-member panel of experts, including doctors, business people and public officials. Finding and reducing this waste may require a systematic approach to examining our processes of care. Lean methodology, recently embraced by our medical center focuses on identifying areas of waste and value in common processes. There are 8 types of waste identified in Lean methodology: Defects: work that contains errors (medical errors, wrong medication delivered to a patient) Over-Production: redundant work from processing too soon before it is needed (multiple copies of the same report, duplicate charting) Waiting: idle time spent waiting for others or services to be available (waiting for procedures; waiting for a bed) Transporting: needing to move something more than is required (non standardized supply location) Inventory: having more materials than necessary (overstocking medicines) Motion: needing to move more than adds value to the task (time spent looking for information) Excess Processing: activities that do not add value from a patient perspective (asking more than once for the same information) Underutilizing Talent: same activities performed by different people because people doing the work aren t confident about the best way to perform tasks (relying on memory to do a task; unclear MD orders) As the medical center embarks on efforts to train those in key positions in LEAN, the goal is to use this methodology to remove the waste in our system. Create Raving Fans of Your Idea Selling an idea to your institution works best when you have internal fans. When people admire your idea, it confirms it's a good one. These people can contribute time and expertise, and can recruit other supporters. Here are three ways to build your fan base: Enlist Yourself. Others can sense if you are not genuinely committed. And if they get that feeling, they are bound to ask: "If he is not really into it, why should I be?" Talk about what you want to do. Be transparent, to anyone and everyone. Give them a complete picture. And, tell them not only the positives, but the negatives too. Offer the chance to act. Present potential followers with real work to do, no matter how small. It's to your advantage and theirs if you can act together.

2 Highlights from Patient Focus Groups Engaging Patients and Care Partners in Redesigning the Patient Experience In April 2012, 15 patients and care partners participated in a focus group to provide feedback and ideas for improving the patient experience. The overall goal of this exercise was to gain more in-depth insight into patient and care-partners desires and expectations on the inpatient medicine service at Parnassus, and to build on that knowledge to implement selected patient driven initiatives. After 2 hours of brainstorming and vetting ideas, it was evident that patients want the same prinicples we are working to enforce through the communication checklist. We hope that these findings will encourage use of the checklist and trigger additional ideas for how we can implement this initiative more effectively and disseminate it more broadly to the entire medicine service. Only then will we truly be able to improve the patient experience for our patients. Patient Feedback Aligns with the Communication Checklist: Introduce by Name and Role My mom had a lot of doctors coming in. at first I didn t know who was in charge. You probably see 6 doctors every morning. It would be nice if they just introduced themselves. I got to the point that I would ask them who are you and what is your service. Inquire about Patient Concerns/Repeat for Understanding I understand it s a teaching hospital, but I should be part of that teaching. AND they are not acknowledging my input. I didn t sign off on discharge because they hadn t answered all my questions. Avoid Jargon I guess it's different for people that have had a lot of experience in hospitals and have been here a bunch of different times and you know how long it takes but this was a whole new world for someone like me This was my mom s first time in the hospital. Things are very different for me than for someone who s been in multiple times Duration 2nd yr resident woke me at 6 am and said your going home today, 8 am attending woke me and said you re being discharged today, at 10 am the nurse said you re going home Summarize and Check for Understanding It was just so funny, I had more care and instruction about how to work the television than I did about what was happening to me. In any field, people get so used to doing what they do, and don t realize: Not only are you ill, but you re scared, you re from out of town, you have to worry about parking, you don t know anything about the medications or the medical problems. As a patient, you have to think up the questions yourself Encourage Questions Encourage communication with patient and family, You feel like you have to interject [to get a question in]. Transition and Thanks She gave me her card. I m terrible at returning calls, she said, but me.

3 Updates on Sepsis Sepsis Measurement The Bundle To improve the care of our sepsis patients and reduce sepsis mortality we are tracking and feeding back our performance on a bundle of interventions thought to improve care of Septic patients In cases of SEVERE SEPSIS or SEPTIC SHOCK perform the following: Bundle Element Timing Measurement of Serum Lactate Within 4 hours of time of presentation Blood cultures Before Antibiotics Broad spectrum antibiotics Within 1 hour of time of presentation Fluid resuscitation At least 20 mg/kg or 1L bolus within 1 hour Remember FIRST DOSE MATTERS with fluids and antibiotics 2 Real time Sepsis Performance Feedback s Working with the Medical Center Quality Department, we receive weekly feedback on our performance with septic medicine patients coming through the ED and on the floors. In the spirit of continuous improvement we will be sending your teams sepsis performance data to help inform and improve practice. We realize that you are part of a larger team of ED physicians, ICU physicians and nurses, but we hope this feedback will encourage dialogue between treating physicians. Bundle Performance As a consequence of nurse screening in the ICUs and on 14, involvement of rapid response in a code sepsis, data audit and feedback, and increased availability of antibiotics on the floor, Sepsis performance has improved dramatically!

4 Mapping Discharge Improvement In 2008, the Division of Hospital Medicine launched its Discharge Improvement Process. We felt that to understand the process, we needed to map it. This 48 step process helped us understand what wasn t working in our discharge process. Four years later and with a new EMR we need to redo this process map for our changing times. In September and October, quality nurses may approach you and ask you questions about your discharge process with the goal of creating an updated process map. Once our new process map is complete will look for steps that compromise patient safety as well as wasteful or inefficient steps. The yearly BOOST projects will stem from these steps. Lean Training at UCSF As many of you know, our own Maria Novelero is currently participating in the Med Center s Lean Reach for Excellence Program where the trainees, are learning about Lean and applying it as an improvement approach in two areas: securing insurance authorizations for scheduled services and timely delivery of Pathology results. After wrapping up rapid improvement events this month, each one of the program participants will have to identify their own Lean project in their respective services/units. She would love your insight and suggestions. Interested in getting trained? Stay tuned for physician training opportunities in January.

5 APeX tips for quality Ordering Urgent Referrals When making a referral for outpatient subspecialty services, many things can go wrong. The patient s insurance may not be taken by UCSF, the clinic may be too busy to accommodate the patient in the time frame requested or once the appointment is made, the patient may be unable to be reached. In talking to many of you, we are all a little gun shy about ordering electronic referrals in APeX without communication with the clinics that these referrals will be made. There is a solution in APeX. Rather than specifying your appointment as Rountine or Urgent use: Urgent Referral Service requested. Follow this up with an with: Requesting Physician ( Name, Provider #, Pager #) Request Type (Facility, Provider of Service, Specialty) Clinical Information: Diagnosis or ICD-9 Code Patient Symptoms to assist with triage (Please specify justification for urgency.) to UrgentReferrals@ucsfmedctr.org Pending Tests at Discharge APeX doesn t have a single place in the chart to look for pending tests, but there is a simple and quick way to look up tests pending at discharge. In the "Chart Review" navigator, click on the tabs of Labs, Microbiology, Pathology, Imaging and make sure everything has a status of "Final Result." Anything that doesn't (for example if the Status is In Process or Preliminary result ) is still a pending test. Include these pending tests in your discharge summaries.

6 Division Incentive Metric Performance Achieve >60% full bundle compliance with Lactate, Blood Culture, Broad Spectrum Antibiotics, and Fluid Resuscitation FY 2012 Compliance 40% 81% 87% î 1 of 4 quarters FY 2012 HCAHPS Achieve HCAHPS Communication with 6 of 12 Top Box Score: Doctors Top Box score above 80% months 72% 73% 73% 100% 90% 80% 70% 60% 50% Jan Feb Mar April May June July Aug Sept Oct n=33 n=28 n=25 n=30 n=27 n=28 n=35 n=32 Promote appropriate nebulizer use and early transition to MDI; Reduce nebulizer use by 15% FY 2012 Baseline: 2 of 4 quarters 3.5 per hospitalization TBD Achieve an average MD hand hygiene rate of >85% for Medicine/Hospitalist Nov Dec CY 2012 by floor: 91% 90% 88% MD Communication total Explained in a way you could understand Target 9 of 12 months CALENDAR OF EVENTS RESIDENT QI LUNCHES M&M type format for Quality Cases: September 19 October 24 RESIDENT COST AWARENESS Sept 17 COPD Oct 19 Anemia Nov 20 CHF FACULTY QI LUNCHES SEPTEMBER: Focus Groups OCTOBER: Division Incentive Metrics 100% 90% 80% 70% Jan n=21 Feb n=24 Mar n=32 Apr n=43 May n=29 June n=26 July n=34 Aug n=41 Sept Oct Nov Dec Hospitalist Specialty Medicine Floor Summary Target CENTER FOR HEALTH PROFESSIONS SUMMER BREAK Respond to >80% of nurse queries FY 2012 Baseline: No Data Available 2 of 4 quarters