MSQC Quality Improvement Initiative Summary- EXAMPLE

Transcription

1 MSQC CQI Performance Index and Scoring 2014 Attachment D MSQC Quality Improvement Initiative Form MSQC Quality Improvement Initiative Summary- EXAMPLE Goal (Based on MSQC data) Decrease MSQC VTE rate of occurrence for post-operative patients Time Period: 9/1/2013 8/30/2014 Department/Discipline/Committee Involved: Multidisciplinary team comprised of Hospital administration, Surgeon Champion, SCQR, Vascular surgeon, Perioperative Director, Medical-Surgical Nursing Leadership, Pharmacy, Quality staff, Staff nurse, Nursing Education, Pharmacy, Internal Medicine physician, HMS-VTE Coordinator (See example VTE Team Matrix in VTE Toolkit for forming a Steering Committee) BASELINE DATA CHART (NOTE: THIS IS A PLACEHOLDER TEXT BOX ONLY POST-IMPLEMENTATION DATA CHART (NOTE: THIS IS THIS IS A PLACEHOLDER TEST BOX ONLY) Insert MSQC VTE summary chart for 9/1/2013 here. Insert MSQC VTE Summary chart for 8/31/2014 here. **Note: Could also add a third chart for the trend to show the change between 2013 and 2014.

2 Identify opportunities for decreasing VTE rates Data Drill Down: Review MSQC Reports: Identified perioperative heparin rate lower than collaborative SCIP: Identified 98% compliance with VTE measures. Review last quarter VTE cases using VTE Case Peer Review form: Found that 25% of cases reviewed were considered preventable. Risk Assessments/orders not consistently being done. Presented data & graphs to Surgeon Champion (date) Presented data/graphs to CORE Measure Committee (date) Presented data/graphs to Surgery Quality Committee (date) Provide individual VTE rates to surgeon providers (date) All parties/committees concerned with VTE rates & request hospitalwide VTE initiative to include HMS- VTE (medical patients). Requested formation of VTE committee to address both surgical and medical VTE s. Form multidisciplinary VTE Team Present data to Administrative staff to obtain support in developing and implementing a VTE task force team. Identify priorities for action based on drill down data information (VTE case review template). Provide case information about preventable VTE to specific surgical providers. Presented Administrative slide deck at the Leadership Performance Improvement meeting on 1/3/14 Utilized the Forming a Steering Committee document in the VTE toolkit to form and implement a VTE team Conducted data drill down using the VTE case review form on all 8 patients who had VTE/PE during this time period. Drill down was used to identify priorities for initiatives. Team members were identified and accepted request for membership. Surgeon Champion & Internal Medicine Chief designated as Co- Chairmen. First VTE meeting held on 3/14/14. Identified standard monthly meeting date & time, ground rules and objectives.

3 Develop and implement use of VTE Risk Assessment within EMR. VTE team to review available Risk Assessment models; determine which one to use, and meet with IT to add in EMR. Met with IT staff and developed steps necessary to add MSQC VTE risk assessment into EMR. Implemented hard-stop for completing VTE risk assessment and the corresponding orders based on the VTE score. ( Educated physicians regarding need to do risk assessment both pre- and post- operatively using tool in EMR. MSQC risk assessment and hardstop - operative in EMR as of 6/1/14. 90% of surgeons received formal education regarding need to do risk assessment and write orders based on VTE score. MSQC Risk Assessment cards distributed at the Surgery Quality meeting and Quarterly staff meeting. Distributed MSQC Risk Assessment Cards to Surgeons (list meetings attended &. 100% compliance with nursing staff VTE awareness education. Educated nursing staff regarding VTE risk factors & need for assessment.

4 Increase compliance with administration of pharmacological prophylaxis Provide VTE education to nursing staff. Provide VTE Education to patients. Conducted Lunch & Learn for VTE education for nursing staff. (date) Utilized MSQC VTE toolkit to develop online learning module for VTE awareness. Included as part of yearly mandatory education. (date) Implemented patient education VTE video produced by MHA. (date) Provided patients with VTE educational brochures. (date) Included Heparin administration as part of the Time Out Briefing process & added on OR White Boards. (date) Lunch & Learn staff attendance rates 75%. VTE online learning module now included in new employee orientation program. VTE mandatory yearly learning module completed by 100% of staff. Spot checks being done in OR reveal 95% compliance with Time Out Briefing and use of OR White Boards. Spot checks will continue throughout the upcoming year.

5 Increase compliance of SCD use Assure that there are enough SCD s for all patients requiring their use. Increase staff and patient awareness regarding the importance of SCD compliance Identified that there were not enough SCD machines in the hospital and presented this as well as the costs associated with treating VTE s to hospital administration. They approved purchase of 30 more SCD machines. (date) Presented information to administration regarding purchase of battery operated SCD s for when patient is up in chair in order to improve compliance of SCD use. (date) Hospital purchased additional SCD machines and they were available for use starting 5/1/14. Cost of battery operated SCD s were prohibitive at this time. Will consider with new yearly budget planning. SCD compliance up to 95%. VTE rates decreased by 10% overall. See above educational offerings implemented to increase compliance with administration with pharmacological prophylaxis; as they also included education on increasing compliance with SCD use.