Performance Improvement at. Be the leader in Quality

Transcription

1 Performance Improvement at Be the leader in Quality

2 To Err Is Human Health care in the United States is not as safe as it should be and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Errors also are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals.

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4 Environmental forces driving requirements for Performance Improvement Economic/ Demographic Trends Co-Worker & Physician Relations Regulation/ Reform Employer Markets Critical External Factors Consumer Markets Payers/ Health Plans Competitors Technology Trends

5 NATIONAL QUALITY AND PATIENT SAFETY EFFORTS Quality-In-Sights : Hospital Incentive Program (Q-HIP),

6 Institute for Healthcare Improvement Some Is Not a Number. Soon Is Not a Time. 1. Deploy rapid response teams to patients at risk of cardiac or respiratory arrest 2. Deliver reliable, evidence-based care for acute myocardial infarction 3. Prevent adverse drug events through drug reconciliation (reliable documentation of changes in drug orders) 4. Prevent central line infections 5. Prevent surgical site infections 6. Prevent ventilator-associated pneumonia 7. Prevent pressure ulcers 8. Reduce methicillin-resistant Staphylococcus aureus (MRSA) infection 9. Prevent harm from high-alert medications 10. Reduce surgical complications 11. Deliver reliable, evidence-based care for congestive heart failure 12. Get boards on board 13. WHO Surgical Safety Checklist 14. Prevent Catheter-Associated Urinary Tract Infections 15. Link Quality and Financial Management: Strategies to Engage the Chief Financial Officer and Provide Value for Patients

7 The Leapfrog Group is a voluntary program aimed at mobilizing employer purchasing power to alert America s health industry that big leaps in health care safety, quality and customer value will be recognized and rewarded. Program sponsors in Georgia who participate in rewards and incentives programs such as Quality-In-Sights : Hospital Incentive Program (Q-HIP), include Blue Cross Blue Shield of Georgia, Inc., Blue Cross Blue Shield of Georgia Healthcare Plan of Georgia and Savannah Business Group on Health Four Leaps in Hospital Quality, Safety and Affordability Computer Physician Order Entry (CPOE): CPOE has been shown to reduce serious prescribing errors in hospitals by more than 50%. Evidence-Based Hospital Referral (EHR): Consumers and health care purchasers should choose hospitals with extensive experience and the best results with certain highrisk surgeries and conditions. ICU Physician Staffing (IPS): Staffing ICUs with doctors who have special training in critical care medicine, called intensivists, has been shown to reduce the risk of patients dying in the ICU by 40%. Leapfrog Safe Practices Score: The National Quality Forum-endorsed 30 Safe Practices. Included in the 30 practices are the three leaps above. This fourth leap assesses a hospitals progress on the remaining 27 NQF safe practices.

8 Quality-In-Sights : Hospital Incentive Program (Q-HIP) Sponsored by Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. and offered to participating Hospitals in Georgia that have signed a Q-HIP Agreement. Q-HIP is a performance based reimbursement program that financially rewards Hospitals for practicing evidence-based medicine and implementing industry recognized best practices in patient safety, health outcomes and member satisfaction. Clinical measures were developed by national quality organizations such as The Joint Commission (JC), National Quality Forum (NQF) and the Leapfrog Group. Q-HIP focuses on evaluating institutional processes for patient safety, as well as specific indicators of care for patients with three common conditions: heart attack, heart failure and pneumonia. Patient safety performance objectives are based on guidelines set by the Joint Commission (TJC), the National Quality Forum (NQF), the Institute for Healthcare Improvement (IHI), and other respected organizations. A patient s perspective on their hospital care is captured through the national, standardized survey instrument called HCAHPS or the hospital administered patient satisfaction survey.

9 HQID Facts The Hospital Quality Incentive Demonstration Project, launched in 2003, provides additional Medicare payments and recognition to hospitals that perform well on specific quality measures. The purpose of this demonstration project is to improve the quality and efficiency of patient care. If the project is successful, it will result in better patient care and help establish standard, recognized measures for healthcare quality. Publicly available standardized measures are key to promoting accountability, learning, transparency, competition, and performance improvement.

10 National Hospital Quality Measures selected for Value Based Purchasing (Reporting Hospital Quality Data for Annual Payment Update) Inpatient Prospective Payment System Year Number of Reporting Hospital Quality for Annual Payment Update Measures 10 AMI, HF, PN Topics Covered (Final Rule Aug 2009, 1,613 pages) AMI, HF, PN, SCIP (includes CABG, Hip & Knee, etc.) AMI, HF, PN, SCIP, Mortality, HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) AMI, HF, PN SCIP, Mortality, HCAHPS AMI, HF, PN SCIP, Mortality, HCAHPS, Nursing Sensitive, Readmission, Agency for Healthcare Research & Inpatient Quality/Patient Safety Measures, Participation in Cardiac Surgery Database

11 CMS Proposed Measures for Quality in Healthcare Chronic Pulmonary Obstructive Disease Measures Complications of Vascular Surgery AAA stratified by open and endovascular methods Carotid Endarterectomy Lower extremity bypass Inpatient Diabetes Care Measures Healthcare Associated Infection Central Line-Associated Blood Stream Infections Surgical Site Infections Timeliness of Emergency Care Measures, including Timeliness Median Time from ED Arrival to ED Departure for Admitted ED Patients Median Time from ED Arrival to ED Departure for Discharged ED Patients Admit Decision Time to ED Departure Time for Admitted Patients Surgical Care Improvement Project (SCIP) SCIP Infection 8 - Short Half-life Prophylactic Administered Preoperatively redosed Within 4 Hours After Preoperative Dose SCIP Cardiovascular 3 - Surgery Patients on a Beta Blocker Prior to Arrival Receiving a Beta Blocker on Postoperative Days 1 and 2 Hospital Inpatient Cancer Care Measures Patients with early stage breast cancer who have evaluation of the axilla College of American Pathologists breast cancer protocol Surgical resection includes at least 12 nodes College of American Pathologists Colon and rectum protocol Completeness of pathologic reporting Serious Reportable Events in Healthcare ( Never Events ) Surgery performed on the wrong body part Surgery performed on the wrong patient Wrong surgical procedure on a patient Retention of a foreign object in a patient after surgery or other procedure Intraoperative or immediately post-operative death in a normal health patient (defined as a Class 1 patient for purposes of the American Society of Anesthesiologists patient safety initiative) Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility Patient death or serious disability associated with the use or function of a device in patient care in which the device is used or functions other than as intended Patient death or serious disability associated with patient elopement (disappearance) for more than four hours Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility

12 St. Joseph s/candler Health System Performance Improvement and Safety Plan Quality and safety of healthcare has become the standard for success Quality, one of our six core beliefs, is defined as doing things the right way the first time. Quality will be defined by agreed upon, measurable, outcomes

13 SJ/C Strategy Sets Strategy Overall Objective Improve Co-worker and Customer Satisfaction Improve Co-worker and Customer Satisfaction Clinical Quality Clinical Quality Financial Performance Strategy #1 Be the Preferred Employer Strategy #2 Increase Market Share Strategy #3 Improve Financial Performance Strategy #4 Collaboratively Engage Physicians Strategy #5 Be the Leader in Quality Achieve targeted Co-Worker satisfaction levels through the work climate survey as as the key to to customer satisfaction & operational viability. Through a comprehensive market development plan, increase SJC Health System s Market Share in in Savannah and the regional clusters. Focusing on medical management, achieve top 25% of of benchmarked targets. Foundation to to financially support the Health System. Co-create infrastructure for achieving national standards of of performance for convenience, safety, quality and cost. To differentiate SJC through Exceptional quality, service and patient experience.

14 The Performance Improvement and Safety Plan integrates with the strategic objectives of St. Joseph s/candler by: Focusing on core competencies delivered by an Integrated Health Care Delivery System. Collaborating with the medical staff and health system coworkers to identify performance improvement activities for the purpose of improving clinical processes of care. Empowering each co-worker to effect quality in the health system. Supporting the goal of the strategic plan to be the preferred employer and therefore preferred provider. Supporting interdisciplinary approaches by providing sound methodological and technological resources, to ensure that valid and reliable measures drive the evaluation of clinical processes and patient outcomes.

15 TYPES OF QUALITY INDICATORS STRUCTURAL Assesses whether the organization has the capability and resources to provide high-quality patient care appropriate staffing levels equipment standards safety codes being met PROCESS The process that occurs prior to a given point, intended to achieve optimal care (outcomes) "doing the right things" clinical protocols being followed surgery consent form completion appropriate ordering of lab tests OUTCOME Outcome indicators answer the question, "Did the patient get better?" postoperative wound infections deaths within 24 hours of admission

16 St. Joseph s Hospital Board Professional Relations Committee Candler Hospital Board Medical Executive Committee Leadership Council Quality Council Quality Analysis and Implementation Committee Nursing Quality Council Institute for Healthcare Improvement Clinical Initiative Leadership Team Centers for Medicare/Medicaid Services Clinical Initiative Leadership Team The Joint Commission Clinical Initiative Leadership Team OTHER IMPROVEMENT PROGRAMS IHI Clinical Resource Development Teams CMS Clinical Resource Development Teams TJC Clinical Resource Development Teams Human Resources & Risk Management Nursing Clinical Resource Development Teams SSI/SCIP RRT/CAT VAP CLI D2B (Door to Balloon) HQID COMPOSITE SCORES: AMI & CABG Heart Failure Hip and Knee Pneumonia POA / Never Events Mortality Infection Control NPSG FMEA -System/Departmental Smart Services Stroke Home Health Leapfrog Leapfrog Hospital Rewards QHIP (BC/BS of GA) Ambulatory Services Eye Center PT/OT Pressure Ulcers Falls Medication Errors Magnet Forces NDNQI -SSI/BSI/CLI/UTI

17 QAIC Reporting Calendar April St. Joseph s Board Room HUMAN RESOURCES AND RISK MANAGEMENT SMART SERVICE HOME HEALTH May Candler Board Room INFECTION CONTROL Central Line Blood Stream Infections UTI MEDICATION ERRORS TJC NPSG MAGNET FORCES NDNQI June St. Joseph s Board Room SSI/SCIP RRT/CAT VAP AMI/CABG July Candler Board Room HEART FAILURE HIP AND KNEE PNEUMONIA MORTALITIES August St. Joseph s Board Room STROKE POA/Never Events September Candler Board Room FMEA (System/Departmental) HUMAN RESOURCES AND RISK MANAGEMENT SMART SERVICE HOME HEALTH October St. Joseph s Board Room November Candler Board Room INFECTION CONTROL Central Line Blood Stream Infections UTI MEDICATION ERRORS TJC NPSG MAGNET FORCES NDNQI December St. Joseph s Board Room

18 SJC HQID Project Teams 2011 STEERING COMMITTEE STEERING COMMITTEE HQID WORK GROUP HQID WORK GROUP INITIATIVE TEAM #1 INITIATIVE TEAM #1 PNEUMONIA PNEUMONIA Leamon Johnston Dr. Leamon Ryan Moody Johnston Ray Dr. Maddox Ryan Moody Marianne Ray Maddox Fields Dewey Marianne Winkler Fields MaryAlice Dewey Winkler Smiley Rita MaryAlice Allen Smiley IS Rita Liaison Allen Sherry IS Liaison Danello Sherry Danello INITIATIVE TEAM #2 INITIATIVE TEAM #2 AMI AMI Ginger Carlisle Dr. Ginger Brian Carlisle Hartley Anne Dr. Brian ByerlyHartley Janet Anne Longenberger Byerly Dewey Janet Winkler Longenberger Evelyn Dewey Green Winkler Richard Evelyn Steinbach Green Carey Richard Freeland Steinbach Anne Carey Ingram Freeland Theresa Anne Ingram Warren Jen Theresa Burke Warren Stephanie Jen Burke Wilson Stephanie Wilson INITIATIVE TEAM #3 INITIATIVE TEAM #3 HEART FAILURE HEART FAILURE Melanie Willoughby Dr. Melanie Mohammad Willoughby Masroor Suzanne Dr. Mohammad Cosby Masroor Leamon Suzanne Johnston Cosby Richard Leamon Steinbach Johnston Annette Richard Hayman Steinbach Marie Annette Pilz Hayman Emily Marie Parks Pilz Emily Parks INITIATIVE TEAM #4 INITIATIVE TEAM #4 CABG CABG Ginger Carlisle Dr. Ginger David Carlisle Capallo Carey Dr. David Freeland Capallo Anne Carey Ingram Freeland Dewey Anne Winkler Ingram Suzanne Dewey Winkler Cosby Dian Suzanne LaRueCosby Mary Dian Alice LaRue Smiley Mary Alice Smiley INITIATIVE TEAM #5 INITIATIVE TEAM #5 HIP AND KNEE HIP AND KNEE Dr. Mark Winchell Leigh Dr. Mark Craft Winchell Patti Leigh Haselden Craft Heather Patti Haselden Hugener- Sheffield Heather Hugener- Sheffield INITIATIVE TEAM #6 INITIATIVE TEAM #6 STROKE STROKE Julie Long Dr. Julie Michael LongHemphill Cindy Dr. Michael JohnsonHemphill Stroke Cindy Committee Johnson Stroke Committee INITIATIVE TEAM #7 INITIATIVE TEAM #7 SCIP SCIP Dr. Jeffrey Mandel Rita Dr. Allen Jeffrey Mandel MaryAlice Rita AllenSmiley Ray MaryAlice MaddoxSmiley Denise Ray Maddox Daly Ginger Denise Carlisle Daly Laura Ginger Coleman Carlisle Carolyn Laura Coleman Lucas Elaine Carolyn Conner Lucas Cheryl Elaine Capers Conner Cheryl Capers

19 Physician Champion Role Respected expert with interest in target populations Grasps evidence based medicine and rationale for quality measures Receives and forwards feedback Educates colleagues on best practices Performs as a role model for best clinical practice

20 The New Premier Practitioner Profiles

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22 Physician Preference Orders, Care Paths Physician Preference Orders guide evidence-based practice, driven by quality improvement initiatives, that standardizes care, and improve patient safety and clinical outcomes. Care Paths with an explicit statement of the goals and key elements of care based on evidence, best practice, and patient expectations for a defined population of patients facilitates communication, coordination of roles, and sequences the activities of the multidisciplinary care team.

23 Fact-Based Management -- Dashboards A dashboard is a tool used by policy makers and managers to clarify and assign accountability and responsibility for the key objectives needed to steer an organization toward its mission statement. Dashboards are used to deploy the mission statement throughout the levels of a healthcare system, from top to bottom, through the development of a cascading and interlocking set of key objectives as measured through numeric targets or deadlines.

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25 SJC System Dashboard

26 National Hospital Quality Measures Acute Myocardial Infarction (AMI) Core Measures 2011 AMI-1 Aspirin at Arrival AMI-2 Aspirin Prescribed at Discharge AMI-3 ACEI or ARB for LVSD AMI-4 Adult Smoking Cessation Advice/Counseling AMI-5 Beta-Blocker Prescribed at Discharge AMI-7 Median Time to Fibrinolysis AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI-8 Median Time to Primary PCI AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival AMI-T1a1 LDL-Cholesterol Assessment (Optional Test Measure) AMI-T21 Lipid-Lowering Therapy at Discharge (Optional Test Measure)

27 National Hospital Quality Measures Heart Failure (HF) Core Measures 2011 HF-1 Discharge Instructions HF-2 Evaluation of LVS Function HF-3 ACEI or ARB for LVSD HF-4 Adult Smoking Cessation Advice/Counseling

28 National Hospital Quality Measures Pneumonia (PN) Core Measures 2011 PN-2 Pneumococcal Vaccination PN-3a Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival PN-3b Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital PN-4 Adult Smoking Cessation Advice/Counseling PN-5c3 Initial Antibiotic Received Within 6 Hours of Hospital Arrival PN-6 Initial Antibiotic Selection for CAP in Immunocompetent ICU Patient and Non ICU Patient PN-7 Influenza Vaccination

29 National Hospital Quality Measures Pregnancy and Related Conditions (PR) Perinatal Core Measures 2011 PC 01 Elective Delivery PC 02 Cesarean Section PC - 03 antenatal Steroids PC - 04 Health Care Associated Bloodstream Infections in Newborns PC - 05 Exclusive Breast Milk Feeding

30 National Hospital Quality Measures Surgical Care Improvement Project (SCIP) 2011 SCIP-Inf-1a Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Overall Rate SCIP-Inf-1b Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - CABG SCIP-Inf-1c Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Other Cardiac Surgery SCIP-Inf-1d Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty SCIP-Inf-1e Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Knee Arthroplasty SCIP-Inf-1f Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Colon Surgery SCIP-Inf-1g Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hysterectomy SCIP-Inf-1h Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vascular Surgery SCIP-Inf-2a Prophylactic Antibiotic Selection for Surgical Patients (Infection) Overall Rate SCIP-Inf-2b Prophylactic Antibiotic Selection for Surgical Patients - CABG SCIP-Inf-2c Prophylactic Antibiotic Selection for Surgical Patients - Other Cardiac Surgery SCIP-Inf-2d Prophylactic Antibiotic Selection for Surgical Patients - Hip Arthroplasty SCIP-Inf-2e Prophylactic Antibiotic Selection for Surgical Patients - Knee Arthroplasty SCIP-Inf-2f Prophylactic Antibiotic Selection for Surgical Patients - Colon Surgery SCIP-Inf-2g Prophylactic Antibiotic Selection for Surgical Patients - Hysterectomy SCIP-Inf-2h Prophylactic Antibiotic Selection for Surgical Patients - Vascular Surgery SCIP-Inf-3a Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time (48 hours for CABG/ Other Cardiac Surgery) SCIP-Inf-3b1 Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time CABG SCIP-Inf-3c1 Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time - Other Cardiac Surgery SCIP-Inf-3d1 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Hip Arthroplasty SCIP-Inf-3e1 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Knee Arthroplasty SCIP-Inf-3f1 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Colon Surgery SCIP-Inf-3g1 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time Hysterectomy SCIP-Inf-3h1 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Vascular Surgery SCIP-Inf-4 Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose SCIP-Inf-6 Surgery Patients with Appropriate Hair Removal SCIP-Inf-9 Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero. SCIP-Inf-10 Surgery Patients with Perioperative Temperature Management SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

31 National Hospital Quality Measures Stroke (STK) 2011 STK-1 Venous Thromboebolism (VTE) Prophylaxis STK-2 Discharged on Antithrombotic Therapy STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter STK-4 Thrombolytic Therapy STK-5 Antithrombotic Therapy By End of Hospital Day Two STK-6 Discharged on StatinMedication STK-7 Dysphagia Screening STK-8 Stroke Education STK-10 Assessed for Rehabilitation

32 Hospital Outpatient Quality Data Reporting Program (HOP QDRP) HOSPITAL OUTPATIENT DEPARTMENT QUALITY MEASURES Acute Myocardial Infarction (AMI) and Chest Pain 2011 OP-1 Median Time to Fibrinolysis OP-2 Fibrinolytic Therapy Received Within 30 Minutes OP-3 Median Time to Transfer to Another Facility for Acute Coronary Intervention OP-4 Aspirin at Arrival OP-5 Median Time to ECG OP-6 Antibiotic Timing OP-7 Antibiotic Selection Surgical

33 HOSPITAL-ACQUIRED CONDITIONS (HAC) AND PRESENT ON ADMISSION (POA) INDICATOR REPORTING Beginning October 1, 2008 selected hospital-acquired conditions will group to the lower paying MS-DRG with the following caveats: 1) The condition was not present on admission (POA). 2) The condition is the only Major Complicating Condition (MCC) or Complicating Condition (CC) reported. If other secondary diagnoses that are MCC/CC are reported, the case will still group to the appropriate higher level MS-DRG.

34 HOSPITAL-ACQUIRED CONDITIONS (HAC) AND PRESENT ON ADMISSION (POA) INDICATOR REPORTING 1. Foreign Object Retained After Surgery* 2. Air Embolism* 3. Blood Incompatibility* 4. Stage III and IV Pressure Ulcers 5. Falls and Trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Electric Shock 6. Manifestations of Poor Glycemic Control Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity *SERIOUS PREVENTABLE EVENT OR NEVER EVENT 7. Catheter-Associated Urinary Tract Infection (UTI) 8. Vascular Catheter-Associated Infection 9. Surgical Site Infection Following: Coronary Artery Bypass Graft (CABG) - Mediastinitis Bariatric Surgery Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery Orthopedic Procedures Spine Neck Shoulder Elbow 10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following Total Knee Replacement Hip Replacement

35 Hospital Consumer Assessment of Healthcare Providers and Systems - HCAHPS HCAHPS is the first national, standardized, publicly reported survey of hospital patients perspectives of their care What patients/consumers want to know: 1. Communication with nurses 2. Communication with doctors 3. Responsiveness of hospital staff 4. Pain management 5. Communication about medicines 6. Discharge information 7. Cleanliness of the hospital environment 8. Quietness of the hospital environment

36 2011 National Patient Safety Goals 1. Improve the accuracy of patient identification Use at least two patient identifiers when providing care, treatment and services. Eliminate transfusion errors related to patient misidentification 2. Improve the effectiveness of communication among caregivers. Report critical results of test and diagnostic procedures on a timely 3. Improve the safety of using medications Label all meds, med containers or other solutions on and off the sterile field Reduce the likelihood of patient harm associated with the use of anticoagulant therapy 7. Reduce the risk of health care associated infections 15. The organization identifies safety risks inherent in its patient population - Identify patients at risk for suicide. Universal Protocol - Implement a pre-procedure process to verify the correct procedure, for the correct patient, at the correct site. - Mark the procedure site. - A time out is performed immediately before starting the invasive procedure or making the incision. Comply with current WHO and CDC hand hygiene guidelines Implement evidence based practices to prevent HAI s due to MDRO s Implement evidence based practices to prevent central line associated bloodstream infections Implement best practices for preventing surgical site infections

37 Improving Organization Performance Standard PI The hospital collects data to monitor its performance Standard PI The hospital compiles and analyzes data Standard PI The hospital improves performance on an ongoing basis. Standard PI The hospital uses data from clinical/service screening indicators and human resource screening/indicators to assess and continuously improve staffing effectiveness.

38 Fact-Based Management -- Balanced Scorecards Is a proactive response to external forces including financial pressure, competition, consumerism, industry consolidation, regulatory reporting, information management and new technology Journal of Healthcare Management 2002:47 Three focuses of our balanced scorecard Growth Financial Clinical Performance

39 Improve Upward Trend Maintain OVERALL SYSTEM Balanced Scorecard FY 2010 Community Impact provided Current Level Past Level through Mission FY 10 FY 09 Variance/% Target Action St. Mary s Community and Total Visits Total Visits Health Centers 14,241 12,929 1,312/10.1% >2.0% Good Samaritan Clinic Total Pt Visits Total Pt Visits 1,509 1, /20.8% >2.0% African American Health Information & Resource Center Total Encounters 15,304 Total Encounters 13,675 1,629/11.9% >2.0% Be The Preferred Employer Co-worker Satisfaction: Retention Rate Current Level Past Level FY 10 FY 09 Variance/% Target Action 86.6% 85.3% 1.3% >85% Growth Inpatient Admissions Outpatient Visits SJ/C SJ/C Current Level Past Level FY 10 FY O9 Variance/% Target Action 23,361 24, /-3.4% +2.6% 459, ,647 20,648/4.7% +2.0% Improve Financial Performance Average Length of Stay (Overall excluding OB) Current Level Past Level FY 10 FY O9 Variance/% Target Action <5.36 Operating Margin 1.79% 1.51% 0.28% >1.83% Days Cash on Hand >101.7 Be the Leader in Quality Patient Experience Scores CMS Composite Scores Inpatient ED Testing OP Surgery OP General OP Rehab Acute Myocardial Infarction Heart Failure Coronary Artery Bypass Graft Pneumonia Hip & Knee Surgical Care Improvement SA Complication Rate Index Current Level Past Level FY 10 Q4 FY 10 Q3 Variance/% Target Action Percent Positive Percent Positive 75th CH SJ CH SJ CH SJ Percentile FY 10 Q3 CH SJ 100% 98.5% 95.0% 97.9% % 97.1% 96.1% % 90.5% 97.8% CH SJ FY 10 Q2 CH SJ 96.6% 99.3% 99.6% 97.0% % 92.3% 94.7% % 92.6% 96.5% CH SJ CH SJ 3.4% -0.8% -4.6% 0.9% - 3.8% 4.8% 1.4% - 0.2% -2.1% 1.3% CH SJ % 95.9% 98.0% 95.0% 98.0% 96.9% <1.0 Mortality Rate Index CH SJ CH SJ CH SJ <1.0

40 How you can help: As outlined in our PI & Safety Plan System Department Directors participate in Clinical Initiative Leadership Teams applicable to Department s scope of practice and provide staff resources for participation in Clinical Initiative Team performance, monitoring and improvement activities. Department directors serve to identify, monitor and improve performance improvement activities within their respective departments and disseminate this information to the appropriate Vice President via a monthly report. In addition, each Director will identify potential performance improvement activities for St. Joseph s/candler for submission to the Performance Improvement Council Objectives: To evaluate department focused quality and safety activities for efficacy and relevance to system objectives and needs. To report department performance improvement findings to Vice President/Leadership council. To participate on Clinical Initiative teams through strategic planning and implementation of operational objectives. To support and provide resources for Clinical Initiative Teams efforts in performance improvement.

41 How you can help: As outlined in our PI & Safety Plan The Medical Staff Executive Committee is directed by the Board of Trustees to oversee physician quality improvement and peer review activities. Quality data related to by-laws, credentialing, privileging, and peer review are reported directly to the Medical Executive Committee. Summary reports of system quality improvement activities are presented to the Medical Executive Committee for review. Aggregate data from medical staff committees or functions are reported to the Performance Improvement Council. Objectives: To coordinate medical staff quality and safety improvement activities while ensuring integration with system goals. To communicate performance improvement and safety information and initiatives to the members of the Medical Staff. To provide medical direction and promote Medical Staff participation in quality improvement and safety initiatives throughout the system. To take appropriate action on Bylaw, credentialing, privileging and peer review information in a timely manner.

42 Examples of Performance Improvement Projects SMART PUMPS - BMV MOBILAB VERIPHY Navigator Program Falls Prevention Patient Lift Equipment

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