Greetings from Michelle & Katie QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE

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1 IN THIS ISSUE: Make Sure You Are Solving the Right Problem P. 1 Are Electronic Health Records Contributing to Fraud? P. 1 Stress Ulcer Prophylaxis P. 2 Antibiotic Stewardship P. 3 APeX tips for a safe discharge P.4 Division Incentive Metrics P. 5 The Post Monthly Quality Improvement Newsletter FOR THE Division of Hospital Medicine October 2012 Issue 22 Greetings from Michelle & Katie QUALITY IMPROVEMENT DIVISION OF HOSPITAL MEDICINE Welcome to the 22nd edition of the Quality Post. In this issue, we feature two new projects centered around health care value. Stephanie Rennke is leading an initiative to increase appropriate use of stress ulcer prophylaxis and Steve Ludwin is leading initiatives to guide judicious use of antibiotics. Are Electronic Health Records Contributing to Fraud? Hospitals with electronic health records are under increased scrutiny after Attorney General Eric Holder and health and human services secretary, Kathleen Sebelius cited troubling indications that providers are billing for services never provided. The concern is that providers and hospitals are taking advantage of the ease of electronic documentation to falsely document care. The letter was sent to five major hospital trade associations including AAMC (Association of American Medical Colleges) and cited two abuses: 1) cloning, which we know as cut and paste, to bill for services never provided like a complete history and physical and 2) upcoding, an attempt to overstate the intensity of care or severity of patients condition. These two practices have likely cost Medicare billions in the last 5 years. This letter underscores our resolve to ensure payment accuracy and to prevent and prosecute health care fraud. CMS is conducting audits to prevent improper billing and identifying hospitals and doctors with questionable practices. According to an article in the New York Times, many hospitals and doctors argue that EHRs allow their documentation to more accurately reflect patient s severity of illness as a way to explain the increase in payments. As we face stricter requirements to document our physical exams and as we work to accurately document our patient s severity of illness, it is important to be careful with our documentation and not misuse the tools our EHR provides. Make Sure You Are Solving the Right Problem It may be obvious that you can't solve a problem that's not well defined, but many people neglect this detail. Next time you think you're ready to go into problemsolving mode, consider the following: Establish the basic need for a solution. Why does the problem need solving? Justify the need. Make sure it's worth your time. Is the effort aligned with your group s strategy? What do you, your team, or the institution stand to gain from a solution? Give it context. What approaches have you already tried? What have others done? Are there constraints on the solution? Write the problem statement. Take your answers to the questions above and lay out the problem. Indicate the scope, the requirements of a solution, and who will be involved.

2 Stress Ulcer Prophylaxis Do we know when we need it? Introduction to the Project Proton pump inhibitors (PPIs) are the third most commonly prescribed medication in the US with $13.6 billion in yearly sales. Despite their effectiveness in treating acid reflux and their mortality benefit in the treatment of GI bleed, recent literature has revealed a number of risks associated with PPIs, including an increased incidence of Clostridium difficile infection, increased risk of community and hospital-acquired pneumonia, and an increased risk of hip fracture. Studies have demonstrated that initiation of PPIs in the hospital may be in part responsible for the explosion of PPI use. A recent JHM study suggests that PPIs are often prescribed for inappropriate indications, especially in the ICU. Project Team: The project is a collaborative effort through the Medication Outcomes Committee: Stephanie Rennke is the lead and has engaged the Division of Hospital Medicine to participate alongside the pharmacists in the group. Goals: To decrease use of inappropriate stress ulcer prophylaxis in the ICU by 25% by February 2013 Develop and implement evidence-based clinical guidelines on the indications for stress ulcer prophylaxis in the ICU What about our data? The project team drilled down on two weeks of admissions to the ICU to understand if UCSF potentially overuses stress ulcer prophylaxis. Stress Ulcer Prophylasix on Admission to the ICU No Indication 64% n=41 True Indication 36%, n=23 In a sample of 77 patients, 83% had stress ulcer prophylaxis prescribed on admission The most common appropriate indications were Coagulopathy (37%) and mechanical ventilation >48 hours (24%) Most patients (72%) had a PPI prescribed, whereas the rest had an H2 blocker Bundled intervention: December February 2013 Education campaign: Educational conferences with ICU providers (nurses, attendings, residents/interns) and medicine residents and hospitalists Guidelines: Approve evidence-based UCSF and project specific guidelines for SUP in the ICU Pharmacist-led intervention ( alert/text page) with targeted feedback to prescribers and ICU providers

3 Antibiotic Utilization Projects Antibiotic Stewardship Working Group As hospitalists, prescribing timely and appropriate antibiotics is one of the most important things that we do. However overuse of antibiotics breeds resistant organisms and puts our patients at risk for c.diff. As we work to reduce the use of unnecessary tests, medications and procedures, our Division should also work to reduce unnecessary antibiotic usage. Under the leadership of Steve Ludwin, DHM has recently partnered with Infectious Disease clinicians and pharmacists to identify opportunities for antimicrobial stewardship efforts. Mission: To develop projects that promote optimal antibiotic usage within the medical center Goal: To be a national leader in developing a collaborative, interdisciplinary stewardship program. The Antibiotic Timeout Background: Broad Spectrum Antibiotics are often continued unnecessarily, leading to prolonged hospitalization, antibiotic resistance, adverse drug effects, C Diff, and cost inefficiencies. A snapshot of utilization on the medicine service in the first 6 months of CY 2012: 46.7% of patients received at least one dose of vancomycin with a mean duration of 4.3 days 7.9% received meropenem with a mean duration of 5.2 days 30.3% received pip/tazo with a mean duration of 4 days Project Goals: Establish a process by which providers critically assess broad spectrum antibiotic therapy hours after initiation. Other measures include: total length of stay, cdiff rates, cost, adverse outcomes. Project Plan: 1) Develop specific criteria that clinicians should assess during the time out 2) Develop process for identifying antibiotics & notifying providers to re-assess 3) Develop educational materials for clinicians to guide decision making regarding stopping or deescalating antibiotic therapy 4) Document results of antibiotic timeout Future projects this group will be planning in the late fall include: 1. Asymptomatic Bacteuria: Developing a management algorithm for in-hospital patients with a positive UA and no clear clinical symptoms 2. Promoting the IDMP website and current UCSF Antibiotic guidelines If you are interested in participating in these planning efforts, please contact Steve Ludwin.

4 Best Practices: Ordering Follow up Appointments in APeX Patients often leave the hospital without information about instructions for follow up. Since APeX DGIM has been making follow up appointments for approximately 50% of patients who don t have a follow up appointment at discharge. We can help out our patients, and our primary care colleagues by making follow up appointments in APeX. To Schedule follow up appointments internally through UCSF use the discharge navigator to put in a new order: Use the discharge referral order, some clinics also allow you to pick a provider. To Schedule follow up appointments outside of UCSF send a staff message to Yolanda Jones. You can search for Yolanda and cc the PCP. Compose a message that includes the data here, or steal my smart text.mmmedfollowup Use patient look up to pull the patient information into the message Remember that the Follow Up tool only communicates follow up plans to your patients, but doesn t schedule it. If Yolanda has scheduled an appointment, you can notify your patient of the time, date and provider using the tool. The tool contains a large database of providers.

5 Division Incentive Metric Performance Achieve >60% full bundle compliance with Lactate, Blood Culture, Broad Spectrum Antibiotics, and Fluid Resuscitation FY 2012 Compliance 40% 81% 87% 56% (prelim) î 1 of 4 100% 100% 89% 100% 67% 56% 75% 50% 25% 0% Lactate Blood Culture Antibiotic Fluid Resuscitation Full Bundle Compliance % Compliance Baseline FY 2012, n=107 % Compliance July, n=45 FY 2012 HCAHPS Achieve HCAHPS Communication with 6 of 12 Top Box Score: Doctors Top Box score above 80% months 72% 73% 76% 65% 100% 90% 80% 70% 60% 50% % Compliance August n=45 % Compliance September n=35 Jan Feb Mar April May June July Aug Sept n=33 n=28 n=25 n=30 n=27 n=28 n=37 n=44 n=8 Promote appropriate nebulizer use and early transition to MDI; Reduce nebulizer use by 15% FY 2012 Baseline: 2 of per hospitalization TBD TBD TBD Achieve an average MD hand hygiene rate of >85% for Medicine/Hospitalist Oct Nov Dec CY 2012 by floor: 91% 90% 95% 88% MD Communication total Explained in a way you could understand Target 9 of 12 months CALENDAR OF EVENTS RESIDENT QI LUNCHES M&M type format for Quality Cases: October 24 November 28 RESIDENT COST AWARENESS Oct 19 Anemia Nov 20 CHF FACULTY QI LUNCHES OCTOBER: Division Incentive Metrics OTHER EVENTS PAUL FARMER Global Health Delivery OCTOBER 17 Respond to >80% of nurse queries FY 2012 Baseline: No Data Available TBD 2 of 4