Quality & Patient Safety Annual Report

Transcription

1 Quality & Patient Safety 2018 Annual Report

2 Contents Who We Are... 1 Mission, Vision and Values... 1 Clinical Quality of Care... 2 Timely and Effective Care... 2 Efficient Care... 2 Culture of Safety... 3 Hospital Acquired Conditions... 3 Preventing C. Diff Infections... 3 Surgical Site Infections... 4 Readmissions... 5 Patient Experience of Care... 6 HCAHPS Patient Experience Comments... 7 Patient and Family Advisory Council... 8 Patient and Employee Safety... 8 Patient Falls... 8 Own the Bone... 8 Pressure Ulcers... 9 Injuries from Restraint Use... 9 Workplace Safety Internal Quality Assurance Process Improvement Program Electronic Medical Record Optimizations National Quality Awards Looking Forward to

3 We are pleased to share the Newton Medical Center Fiscal Year 2018 Quality and Patient Safety Annual Report with you. Our medical staff and employees share an interest in providing safe, high-quality care and exceptional service for every patient, every time. We look for ways PROTECT and DEFEND our patients and we aim to provide a rich patient experience from beginning to end. We use data to help us optimize outcomes of care. Our annual quality and performance program starts with clearly defining desired goals. From there, we work in teams to build the processes and structures to achieve those goals. Thereafter, we frequently measure and evaluate our outcomes. This allows us to rapidly adjust, to gain understanding and to continuously improve. We compare ourselves to performance of other hospitals, professional organizations, or quality watchdogs to demonstrate the validity and relevance of our activity. This year s report highlights several essential projects that, through hard work and dedicated effort, produced outcomes that often met and sometimes exceeded our dreams. I hope you enjoy reading about the things that we considered essential in earning your trust. We want to be your choice for healthcare every time. We will continue our work in such a way that we truly earn the privilege of your respect and trust. Thank you for allowing us to serve you. Sincerely, Vallerie L. Gleason President & CEO

4 Who We Are Newton Medical Center (NMC) is a 103-bed, not-for-profit facility dedicated to providing health care services to residents of Harvey and surrounding counties. Formed in 1988, NMC has evolved from an established tradition of excellence. More than a century ago, Dr. John T. and Lucena Axtell founded Newton s first hospital, Axtell Hospital. For four decades, the Axtells served the community until they passed on the hospital to the Kansas Christian Missionary Society. At that time, the name was changed to Axtell Christian Hospital, a Christian Church/ Disciples of Christ organization. At the turn of the century, Reverend David Goerz and Sister Frieda Kaufman founded Bethel Deaconess Hospital as a mission of the Mennonite Church. Mennonite deaconesses remained involved with the hospital s operations until On Jan. 1, 1988, the two hospitals merged to become Newton Medical Center. Mission: To excel in providing healthcare by understanding and responding to the individual needs of those we serve. Vision: To be the community s choice for healthcare. Values: Respect. Excellence. Service. Trust. 1

5 Clinical Quality of Care Our goal is to provide safe, quality care for the patients who entrust their care to NMC. Through an interdisciplinary approach led by the medical staff leadership, and approved by the governing board, this annual quality report details internal and external quality assurance and process improvement initiatives for fiscal year (FY) Every quarter, NMC submits data to Centers for Medicare and Medicaid Services (CMS) to identify illnesses and clinical conditions. These measures are adopted by the National Quality Forum and parallel those required by CMS. They promote best practices associated with targeted clinical disorders, prevention or reduction in clinical variance and prevention of harm. The following report highlights patient care and safety outcomes related to delivery of care at NMC. Timely and Effective Care Clinical Quality Indicators Worse than Average Average Better than Average Patients who received appropriate care for severe sepsis and/or septic shock Patients receiving appropriate recommendations for follow-up screening colonoscopy Average number of minutes before outpatient with chest pain or possible heart attack got EKG Outpatients with chest pain or possible heart attack who received aspirin within 24 hours of arrival or before transferring Percentage of patients who left the emergency department before being seen Patients assessed and given influenza vaccination Healthcare workers given influenza vaccination Acute Myocardial Infarction Survival Rate Pneumonia 30 day Survival Rate Total Hip and Knee Complications Efficient Care Providing efficient quality care through quality discharge planning, follow-up care alignment and appropriate ordering of procedures and testing, NMC demonstrated that Medicare spending was lower than the state or national average. NMC continually performs better than the Kansas and National average cost per beneficiary. NMC provided quality care with positive outcomes at an efficient price per care for FY

6 Medicare Spending Per Beneficiary* 1.2 Amount spent/episode of care NMC Kansas Average National Average *Lower values indicate better performance. Culture of Safety NMC strives to create a healthcare culture of safety. Free and open communication that is non-punitive in nature is encouraged in reporting adverse events and patient safety concerns. Organizational objectives align with the goal of improving patient safety and health outcomes. Hospital Acquired Conditions For FY 2018, NMC performed better than the benchmark for central line associated blood stream infections (CLASBI), catheter associated urinary tract infections (CAUTI), methicillin-resistant Staphyloccocus aureus (MRSA) blood infections and ventilator associated events (VAE). Clostridium difficile (C. diff) infections reported above the benchmark for this fiscal year. NMC Quarter 1 Quarter 2 Quarter 3 Quarter 4 Target CLASBI <1 <1 <1 <1 1 CAUTI <1 <1 <1 <1 1 MRSA Blood <1 <1 <1 <1 1 C. Diff VAE <1 <1 <1 <1 1 Preventing C. Diff Infections Clostridium difficile (C. diff) infections are not only an infection with serious symptoms but also a patient safety indicator for hospitals across America. A detailed performance improvement project is in place to address appropriate testing for C. diff and improvement of this measure. This action plan focuses on hand hygiene compliance, in addition to evidence-based testing methodology and aligns with the organizational goal of safe delivery of care. 3

7 Surgical Site Infections Surgical site infections (SSIs) are infections that occur after surgery on the part of the body where the surgery took place. Per the Centers for Disease Control and Prevention (CDC), SSIs can be superficial and affect the skin only. NMC continues to perform well in the patient safety indicator. The percentage of SSIs are listed below for the time period of July 1, 2017 to June 30, Total Colon SSI.03% Total C-Section SSI.01% Total Colon Surgeries 1 Colon SSI Occurrences 0 Total C-Sections 2 C-Section SSI Occurrences Total Hysterectomy SSI 0% Total Joint Infections.002% Total Hysterectomies 0 Hysterectomy SSI Occurrences Total Joint Surgeries 1 Joint SSI Occurrences In 2017, NMC became the second hospital in the state of Kansas to offer Stryker s Mako Robotic Arm- Assisted Total Hip and Knee replacement procedures. Robotic-arm assisted surgery is a new approach to joint replacement that offers the potential for a higher level of patient-specific implant alignment and positioning. The technology allows surgeons to create a patient-specific 3D plan and perform joint replacement surgery using a surgeon controlled robotic-arm that helps the surgeon execute the procedure with a high degree of accuracy. Orthopaedic Surgeon J. Scott Pigg, MD, with Stryker s Mako Robotic Arm-Assisted technology. The Mako total hip application is a treatment option for adults who suffer from degenerative joint disease 4

8 of the hip, whereas Mako s total knee procedure is a treatment option for adults living with mid to latestage osteoarthritis of the knee. During surgery, the surgeon guides the robotic-arm during the surgery to position the implant according to the pre-determined surgical plan. Robotic-arm assisted surgery is the latest advancement in joint replacement, offering the potential for a higher level of patient-specific implant alignment and positioning. This man (Dr. J. Scott Pigg) knows what he s doing. He s very particular about his patients. I was as comfortable as anyone could be I knew I was going to get the best of care. And I got it. I am absolutely impressed with the procedure that was done and the care I received as a patient was absolutely second to none. My experience with this I would not do it one bit different. - Art T., Mako bilateral knee replacement patient Readmissions NMC continues to exhibit stellar performance in preventing patients from being readmitted after an acute care episode. Much of this successful transition is can be attributed to the Right on Track program. The Right on Track program is a transitional care program created to help reduce 30-day hospital readmissions. This program is offered to assist patients at high risk of readmission in maximizing optimal health after discharge from acute care. All patients are screened for re-admission risk while in the hospital. Those found to be a high-risk are referred by their case manager to NMC Hospitalist Karen Lehman, APRN, for close post-acute follow up. Karen and NMC s Case Management team work in close coordination to provide patients with frequent follow-up phone calls for four weeks post-discharge and a home visit (for those who qualify.) When concerns are found, the team then works with the patient s primary care physician and other members of their care team to quickly resolve problems before they result in re-hospitalization. Because patients with complex medical and social determinants may lack supportive services at home, an APRN home visit allows for a comprehensive evaluation in the comfort of the patient s home. Karen Lehman, APRN, (left) with Jennifer Speer, RN, CM, Director of Case Management. During these visits, Karen reviews discharge instructions and medications, provides diagnosis-specific education and ensures close follow up with primary providers or specialists. In addition, further assessments 5

9 are conducted based upon individual needs. These may include the following assessments: home safety, mental and emotional health, nutrition, cognitive status, ability to complete activities of daily living, caregiver strain, and identification of other social determinants such as education level, transportation options and financial stress that may pose threats to obtaining the best health possible. After a visit, phone calls are frequently made to primary care providers to relay pertinent information and ensure close follow up to prevent readmission. Occasionally, adjustments are made in real-time, such as changing medication doses, in order to prevent an emergency situation. In FY 2018, 118 patients were referred to the Right On Track Program. This is a 10% increase from the previous year. Since its inception, 176 high-risk patients have received post-acute services from the program. Karen has seen 24 patients in their homes, two of whom were readmitted by the 30-day mark (8%). Overall readmission rates for NMC are between 4-5% compared with state and national peer benchmarks of 14-15% readmission rates. Use of the Right on Track Program has allowed many patients in a cycle of hospital readmission to maximize wellness and avoid return to the hospital. Patient Experience of Care Providing safe, efficient, customer-oriented care is a top objective of hospitals today. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is one of the major survey tools utilized to measure the patient perception of care and experience. The intent is to improve the quality of care through accountability and public disclosure. NMC scores above the 83rd percentile rank in overall rating of hospital, discharge information, recommendation of hospital and communication with doctors. Source: NRC Health 6

10 Opportunities for improvement exist in care transitions, quietness at night and communication about medications. NMC is committed to patients understanding medications and care upon discharge. Care transitions is a FY 2019 interdisciplinary performance improvement project. HCAHPS Patient Experience Comments I was very pleased, the staff at NMC is phenomenal. I received excellent care at NMC Excellent staff, excellent facility. I was expertly cared for and my family and I were treated with kindness, I like the compassion and respect. NMC is a 10 out of 10. way the food is served. The ER doctor went out of his way with kindness. Outstanding, best care ever, thank you. Staff was all attentive. Even the janitor was concerned with my status. Thank you for looking out for my best interests. NMC is amazing. I came here for both of my births and had excellent experiences both times! 7

11 Patient and Family Advisory Council The Patient and Family Advisory Council (PFAC) is additional evidence of NMC s commitment to enhancing the patient experience. PFAC serves to provide the patient and family perspective on patient care initiatives, projects and programs that impact patient and family care at NMC. The council works to identify concerns, serve as advisors on specific care initiatives and represent the voice of patients. PFAC consists of 6-12 members of the community who volunteer their time and ideas to enhance patient care. The PFAC is facilitated by the Patient Family Engagement Coordinator. Specific programs the council assisted with during the 2018 FY include wheelchair selections, Food and Nutrition Services options, the hand hygiene initiative, Imaging registration forms, clinic portal navigation and the employee dress code. Pictured (left to right): Marge Roberson, Casey Jacob, Ruthe Spexarth, Betty Vega, Willis Heck (NMC Board Designee), Amy Sherbenou. Not pictured: Jim Patterson, Hilda Conrade, Nancy Craig, Sandra Banman and Loretta Thomas (NMC Patient Family Engagement Coordinator). Patient and Employee Safety Protecting and defending the safety of our patients and employees is top priority at NMC. The Safety Committee leads the charge to deliver continuous safety efforts to better serve patients, their families and employees of NMC. Patient Falls According to the CDC, over 800,000 persons are hospitalized due to fall injuries each year. A fall is defined as an unplanned descent to the floor. NMC is committed to a continuum of care approach that reduces the risks of falls and fall-related injuries. NMC reduced the total number of falls by 12% this FY. This was accomplished through a FY 2017 performance improvement project led by the Interdisciplinary Fall Prevention Committee. A Fall Ball and departmental safety competition set the stage for heightened awareness and appropriate care planning to mitigate falls. NMC follows best practice guidelines to assess fall risk and apply fall prevention protocols and techniques. Next steps include adding a patient representative on the Fall committee. Own the Bone NMC is committed to the prevention of falls inside and outside the walls of the hospital. Under the leadership of Chief Medical Officer Dr. Charles Craig, NMC has taken steps to ensure its osteoporotic fracture 8

12 patients receive the treatment and care they deserve by joining over 225 other health care institutions nationwide in the American Orthopaedic Association s Own the Bone quality improvement (QI) program. Through the Own the Bone program, and its national web-based quality improvement registry, NMC has been provided with the tools to establish a fracture liaison service (FLS) and to document, track and benchmark care of fragility fracture patients. Through an FLS program, a care coordinator, such as a nurse or physician s assistant, ensures that fragility fracture patients are identified, evaluated and treated. Newton Medical Center is committed to protecting and defending our patients and this community. Through the Own the Bone program, we are helping patients understand their risk for fractures and the steps they can take to prevent them. - Charles Craig, MD, Orthopaedic Surgeon and Chief Medical Officer In 2018, NMC was recognized by Own the Bone as a Star Performer. This designation is reserved only for institutions that have achieved a 75% compliance rate with at least five of the ten Own the Bone prevention measures including: educating patients on the importance of Calcium and Vitamin D, physical activity, falls prevention, limiting alcohol intake and quitting smoking; recommending and initiating bone mineral density testing; discussing pharmacotherapy and treatment (when applicable); and providing written communication to the patient and their physician regarding specific risk factors and treatment recommendations. Pressure Ulcers NMC has exhibited zero episodes where a patient acquired a pressure ulcer during their hospital stay. Performance Baseline Baseline Period Rate 10/15-09/ (286/2,262) Current 3-Mo. Rate Current Period Project Rate 10/ / rate 0.0 rate Source: Kansas Hospital Collaboration Injuries from Restraint Use NMC continues to have no injuries due to restraint use. Continued monitoring occurs to promote patient safety and the least restrictive restraint method. 9

13 Workplace Safety NMC is committed to a safe environment for patients, visitors and employees. Over the past performance year, NMC performed a facilities environmental hazards assessment. From that assessment, increased security measures were implemented. NMC additionally developed a zero tolerance policy for aggressive behavior. (See signage on the right.) Hospital Administration and the Board of Directors support our staff s right to work in a safe and peaceful environment. ATTENTION Patients & Visitors This is a place of healing. Aggressive behavior will not be allowed. Examples of aggressive behavior include: Physical assault Verbal harassment Abusive language Sexual language directed at others Threats There is no tolerance for all forms of aggression. Incidents will be reported and may result in removal from this facility as well as legal action. All employees at NMC participate in TEAM (techniques for effective aggression management) training, which Administration supports our staff s right to work provides staff with the tools and knowledge to stay safe in in a safe and peaceful environment. their work environment. It leads to fewer staff and patient injuries and reduction in the use of patient restraints. TEAM utilizes a blended educational model to teach staff how to effectively manage the aggression cycle to act proactively to create a safe working environment. NMC is working toward a goal of 100% staff completion of TEAM training by the end of FY % of staff had completed training. This percentage should increase dramatically by the end of the calendar year 2018 due to increase in offerings of the TEAM classes and internally-trained TEAM instructors. - Emily Newhouse, Associate Chief Nursing Officer - Nursing Services, Safety Officer NMC Leadership, which includes administration and department directors, participated in educational sessions to maximize application skills relative to a just culture. Just culture desires better ways to prevent adverse outcomes with accountability delivered fairly to both staff and the hospital as an entity. At NMC, main duties include avoiding unjustifiable risks, following procedural roles and producing outcomes. Organizations that apply the just culture methodology evaluate systems of care to improve patient safety. Employees are dedicated to the mission and values of NMC. It matters to me that the management body treats each employee with respect, excellence and dignity in an environment of trust. - Vallerie Gleason, President & CEO 10

14 Internal Quality Assurance Process Improvement Program NMC developed, implemented and works to maintain an effective, ongoing, organizational wide, data driven quality assessment and performance improvement (QAPI) program. The goals of this hospital-wide program include identifying and reducing medical errors and improving health outcomes. Quality indicators are measured, analyzed and tracked on an ongoing basis. For FY 2018, NMC hospital-wide initiatives focused efforts on improving communication, improving employee workforce retention and maximizing the operations of the electronic medical record Meditech. 93% of the departments at NMC participated in the AIDET initiative. AIDET is an acronym for acknowledgement, introduction, duration, explanation and thank you. NMC uses this acronym as a communication tool when communicating with patients, visitors and fellow staff. This communication style enhances the patient experience and provides clarity to the exchange. The workforce goal for NMC remains to retain those employees that are committed to providing care to the community NMC serves. For FY 2018, NMC retained 79% of employees. Retention efforts include professional growth development, onsite continuing education offerings and virtual web education subscriptions. As NMC s most valuable asset, our staff are what differentiates NMC from other competitors by providing the best available care to anyone who enters NMC s doors. Departmental QAPI: This FY, 77% of departments met their quality outcomes. The other 23% require continued monitoring for improved outcomes. Electronic Medical Record Optimization As one of its Board-approved projects, NMC developed and implemented an updated information technology system. The goal of the optimization project is to utilize EMR enhancements and information to improve patient safety and quality of care. For FY 2018, 100% of the optimization goals were met. This was an organizational, multidisciplinary effort to improve efficiency and accuracy in the documentation of care. 11

15 National Quality Awards NMC received several distinct quality awards from unsolicited, outside entities this fiscal year. Blue Distinction Center+ for Knee and Hip Replacement and Maternity Care Blue Distinction Centers+ for Knee and Hip Replacement and Maternity Care, an expansion of the national Blue Distinction Specialty Care program, are hospitals recognized by Blue Cross and Blue Shield (BCBS) of Kansas for delivering quality specialty care safely and effectively, based on objective measures developed with input from the medical community. To receive this designation, a hospital must also meet requirements for cost efficiency. Performance Leader in Outcomes NMC was recognized by ivantage Health Analytics and the National Organization of State Office of Rural Health (NOSORH) for overall excellence in outcomes, reflecting top quartile performance among all rural acute care hospitals in the nation. Rankings are determined by the Hospital Strength Index, the industry s most comprehensive and objective assessment of rural hospital performance. Top 100 Great Community Hospital Since 2016, NMC has been named each year by Becker s Hospital Review as one of America s 100 Great Community Hospitals. Hospitals are selected based on rankings and awards from such organizations as ivantage Health Analytics, Truven Health Analytics, Healthgrades, CareChex, the American Nurses Credentialing Center and the Leapfrog Group. Included organizations have earned recognition from one or more of these organizations. Looking Forward to 2019 To strive for continuous improvement and safe patient outcomes, departments, medical staff, administration and the governing board have set the following as key QAPI initiatives for FY (The following lists highlights of the FY 2019 QAPI plan and is not a complete list of projects and initiatives.) HCAHPS transitional care performance improvement interdisciplinary project C. Diff process improvement project Just Culture application hospital wide Continued fiscal stewardship Documentation initiatives Facilities preventative maintenance Clinical contract review and utilization MIPS and MACRA requirements Emergency response times enhancement Employee retention Medical imaging appropriate use criteria HIPAA risk assessment mitigation activities Enhanced clinic laboratory turn around time Increase medication scan rates Increased sepsis bundle completion rate Improved functional outcomes for patients with lower extremity diagnosis Increased identification of patients with OSA pre-operatively 12