2013 ANNUAL REPORT Performance Improvement and Patient Safety

Transcription

1 2013 ANNUAL REPORT Performance Improvement and Patient Safety

2 THE BASSETT DIFFERENCE At Bassett Medical Center, we begin each day with a commitment to be better than we were yesterday, last week, last month, last year. We wish to hold true to our promise of exceptional care, so we measure many aspects of our care processes. We learn from these measures what needs to be changed, and most importantly, what we need to do to ensure we provide high quality, safe patient care for those who come to us in need. We are led to continual improvement by our governing body, whose pursuit of excellence is unparalleled. Our physicians are experts in their fields and because of their focused expertise, we are able to provide high quality clinical care. Our employees are committed to our patients and families, as well as to one another. In these pages you will see the results of the work completed by many of our committed colleagues. You will also see by some of our measures that we are not perfect. This past year has taught us a great deal about where we need to improve and enhance our efforts. Much work is ahead in order for us to earn top marks in every area. But we are working hard to get there. We are proud to lead an organization with such dedication and drive to deliver on the promise of exceptional care that every patient deserves. Sincerely, Dr. William F. Streck Bertine McKenna, Ph.D. Dr. Steven Heneghan President Executive Vice President Chief Clinical Officer Chief Executive Officer Chief Operating Officer

3 TABle of CoNTENTS CLINICAL QUALITY Core Measures Performance 2 Value Based Purchasing Programs 11 Efficiency Measures of Hospital Outpatient and Inpatient Care 12 Physician Quality Reporting System (PQRS) 15 Group Practice Reporting Option (GPRO) Stroke Quality Performance 18 Safer Patients and Staff: Infection Prevention 20 and Control at Bassett Medical Center Patient Safety: Hospital-Acquired Pressure Ulcers 22 Bassett Earns Top Performer Status 24 Performance Improvement Project: Reducing Length of Stay 25 Patient Safety: Fall Prevention 26 Patient Quality: Obstetrics Exclusive Breastfeeding 27 SAFETY Good Catch 28 Medication Safety 29 Serious Events: The New York Patient Occurrence 30 and Tracking System (NYPORTS) PERFORMANCE IMPROVEMENT 2013 Accomplishments 32 Surveys 33 Awards and Recognition 34 LOOKING AHEAD TeamSTEPPS 36 Patient and Family Shadowing 38

4 2 ClINICAl QUAlIT Y The Institute of Medicine defines health care quality as, the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making. At Bassett, staff constantly strives for excellence and is committed to continuous quality improvement in all that we do. We measure and analyze our performance in order to inform change and improve, with the goal of developing the best systems of patient care possible. Ronette Wiley, Vice President of Performance Improvement, and Ruth Blackman, Senior Director of Quality Resources Management Core Measure Performance Bassett Medical Center Recognized as Joint Commission Top Performer on Key Quality Measures Bassett Medical Center was one of 1,099 hospitals, of 3,300 Joint Commission accredited hospitals, recognized in the Joint Commission s 2013 Annual Report and Top Performer on Key Quality Measures program. When determining top performers, the Joint Commission looks at core measure data and performance for evidence-based clinical processes and best treatments for heart attack and pneumonia care. At Bassett Medical Center, we continuously measure and evaluate our performance in Core Measures of care. These measures are established in a collaborative effort by the Centers for Medicare & Medicaid (CMS) and The Joint Commission. Core Measures are a uniform set of national hospital quality standards of care for common hospital conditions. These standards are based on evidence-based best practices endorsed by the National Quality Forum (NQF). Hospitals across the country measure Core Measures to identify opportunities for improvement. Core Measures track specific elements of process of care that, when applied, contribute to improved patient outcomes for the following hospital conditions: acute myocardial infarction, heart failure, pneumonia, surgical care, and immunizations. At Bassett Medical Center, we monitor and benchmark our performance against all New York State and national top decile hospitals with the intent of improving the quality of our inpatient care. Core Measure performance is publicly reported on the CMS Hospital Compare website (

5 3 Acute myocardial infarction, aspirin at arrival and prescribed at discharge In 2013, Bassett Medical Center achieved national top decile for patients who received aspirin on arrival and were prescribed aspirin at hospital discharge. Aspirin therapy in patients who have suffered an acute myocardial infarction reduces the risk of adverse events and mortality. Acute myocardial infarction, primary PCI within 90 minutes of arrival The early use of primary angioplasty in patients with an ST-segment myocardial infarction results in significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided the more effective it is in clearing blocked arteries for the patient. At Bassett Medical Center, our 2013 performance was slightly below state and national benchmarks. Acute myocardial infarction, statin prescribed at discharge Bassett Medical Center achieved national top decile for statin drugs prescribed at discharge. Statin drugs are used to reduce cholesterol levels and have been proven to be beneficial in reducing the risk of death and recurrent cardiovascular events for patients with cardiovascular disease, including myocardial infarction.

6 4 Heart failure, discharge instructions given to patient In 2013, Bassett Medical Center s performance was comparable to state and national benchmarks in ensuring that patients and their families were provided written instructions and educational materials to understand their dietary restrictions, activity recommendations, prescribed medication regimen, and the signs and symptoms of worsening heart failure. Heart failure, evaluation of left ventricular systolic function Bassett Medical Center performed at top decile in evaluation of left ventricular systolic function for heart failure patients. Appropriate selection of medications to reduce morbidity and mortality in heart failure requires the identification of patients with impaired left ventricular systolic function. National guidelines advocate the evaluation of left ventricular systolic function as the single most important diagnostic test in the management of all patients with heart failure. Heart failure, ACEI and ARB for left ventricular systolic dysfunction In 2013, Bassett Medical Center surpassed state and national benchmarks for prescribed ACEI and ARBs at hospital discharge. ACE inhibitors reduce mortality and morbidity in patients with heart failure and left ventricular systolic dysfunction.

7 5 Pneumonia, blood cultures performed in the Emergency Department prior to initial antibiotic Bassett Medical Center achieved national top decile in collecting blood cultures in the Emergency Department prior to administering antibiotics for pneumonia patients. Pretreatment cultures are recommended because clinically useful information is greater if the culture is collected before antibiotics are started. Pneumonia, initial antibiotic selection Bassett Medical Center s performance was slightly below state and national benchmarks for selection of initial antibiotic regimen consistent with current guidelines for pneumonia patients. Treating the most common cause of community-acquired pneumonia can be associated with improved survival. Surgical care, antibiotics within one hour of surgical incision In 2013, Bassett Medical Center s performance was consistent with state and national benchmarks in providing the patient prophylactic antibiotics within one hour prior to surgical incision. Evidence indicates that the lowest incidence of post-operative infection was associated with antibiotic administration during the one hour prior to surgery.

8 6 Surgical care, appropriate antibiotic selection In 2013, Bassett Medical Center s performance was consistent with state and national benchmarks for selection of antibiotics for surgical patients. The administration of the appropriate antibiotic has been found to help prevent wound infections for specific types of surgery. Surgical care, antibiotics discontinued within 24 hours after surgery Bassett Medical Center s performance was comparable to state and national benchmarks for the discontinuation of antibiotics within 24 hours after surgery end time. The timely discontinuation of prophylactic antibiotics for surgical patients may reduce the risks associated with opportunistic infections and is consistent with current guidelines. Surgical care, cardiac surgery patients with controlled 6 A.M. blood glucose Bassett Medical Center s performance was comparable to state and national benchmarks for cardiac surgery patients with controlled 6 A.M. blood glucose on postoperative day 1 and postoperative day 2. Elevated blood glucose is associated with increased in-hospital mortality and morbidity for surgical patients. Controlling blood glucose levels can minimize adverse outcomes for cardiac surgery patients.

9 7 Surgical care, urinary catheter removed on postoperative day one or two Bassett Medical Center exceeded state and national benchmarks in the removal of urinary catheters by postoperative day one or day two. It is well established that the risk of catheter-associated urinary tract infection (UTI) is decreased by reducing the duration of indwelling urinary catheterization. Surgical care, patients with perioperative temperature management Bassett Medical Center is consistently at top decile in management of perioperative temperature. Core temperatures outside the normal range pose a risk in all patients undergoing surgery. Surgical care, patients on betablocker therapy who received beta-blocker during the perioperative period In 2013, Bassett Medical Center performed better than state and national benchmarks in ensuring surgical patients on beta-blocker therapy received a beta-blocker during the perioperative period. Continuous betablocker use contributes to a reduction in postoperative complications.

10 8 Surgical care, patients receiving recommended blood clot therapy Bassett Medical Center s performance was slightly below the state and national benchmark for patients receiving blood clot or venous thromboembolism prophylaxis. The development of blood clots is one of the most common postoperative complications, and prophylaxis is the most effective strategy to reduce morbidity and mortality. Patients receiving Pneumococcal Vaccine Bassett Medical Center was comparable to state and national benchmarks for administering pneumococcal immunization to hospitalized inpatients. Pneumococcal vaccine screening and administration are recommended by the Centers for Disease Control and Prevention as studies demonstrate the effectiveness of the vaccine against pneumococcal bacteremia in vaccinated patients. Patients receiving Influenza Vaccine Bassett Medical Center was slightly below state and national benchmarks for administering influenza immunization to hospitalized inpatients. Influenza vaccine screening and administration are recommended by the Centers for Disease Control and Prevention because this is the most effective method for preventing influenza virus infection and its potentially severe complications.

11 9 Venous thromboembolism prophylaxis Introduced by CMS as new measures in 2013, Bassett Medical Center performed above the state and national benchmarks for venous thromboembolism prophylaxis. These measures assess the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given during the hospital admission. Hospital patients are at high-risk for VTE, a potentially fatal event. ICU venous thromboembolism prophylaxis Introduced by CMS as new measures in 2013, Bassett Medical Center performed above the state and national benchmarks for ICU administration of venous thromboembolism prophylaxis. These measures assess the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given during the ICU hospital admission. Hospital patients are at high-risk for VTE, a potentially fatal event. Venous thromboembolism, patients with anticoagulation overlap therapy Introduced by CMS as a new measure in 2013, Bassett Medical Center performed at national top decile for venous thromboembolism patients with anticoagulation overlap therapy. This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous or subcutaneous) anticoagulation and warfarin therapy. The evidence-based practice of using overlap therapy in the initial treatment of VTE events prevents complications.

12 10 Venous thromboembolism, patients receiving unfractionated heparin (UFH) with dosages/platelet count monitoring by protocol or monogram Introduced as another new measure in 2013, Bassett Medical Center performed at top decile for patients receiving UFH with monitoring. This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous UFH therapy dosages and had their platelet counts monitored using defined parameters by nomogram or protocol. Venous thromboembolism, warfarin therapy discharge instructions Also a new core measure in 2013, CMS now assesses the number of patients diagnosed with confirmed VTE that are discharged on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions. In anticoagulation therapy programs, patient education is a vital component to achieve successful outcomes and reduce hospital readmission rates. Bassett Medical Center performed above the state and national benchmarks in this measure. Hospital-acquired potentiallypreventable venous thromboembolism The last new CMS VTE measure in 2013, hospital acquired potentially preventable venous thromboembolism, measures the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date. Bassett Medical Center performed at national top decile in this important measure, indicating compliance with evidencebased practices to prevent VTE and improve patient safety in the hospital setting.

13 11 Value-Based Purchasing Programs: Improving and Rewarding Quality Hospital Care Bassett Medical Center participates in a number of Value-Based Purchasing Programs. The most influential is Medicare s Hospital Value-Based Purchasing (VBP) Program, affecting payment for inpatient stays in over 3,500 hospitals across the country. The VBP Program was created by the Affordable Care Act and intended to transform Medicare from a passive payer for services to a prudent purchaser of services, paying not just for quantity of services but for quality as well. Beginning in fiscal year (FY) 2013, the Medicare VBP Program uses the Hospital Inpatient Quality Reporting (IQR) Program structure to reward hospitals for achievement and improvements for select measures of care in four domains: Clinical Process of Care Domain Patient Experience of Care Domain Outcome Domain Efficiency Domain In 2013, CMS released the Federal Fiscal Year 2014 VBP total performance score and Bassett Medical Center demonstrated improvement from the first year s performance, ranking higher than both the New York State and national average facility score. Bassett Bassett New York State National Medical Center Medical Center Average Average Measure FFY 2013 Score FFY 2014 Score Facility Score Facility Score Total Performance Score

14 12 Efficiency Measures of Hospital Outpatient and Inpatient Care The Hospital Outpatient and Inpatient Quality Reporting Programs provide opportunity to measure and report on a number of efficiency measures designed to ensure high quality care, adherence to evidence-based medicine and practice guidelines, and support efficient use of healthcare resources. Efficiency measures include: Imaging efficiency measures to reduce unnecessary exposure to contrast materials and/or radiation.

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16 14 Medicare Spending per Beneficiary, a claims-based measure that includes risk-adjusted and price-standardized payment for all Part A and Part B services provided from three days prior to a hospital admission through 30 days after the hospital discharge. Bassett Medical Center s performance for imaging, readmissions, and Medicare s spending per beneficiary efficiency measures are comparable to state and national benchmarks. CMS has not applied a readmission penalty to Bassett Medical Center for excess readmissions under the Hospital Readmission Reduction Program since program implementation, October A multidisciplinary group is working to improve performance in the Emergency Department throughput efficiency measures. This will be the group s major work in 2014.

17 15 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO): Improving and Rewarding Quality Physician Care The Centers for Medicare and Medicare Services (CMS) established the Physician Quality Reporting System (PQRS) in 2006 as a quality reporting program for eligible professionals. In 2010, CMS introduced the Group Practice Reporting Option (GPRO) to promote quality reporting for group practices with greater than 100 physicians. Beginning in 2015, the Affordable Care Act mandates a budget neutral Value-Modifier Program to reward physicians for quality, with PQRS GPRO participation as the overall approach to reward physicians for achievement of select quality measures. Bassett Medical Center participates in PQRS GPRO, through a web-interface clinical abstraction, providing clinical data for a sample of 6,165 Medicare beneficiaries for 15 measures that focus on preventive care and care for chronic diseases. Care Coordination/ Patient Safety Preventive Health At Risk Populations Medication Reconciliation Falls Screening for Future Fall Risk Influenza Vaccination Pneumococcal Vaccination BMI Screening and Follow Up Tobacco Use Screening and Cessation Intervention Clinical Depression Screening and Follow Up Colorectal Cancer Screening Breast Cancer Screening High Blood Pressure Screening and Follow Up Diabetes Composite (HbA1c, LDL, BP Control, Tobacco Use, IVD Medication) Hypertension Control Ischemic Vascular Disease LDL Control Heart Failure Beta-Blocker for LVSD Coronary Artery Disease Lipid Control Bassett Medical Center performed at or better than the national mean for the majority of PQRS GPRO measures. Performance improvement projects at Bassett Medical Center in 2013 that aim to improve performance of key measures of preventive care and care of chronic diseases include: an ambulatory quality dashboard to identify patients with gaps in care for follow up; advancement of the Patient Centered Medical Home model of care, and MyBassett Health Connection electronic patient portal to engage patients in their health care.

18 16 Bassett Medical Center performed at or better than the national mean for the majority of PQRS GPRO measures.

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20 18 A multidisciplinary stroke committee continues to work to improve process measures of stroke care. Bassett s focused work in this area has resulted in recognition multiple times by the American Heart Association s Quality Achievement Award for Stroke Care. Connie Jastremski, Vice President of Patient Care Services & Chief Network Nursing Officer Stroke Quality Performance: American Heart Association/American Stroke Association Get With the Guidelines and CMS Core Measure in 2013 Bassett Medical Center is a New York State Department of Health designated stroke center. This means Bassett s stroke clinical team is specially trained and the facility specially qualified to treat people who may have suffered a stroke. In 2013, Bassett Medical Center received the American Heart Association/American Stroke Association s Get With The Guidelines Stroke Gold Plus Quality Achievement Award, recognizing Bassett s commitment and success in 10 Get With The Guidelines Stroke Quality Measures. Beginning January 2013, CMS introduced eight evidencebased practice standards for stroke as core measures of care for the Hospital Inpatient Quality Reporting Program. Discharged on antithrombotic therapy, Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Anticoagulation therapy for Atrial Fibrillation/ Flutter, Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. Venous Thromboembolism (VTE) Prophylaxis, Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.

21 19 Thrombolytic therapy, Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-pa was initiated at this hospital within 3 hours of time last known well. Antithrombotic therapy by end of hospital day two, Ischemic stroke patients administered antithrombotic therapy by the end of hospital day two. Discharged on statin medication, Ischemic stroke patients with LDL greater than or equal to 100 mg/dl, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival and are prescribed statin medication at hospital discharge. Stroke education, Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke. Assessed for rehabilitation, Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. In 2013, Bassett Medical Center received the American Heart Association/ American Stroke Association s Get With The Guidelines Stroke Gold Plus Quality Achievement Award, recognizing Bassett s commitment and success in 10 Get With The Guidelines Stroke Quality Measures.

22 20 Safer Patients and Staff: Infection Prevention and Control at Bassett Medical Center At Bassett Medical Center, the prevention and control of health care associated infections is a priority. We do this through continuous measurement and evaluation of potential and actual infection outcomes of procedures and processes. The Infection Prevention and Control Program addresses this priority through risk assessments, education, surveillance, process tracers, data analysis and reporting, and implementation of evidence-based prevention measures. In 2013, an area of success has been the reduction of surgical site infections in colon, hip replacement and knee replacement procedures. Close attention to evidence-based pre- and post-operative infection prevention practices has resulted in rates of infection for cardiac and hysterectomy procedures being sustained at or near zero for several years. This is reflected in the improved and sustained high rates of compliance with the Surgical Care Core Measures, demonstrating that improvement in process elements leads to improvement in outcomes. Rate of surgical site infections for cardiac, hysterectomy, colon and joint replacement procedures

23 21 A ventilator associated pneumonia (VAP) rate of zero has been sustained since 4Q12. One change in practice implemented in July 2012 was the use of chlorhexidine gluconate (CHG) swabs for mouth care of ventilated patients. This is recommended as part of the VAP bundle. The central line associated bloodstream infection rate in our ICU patients remains comparable to the New York State benchmark and below the National Healthcare Safety Network benchmark. Continued emphasis on use of appropriate infection control precautions for inpatients and outpatients as well as focus on hand hygiene have also contributed to low rates of hospital acquired infections at Bassett Medical Center.

24 22 Patient Safety: Hospital-Acquired Pressure Ulcers At Bassett Medical Center, a multidisciplinary workgroup reviews all hospital-acquired pressure ulcers and the involved prevention processes. The reduction in pressure ulcer rates was the result of a nursing focus on improved interdisciplinary communication and diligent surveillance of preventative measures impacting our nutritionally compromised patients. The following preventative strategies were implemented: Nutrition & Education processes: Created a mandatory Healthstream online education for nurses focusing on nutritional assessment requirements and pressure ulcer prevention strategies for nutritionally compromised patients.

25 23 Registered dietitians place Skin Wound Assessment Team (SWAT) consults for malnourished patients in a reciprocal manner as SWAT places nutritional consults for patients at risk for skin breakdown. Improved (Direct) Communication within Care Areas: High-risk patients discussed in daily unit staff huddles. Increased communication via re: successes and concerns/trends. Skin Champions continued to educate unit staff on performing Pressure Ulcer Prevention strategies. Skin Champion badges increase coworker & patient awareness of the importance of their role in the prevention of skin breakdown. Trends with device related skin breakdown in OR and on acute units resolved with program providers and work group. Mirrors in every patient room to aid skin assessment. Pulsate surfaces purchased in 1st quarter 2013 with education of staff on Support Surface Algorithm with improved collaboration with Materials Management regarding daily support surface use in hospital. Pressure Ulcer Workgroup: Continued monthly case review with root cause analysis to identify and implement process improvement. Systems issues are identified with the creation of a work plan. Continual re-evaluation of progress and improvement to ensure sustainability.

26 24 Bassett Earns Top Performer Status Excellence in Heart Care and Pneumonia Treatment Bassett Medical Center has earned recognition from The Joint Commission s Top Performers on Key Quality Measures program. Bassett was among 1,099 hospitals to meet or exceed The Joint Commission s performance targets for 2012 out of more than 3,300 hospitals across the country that submitted data. The award recognizes hospitals that use evidence-based clinical processes proven to be the best treatments. Applying evidence-based practices to the care of our patients not only improves outcomes, notes Executive Vice President and Chief Operating Officer Bertine Colombo McKenna, Ph.D., It s also the means by which we can achieve continued improvement and, ultimately, realize our goal of delivering high quality care to every patient every time. At Bassett, that has been and continues to be our focus. The Joint Commission is the leading accreditor of health care organizations in the U.S. and has issued a Top Performers report for the past three years. Vice President of Performance Improvement Ronette Wiley, M.H.A., R.N., says, Patients want to know they ll be safe and well cared for, and that s why Bassett invests significant time and resources in this work. In order to earn top performer status, Bassett needed to meet two levels of evaluation criteria. First, the medical center s accountability composite score has to equal or be greater than 95 percent. Second, the score for each individual accountability measure also had to meet or exceed 95 percent. Each accountability measure is based on an evidencebased practice. According to The Joint Commission, the Top Performers on Key Quality Measures program is: Intended to be an incentive for all hospitals to improve and be the best they can be. Consistent with the current themes of the pay-for-performance requirements of federal and state governments, as well as many private payers, and the reported data have been available on The Joint Commission s Quality Check website and the Centers for Medicare & Medicaid Services Hospital Compare website for some time. A way to provide transparency to the public in the reporting of performance at the hospitals where they receive care.

27 25 Performance Improvement Project: Reducing Length of Stay Truven Health Analytics (THA) completed an assessment and made recommendations regarding improvement opportunities in length of stay and discharge planning. To that end, multidisciplinary length of stay reduction teams were mobilized around two targeted populations: total joint replacement and congestive heart failure. Both teams have realized great success in their work: These teams were composed of committed physicians, nurses, case managers, and other professionals who collaborated closely to improve care and reduce length of stay for patients being admitted for joint replacement or heart failure. The processes used by these teams will be replicated by the organization as we seek to reduce length of stay for other patients in the hospital.

28 26 Patient Safety: Fall Prevention Bassett continues to categorize falls in accordance with rigorous Magnet hospital standards; even patients who are assisted to the floor or a chair by personnel to prevent injury are categorized as having fallen. The fall risk assessment and prevention process continues to evolve in Patients assessed to be at risk for falling have specific interventions put in place to protect them from falling. Initial measures include dressing the person in a cautionary yellow ensemble of gown, non-skid footwear and lap blanket with the application of personal and bed alarms. The immediate bed area is cleared of equipment or supplies that could cause a patient to slip or fall. Families are also engaged and educated about the interventions in place for their loved one s protection and informed of how they may help hospital staff prevent falls. Nursing leaders make daily rounds on each unit to ensure fall preventions are in place and to make changes as needed in the moment and provide direction to keep our patients safe. Fall huddles conducted immediately after each fall include the on-site supervisor and staff involved to identify root causes with corrective actions to improve patient safety. Daily reviews of each fall and huddle are reported and trended to the monthly Fall Committee where practice recommendations are determined. The continued pursuit of improvement has led to the establishment of fall squad champions who provide additional real time shift support and direction for falls prevention. The Fall Committee s November Fall Prevention Expo attracted over a hundred nurses, staff, providers and community members with education stations outlining Bassett s Fall Prevention Program and also strategies for preventing falls at home. Bassett s NEAR (Nursing Education and Research) Team conducted a daylong seminar on Care of the Geriatric Inpatient in October to provide specific education to nurses, medical and ancillary staff. Bassett has partnered with the Joint Commission s Center for Transforming Healthcare as a phase two pilot site for Decreasing Falls with Injury on the Medicine-3 inpatient unit to instill evidence-based, best practices for 2014.

29 27 Patient Quality: Obstetrics - Exclusive Breastfeeding The Exclusive Breastfeeding core measure compliance requires that a breastfed infant must not receive feeding supplements of any kind while in the hospital. There are no exclusions based on medical necessity. The Joint Commission benchmark requires that 46% of infants born at the Bassett Birthing Center should receive nothing but breast milk while in the hospital. Additionally, the Healthy People 2020 initiative by the United States Department of Health has a stated compliance goal of 70%. Bassett presently exceeds both goals. The Bassett Birthing Center s improvement in exclusive breastfeeding can be attributed to: The excellent one-to-one breastfeeding support provided by the Birthing Center nursing staff; All staff complete a twenty hour online breastfeeding course sponsored by New York State. The Birthing Center currently has four certified lactation consultants on staff with another nurse in the process of studying for the exam. Use of crib cards identifying breastfed infants and requesting no supplements to be given. Staff education regarding the rationale for avoiding routine supplementation. Breastfeeding class information now posted on the web. The New Beginnings binder presented to women at their first ante-partum visit has been replaced by a user-friendly, easy to read education booklet that outlines the importance of breastfeeding. The increased affordability of beast pumps related to mandatory insurance coverage.

30 28 SAFET Y When we think of patient safety, hardwiring protocols, robust documentation, and analysis of outcomes are critical to success. However, most important is the culture of safety, which is driven by leaders from the board level down. Employees know they have not only permission, but are encouraged to speak up when something isn t quite right and to make suggestions to improve processes and protect our patients. Melane Mulchy, Director of Network Performance Improvement Good Catch In 2013, Bassett Medical Center embarked on an initiative to change any negative perceptions health care providers and others may have about reporting errors, and celebrate the near misses or good catches reported by staff members. Through this program and the RL6 Incident Reporting System, staff is encouraged to report near misses. These reports help to identify areas where patients quality of care and safety might be improved. Reporting a near miss is considered a good catch. A near miss is an event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. Recognizing potential problems is a good catch. What may have led to a mistake was recognized and corrective action was taken. In 2013, staff at Bassett Medical Center reported 37 good catches Fourteen of the near misses were from Bassett s regional sites Thirteen of the near misses were related to near miss medication errors Seven of the near misses were near miss imaging events Six of the events were related to equipment or environmental issues To highlight one great outcome as a result of the good catch program, a good catch was reported for a near miss pediatric medication error for a medication that was weight based. As a result of this near miss event reported, pediatric order sets are being created and efforts are in place to leverage EPIC, Bassett s electronic medical record (EMR) system, with regard to solutions that can be built into the EMR. Through the good catch program, we are positively impacting our culture of safety and improving patient safety by identifying latent errors and allowing us to learn from these events before they harm patients.

31 29 Medication Safety The Intensive Pharmacotherapeutics (IP) Program deploys attending pharmacists to the units, who work alongside attending physicians and nurses to maximize medication therapeutics, minimize adverse drug reactions and reduce readmission. IHI recognized this process as one of the best medication safety initiatives in the country. This work is in place at leading medical centers throughout the country, including the Cleveland Clinic. Bassett Medical Center began its own journey into IP in September IP is ground breaking because it looks at how the medication treatment of one diagnosis may actually interfere or be compromised by medications prescribed for comorbid diagnoses. This process requires specially trained, advanced practice, clinical pharmacists who quarterback the medications of many prescribing specialists. One hundred percent of all medication orders are reviewed at Bassett Medical Center, and through IP, ten percent of those orders have significant changes made to the drug regimen that provide the best therapeutics and least medication side effects. The Advanced Practice Pharmacist Training Program, developed at the Bassett Medical Center Pharmacy, is a 23-week intensive training program that elevates existing staff to advanced practice attending pharmacists. This work has been recognized by Albany College of Pharmacy and other peer hospitals in NYS. It is currently being prepared for publication as the Bassett Model. The Broad Antibiotic Stewardship Program was reviewed by the Joint Commission during a survey in December The surveyor encouraged us to publish our work as a best practice. Our program is indeed one of the best in New York State. It provides state of the art care and more efficient use of medication that has resulted in $500,000 in antibiotic drug cost savings in The Anticoagulation Management Services (AMS) has expanded to include the Oneonta area of the Bassett Healthcare Network. The Cooperstown AMS clinic currently treats 500 patients with serious anticoagulation needs (VTE, PE, Mechanical Heart Valves) in Cooperstown. During the summer of 2013, we expanded to Oneonta where there is a large unmet need for these services. The success of the program has prompted Capital Cardiology to request that we further expand and accept their anticoagulation patients as well. The Bassett Model of Pharmacy Services raises the bar for cutting edge pharmaceutical care. Our goal is to establish BMC as the best practice in New York State and beyond. Bassett Medical Center is implementing the gold standards of safe pharmaceutical care. These are: intensive pharmacotherapeutics, broad antibiotic stewardship services, expanded anticoagulation management services, and the first of its kind non-traditional hospital pharmacist training program. JB Goss, Inpatient Pharmacy Director

32 30 Serious Events: The New York State Patient Occurrence and Tracking System The New York Patient Occurrence Reporting and Tracking System (NYPORTS) is one of many tools used by the NYS Department of Health to identify, correct, and prevent safety deficiencies. NYPORTS is a mandatory reporting system that collects information from hospital and diagnostic treatment centers concerning adverse events, which are defined as unintended, adverse and undesirable developments in a patient s condition. Serious NYPORTS occurrences are those with a significant impact on the patient. On average this is about nine percent of all NYPORTS reports. These occurrences require a root cause analysis of the human, equipment, and/or system failures that led to the adverse event and plan of correction, approved by the department, to reduce the risk of similar failures in the future. In 2013, Bassett Medical Center had ten NYPORTS reportable events. 1. Neonatal death one day after a normal non stress test. Root cause: No root cause was identified. Actions: No actions were taken as a direct result of this event. 2. Burn during dental procedure. Root cause: Preventive maintenance was not carried out and human error. Actions: A preventive maintenance schedule was created for all sterilized drills and other equipment to prevent future occurrences. Staff was educated on steps to take when equipment is malfunctioning. 3. Neonatal brachial plexus injury during delivery with shoulder dystocia. Root cause: Communication between participants. Actions: Implementation of a checklist for patients to complete regarding the patient s previous prenatal and delivery information. 4. Pill cam was a wrong site procedure when the pill was aspirated. Root cause: There was a lack of an effective process in place to guide staff on when patients have difficulty swallowing. Actions: A clinical checklist was developed, and if patients are identified as being at a higher risk for aspiration, there is a clinical decision as to whether or not to confirm the proper location of the capsule after swallowing. 5. Neonatal injury during delivery of right clavicle fracture. Root cause: No root cause was identified. Actions: No actions were taken as a direct result of this event.

33 31 Serious Events: The New York State Patient Occurrence and Tracking System 6. Patient fall with fracture to a facial bone. Root cause: No root cause was identified. Actions: No actions were taken as a direct result of this event. However, the Bassett Medical Center Falls Committee has implemented many actions to reduce falls with injury. 7. Neonatal injury of skull fracture during a delivery assisted with forceps. Root cause: No root cause was identified. Actions: No actions were taken as a direct result of this event. 8. Patient fall while ambulating. Root cause: Procedure was not carried out as intended. Actions: Handoffs will include use of all provisions for mobility and additional information will be communicated on the white board regarding fall prevention interventions. 9. Wrong level spinal surgery. Root cause: Communication between participants and human error. Actions: Implementation of TeamSTEPPS in the Perioperative Services Department to enhance communication and to allow for staff challenging others when they have a concern for patient safety. 10. Neonatal Erb s Palsy injury during delivery with shoulder dystocia. Root cause: No root cause was identified. Actions: No actions were taken as a direct result of this event.

34 32 PERFoRMANCE IMPRoVEMENT Bassett Medical Center 2013 Accomplishments Clinical Outcome Measures with Better than Benchmark or Exemplary Performance Acute myocardial infarction, aspirin at arrival and prescribed at discharge Acute myocardial infarction, statin prescribed at discharge Central Line-Associated Bloodstream Infection Rate Cesarean Section Rate Craniotomy Mortality Decubitus Ulcer Dialysis Waste Removal Dialysis Arteriovenous Fistula Dialysis Patient Death Rate Exclusive Breast Milk Feeding During Hospitalization Rate Heart failure, evaluation of left ventricular systolic function Postoperative Respiratory Failure Postoperative Hemorrhage or Hematoma Postoperative Wound Dehiscence Postoperative Hip Fracture Postoperative Hip Replacement Mortality Pulmonary Embolism/ DVT/ Thromboephlebitis Renal Failure Surgical care, patients with perioperative temperature management Total Hip Replacement Average Length of Stay Unplanned Intubation Urinary Tract Infection Venous thromboembolism, patients with anticoagulation overlap therapy Venous thromboembolism, patients receiving unfractionated heparin with dosages/platelet count monitoring by protocol or nomogram Venous thromboembolism, hospital acquired potentially-preventable Latrogenic Pneumothorax Pneumonia, blood cultures performed in the Emergency Department prior to initial antibiotic

35 33 Bassett Medical Center 2013 Accomplishments Successful Surveys Full CMS Mock Survey (February) JCR Mock Joint Commission Survey Standards and Survey Process Pilot Test ISO 9000 Joint Commission Full Accreditation Survey Joint Commission Follow-up Survey Emergency Medical Treatment and Labor Act Full CMS Mock Survey (October) Joint Commission Office of Quality Monitoring Survey Mammography Quality Standards Act Inspection American College of Radiation Oncologists American College of Surgeons Commission on Cancer New York State Office of Mental Hygiene In the same way we pursue a culture of safety, we also pursue a culture of performance excellence and accountability for results; the two go hand in hand. The journey never ends as we continually strive to improve care practices, but the key is not the practices themselves. The individuals who carry out these practices are the lynch pin to success. The continued education and development of staff in order to properly execute is the foundation for a culture that supports performance excellence. Marie Maxson, Director of Quality Resources & Clinical Effectiveness and Dr. William LeCates, Medical Director

36 34 Bassett Medical Center National Recognition of Bassett Healthcare Network 1. American College of Surgeons Commission on Cancer three year accreditation with Commendation Gold Award 2. Top 100 Heart Hospital Healthgrades 3. IMS Top 100 Most Integrated Health System 4. Bassett Healthcare Network as one of the 100 Integrated Health Systems to Know Becker s Hospital Review 5. U.S. News & World Report ranks Bassett Medical Center No. 39 out of nearly 250 hospitals in New York State & as High Performing 6. U.S. News and World Report Top Rated Medical Center in Central New York 7. Joint Commission, Top Performers (top 33% in U.S.) on Key Quality Measures and Full Accreditation 8. Bassett School-Based Health (SBH) Program recognized as one of only three programs out of 38 in the state to be recognized with a Community Health Improvement Award from HANYS 9. National Magnet Award for SBH 10. Excellus Blue Cross / Blue Shield - Blue Distinction Award for Top Quality Care: Cancer Bariatric Orthopedic Surgery Cardiac 11. American Hospital Association Awards: Stroke Program: Gold level for Get with the Guidelines 12. NCQA Level 3 Patient Centered Medical Home certification at 23 of the regional health centers 13. At Home Care (AHC) listed among Top 100 Home Care Agencies in U.S. 14. Two-year Lab Accreditation with no findings for two consecutive surveys 15. Mammography in the Bassett Healthcare Network is ACR and MQSA accredited

37 35 Bassett Medical Center National Recognition of Bassett Healthcare Network 16. All Bassett Dialysis Units (Cooperstown, Little Falls and Oneonta) achieved IPRO 5 Diamond status for patient safety; Achieved 100% for all CMS Quality Measures for Bassett Pharmacy awarded National Patient Safety Award by HHS 18. Pharmacy has begun transition to Intensive Pharmacotherapeutics (IP) Delivery Model, a National Best Practice 19. NYS State Board of Pharmacy uses our CDTM program as a prototype model for others in NY State 20. Little Falls Hospital won poster recognition for their Biggest Loser campaign at the International Relationship-Based Care (RBC) Symposium 21. Bassett Medical Center selected to present a 30-minute workshop at National Press Ganey conference in Orlando on our RBC culture change related to patient satisfaction 22. Anticoagulation Management Services at Bassett was selected as a PSPC (Patient Safety and Clinical Pharmacy Services Collaborative) award recipient for Life-Saving Patient Safety 23. Dr. Monica Brane voted best pediatrician by Daily Star s Best of the Best poll 24. Selected among the Best Doctors in America (2011, 2012, 2013): Dr. Donald A. Raddatz Dr. Steven D. Resnick Dr. William J. Richtsmeier 25. Selected among the Best Doctors in America (2011, 2012): Dr. Karen M. McGinnis 26. Bassett Medical Center was among 11 hospitals recognized for having one of the best health workforce training programs in the country. Selected by the Hitachi Foundation under its Pioneer Employer Initiative 27. Finance audits with rating of unqualified (perfect score)

38 36 LooKING AHE AD Teamwork and optimal communication are essential in a setting where time is critical and the environment chaotic. Communication failures are frequently identified as the root cause for adverse events in emergency and trauma cases. TeamSTEPPS is an evidence-based teamwork system designed for health care professionals that improves patient safety, communication, and teamwork skill. Dr. David Borgstrom, Director of Trauma and Surgical Critical Care; Dr. Francis Harte, Anesthesiologist; and Sandra Gothard, Director of Perioperatves Services and Anesthesiology TeamSTEPPS In 2013, Bassett Medical Center laid the foundation to implement TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) within several areas throughout the hospital. TeamSTEPPS is an evidence-based teamwork system. TeamSTEPPS provides higher quality and safer patient care by: Producing highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients. Increasing team awareness and clarifying team roles and responsibilities. The Perioperative Services are implementing TeamSTEPPS independently. A kickoff occurred to announce this initiative on November 4, 2013 for the interdisciplinary perioperative team. An assessment was taken at this kickoff meeting regarding perceptions of team performance, and a highlight of two of the questions is indicated below. Resolving conflicts and improving information sharing. Eliminating barriers to quality and safety. Bassett Medical Center is implementing TeamSTEPPS in the following departments: Perioperative Services, Birthing Center, and Emergency Services. We are excited to implement TeamSTEPPS in these departments. TeamSTEPPS will be initiated through a Patient Safety Initiative for the Birthing Center and for Emergency Services as a collaborative effort with our medical liability carrier, CHART.

39 37 TeamSTEPPS is comprised of a three-phased process aimed at creating and sustaining a culture of safety. This approach begins by assessing the need in an organization. The second phase is planning, training, and implementation. Currently, Bassett Medical Center is in the second phase of TeamSTEPPS implementation. The third and final phase is sustainment, and although that work is still ahead of us, we are committed to taking the appropriate steps to ensure that TeamSTEPPS is sustained throughout the organization. Some of the keys to sustaining the TeamSTEPPS initiative in 2014 will be: Providing the opportunity to practice TeamSTEPPS Ensuring leaders re-enforce the newly learned skills Providing ongoing coaching Celebrating wins Measuring success Updating the efforts as needed