STEEEP Care Summary Report Baylor Scott & White Health Enterprise FY2017 YTD (July September 2016)

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1 STEEEP Care Summary Report Baylor Scott & White Health Enterprise FY2017 YTD (July September 2016)

2 BSWH Targets and Performance FY17 YTD (September 2016) 30-Day Readmission** Combined Hospital Acquired Condition (HAC) Outpatient Diabetes Bundle Supportive & Palliative Care Outpatient Inpatient Experience Experience Rate Recommend this this Hospital 9-10 Provider Emergency Likely to Recommend Current Readmission Rate (%) HAC Points Percent of Achievement (%) Palliative Care Attainment Inpatient Points Outpatient Points Emergency Points Attainment Levels BSWH Threshold BSWH Intermediate BSWH Target BSWH Maximum ** 30-day Readmission data lags one month behind all other metrics 2

3 Assessment and Plan - Readmissions Assessment: 30 Day Readmission All Cause Composite Measure is 14.8% which is worse than BSWH target of 13.6% Facilities with small number of patients negatively impacting their readmission rates Final ICD-10 readmission rules not yet released by CMS Opportunities exist in scheduling follow-up appointment prior to hospital discharge ICD-10 seems to have negatively impacted FY 16 performance Plan: Develop tactics to reduce readmission based on chart review results BSWH Heart Failure Integration Initiative ongoing Workgroups to address AMI, CABG, PNE,THKA readmissions established Collaborate with BSWQA to address readmissions across the continuum PIECES risk stratification tool implemented in NTX 10/11/16 Ongoing discussion with leaders to reset FY 17 goals using FY 16 performance as baseline 3

4 Assessment and Plan - HAC Composite Lower is better for HAC Composite Metric Assessment: Plan: For FY17 the HAC composite metric includes all adult patients and current performance for BSWH is 21 with a target goal of 17 (lower is better). BSWH is currently at threshold performance. 13 hospitals are higher than target (worse) 6 hospitals are lower than target (better) Continue with HAC Reduction report out by facility every two months with the focus on areas with the greatest opportunity The HAC Reduction dashboard provides key monthly data for facility level improvement work so ongoing education is being provided to help stakeholders navigate through this tool The CLABSI Improvement Committee work as part of the BSWH STEEEP Clinical Value Initiatives and Diffusion Model should help to reduce the incidence of CLABSI s and provide standardization of evidence practice across BSWH. 4

5 Assessment and Plan - Population Health Diabetes Bundle Assessment: BSWH at MAX Goal. NTX, 6 PODs: 5 at MAX Goal/1 at TARGET Goal. CTX, 4 Regions: 1 at MAX Goal/3 at INTERMEDIATE Goal Both A1C and BP continue to be areas of opportunity Plan: Diabetes Council Outpatient Workgroup reviewing/revising Diabetes Medication Protocols to assist with medication choices that are more patient-centered. NTX Conversion to EPIC occurred on 10/1/16. Educating on KEY documentation for the D3 components Physician Champions continue to work with low performing providers and clinics to improve their scores HTPN Operations leadership working with all HTPN clinics to improve diabetes care HTPN care coordination identifying patients not at goal and scheduling appointments with their PCP Diabetes Improvement Project in Central POD first round of education completed CTX Diabetes AIP Reports revised to make it easier to find patients not meeting targets Physician education being done to socialize report as well as reminders on how to appropriately document rechecks of blood pressures by in the appropriate areas to capture the data for the report. Continuing to implement HTN protocol 5

6 Supportive and Palliative Care Goal Assessment The Supportive & Palliative Care Composite Score is based on the achievement of two metrics: SPC Staffing plan achieved in order to support 5% of inpatient admissions (excluding OBGYN and newborns) SPC Consults Ordered for inpatient admissions (excluding OB-GYN and newborns) Staffing accounts for 60% of the composite score and consults ordered account for 40% This goal is a follow-up to the successful attainment of the FY16 structural goal. While no longer a structural goal, it is a goal that we expect to see a consistent increase in throughout the fiscal year as positions are filled. Plan SPC is working closely with hospital leadership to ensure that staffing levels defined in the goal are achieved early in the fiscal year. There have been hires made and the new staff are working through credentialing so there will be an increase in the metric in the next couple of months. 6

7 Assessment and Plan - Service Assessment: Sites are working to close the gap between their baseline performance and the 90 th percentile rank by 25% this year. At system level, they are doing well. Inpatient Experience: Target Clinic Experience: Max Emergency Department Experience: Target Plan: CNO Press Ganey will be onsite at WAX on Monday December 12th to meet with BSWH leadership (CMO/CNO, and ED leadership) and talk with the ED Council about improvement opportunities; (Angela.Hochhalter@bswhealth.org for details) Emergency Department comments are being evaluated with a new tool to look for improvement opportunities. The same tool will be applied to clinic and hospital comments in the coming months. 7

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