GETTING TO 40%: VTE & HAPU. Opening Town Hall Meeting August 26 & 28, 2014

Transcription

1 GETTING TO 40%: VTE & HAPU Opening Town Hall Meeting August 26 & 28, 2014

2 OBJECTIVES Identify steps in your processes that are prone to failure if not hardwired. Describe successful strategies to overcome implementation failures. Apply measurevention, the process of finding process failure in real time and intervening promptly to prevent an avoidable bad outcome. 2

3 AHA/HRET (HEN) VTE & HAPU Re-Boot Camp Webinar Day 1 repeated - Summary Disclosure & Accreditation Stmt. August 28, 2014 The planners and faculty of the AHA/HRET (HEN) VTE & HAPU Re-Boot Camp have indicated no relevant financial relationships to disclose in regard to the content of this activity. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical education through the joint sponsorship of the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) and the Health Research & Educational Trust. ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 2.75 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. The American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) is an approved provider with the Florida Board of Nursing to provide continuing education for nurses. ABQAURP designates this activity for 2.50 Nursing Contact Hours through the Florida Board of Nursing, Provider # Congress St. New Port Richey, FL Toll Free Telephone

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10 The Flow of The Day VTE Finding the Data (Kim Werkmeister) From Good to Great: Pushing Past 40% (Ian Jenkins, MD, UCSD) Hospital Stories: Health South (FL) and Good Samaritan (OR) Moderators: Jennifer Tucker, Senior Fellow; Steve Tremain and Kim Werkmeister Wrap Up: Discussion of how YOU will get to 40% HAPU HAPU: Breaking Through to 40% and Beyond (Cheryl Ruble) Hospital Stories: Oklahoma University Medical System and St. Elizabeth Healthcare Wrap Up: Discussion of how YOU will get to 40% Close at 1:30 PM CT 10

11 POLLING QUESTION 1 SHARE YOUR ROLE 11

12 POLLING QUESTION 2 SHARE YOUR HOSPITAL SIZE 12

13 VTE: Finding the Data Kim Werkmeister, RN BA CPHQ Cynosure Health

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15 VTE: Where are We? 86 % reporting 38 % harm reduction!! *As of August 8,

16 Goal 80% reporting 40% reduction 16

17 What We Need! VTE: 0 more hospitals to get to 80% Focus on improvement: 2% more! 17

18 How Do We Define VTE Outcomes Data? Joint Commission VTE-6 Potentially Preventable VTE Patients who did not receive VTE prophylaxis prior to the VTE diagnostic test order data Patients who developed confirmed VTE during hospitalization s_manual_for_national_hospital_inpatient_qu ality_measures.aspx AHRQ PSI 12 Post Op PE or DVT Discharges with ICD-9 codes for DVT or PE in any secondary diagnosis field All surgical discharges ages 18 and older for specific DRG s and an ICD-9 code for an operating room procedure oads/modules/psi/v44/techspecs/psi%2012 %20Postoperative%20PE%20or%20DVT%20Ra te.pdf 18

19 Pros and Cons of Each Measure Joint Commission Measure Requires actual chart review Will be labor intensive, depending on the number of cases, to get retrospective data Will give a more accurate representation since abstractors can get the full story by reading through the record AHRQ Does not require any chart review Less labor intensive May not be as accurate and no way to find out if the data is accurate without chart review 19

20 Other Methods for Defining Hospital- Acquired VTE Method 1 (minimum) Method 2 (Better) Method 3 (Better yet) Method 4 (Best) Track total # DVT and PE diagnosis codes in your medical center* Method 1, then pull charts post-discharge and retrospectively determine if hospital or community acquired. Method 2, then retrospectively determine if hospital-acquired VTE were on appropriate prophylaxis when VTE developed. Prospectively capture new cases of DVT or PE as they occur by setting up reporting system with radiology departments. * Then divide by 2 to estimate the fraction that is hospital-acquired. The literature suggests that approximately half of all cases of DVT and PE diagnosed in the hospital are hospital-acquired. Alternately, use all VTE codes listed as secondary diagnosis as a surrogate for hospital-acquired VTE. 20

21 Resources HRET Data Team Improvement Advisors Steve Tremain & Kim Werkmeister State Hospital Association Change Packages ( Listserv 21

22 22

23 Good to Great: Pushing Past 40% Harm Reduction Ian Jenkins, MD Clinical Professor of Medicine UCSD Medical Center

24 The Big Step: The Protocol 1) a standardized VTE risk assessment, linked to 2) a menu of appropriate prophylaxis options, plus 3) a list of contraindications to pharmacologic VTE prophylaxis Challenges: Must be easy to use Should capture almost all patients Balance guidance and ease of use 24

25 VTE Protocols: Failure Modes Skipped (need a hard stop) Used Wrong (simplicity; education) Work Arounds (buy-in, dialog, education) Fake Fill: the low risk multiple trauma on vent The order and discontinue everybody Is bleeding! Procedural interruption (measurvention) Bleed / VTE risk changes (measurvention) To investigate, trend rates, but also survey the front line 25

26 High Reliability Features Ease of Use Default the right choice Beware mindless protocol following Hard stop (at admit and transfer) Standardize work One protocol, or, select carve-outs like ortho Guidance at point of care Redundancy MD, RN, pharmacist measurventionist 26

27 Measurevention Strategies MD / Team driven: safety checklist part of daily note. Beware cut and paste. Designated Measureventionist Fatigue, weekends/holidays, new projects Unit based approach: Charge RN? Nursing Assessment Driven Manual review < pharmacy report < smart report 27

28 Automated Measurevention Screen 28

29 Measurevention Barriers Culture MD response to calls RN driven SCD protocols? Discussion with stakeholders Time burdens Wait until already reliable Easier risk assessments Automated reports / division of labor 29

30 Where are Your Events? If your high risk patients are covered, increasing coverage to 100% won t reduce events VTE case review: Post discharge HA-VTE? Ortho? Trauma? Onc? ICU? Are they line related? Expand the concept of preventable Got some kind of prophylaxis Got optimal prophylaxis without lapses Go beyond prophylaxis 30

31 Beyond Orders Heparin refusal? SCD compliance / patient education? Wear time, portable, comfort, products CVC practices? PICC vs. traditional central lines # lumens, attempts, location, duration, product Mobility programs? Then: do not flail against nonpreventable VTE 31

32 Discussion Welcome, Jennifer! Jennifer Tucker, RN, BA, CPHQ Clinical Quality Specialist AHA/HRET HEN Senior Fellow South Seminole Hospital, FL 32

33 HOSPITAL STORIES Kathryn A. Deel, LPN, CPHQ, CPHRM, CPL LEAN SIX SIGMA Black Belt Director - Quality Management/Health Information Management Health Central. Ocoee, FL Vicki Beck, RN MN, CPHQ Director, Quality Resources Dawn Prall, RN MSN CCRN CEN CPHQ Quality Improvement Review Coordinator Good Samaritan Regional Medical Center Corvallis, OR 33

34 Health Central J. Bart Rodier, M.D., Chief Quality Officer Kathy Deel, Director-Quality Management/Health Information Management Hospital Engagement Network Reboot VTE August 26 and 28, 2014

35 Health Central Who we Are 171 licensed bed community hospital located in Ocoee, Florida, 12 miles from downtown Orlando, Florida Medical, Surgical, Intensive Care Services, Labor and Delivery, Maternal Child Hospital owned physician practices, Urgent Care Clinic, Wound Care Center and Ambulatory Surgery Center Nationally recognized skilled nursing facility A part of Orlando Health Hospital System since 2012 Joint Commission Accreditation March 2014 Multiple Best Practices cited Recognized Statewide for Patient Safety Initiatives and Outcomes 35

36 Health Central s VTE Reduction Journey VTE Reduction LEAN Team launched in FY 2012 in response to a rise to 16 hospital acquired DVT in FY 2011 Data driven Listened to the voice of the customer 36

37 What Did We Learn? Identified clinical documentation improvement opportunities Lack of tools and equipment to ensure 100% of patients receive appropriate treatment Opportunity to improve patient and family engagement 37

38 What Barriers Did We Encounter? No efficient method for point of care review Manual processes Inconsistent use of VTE Prophylaxis Order Sets Inconsistent use of Horizon Expert Orders Lack of communication and hand off at the bedside No scripting and work flow to engage patients and families 38

39 How Did We Overcome These Barriers? Leveraged technology for real time reporting and action Mandatory use of VTE Prophylaxis Order Sets Amended Hospitalist Group Contract Board of Directors - Reduce harm by 80% by

40 How Did We Overcome These Barriers? White Boards and Quality Boards Mandatory Touchpoint Training Scripting for patient and family education Elevation of non-compliance to attending physician Accountability Transparency 40

41 2014 Breakthrough in Reducing DVT: Chasing Zero 41

42 Data integrity Accountability What Can Others Learn From Our Journey? What we focus on we achieve Reduced incidence in FY 2014 to 1 DVT. The hospital acquired DVT in FY 2014 was deemed to be unpreventable after Care Review (RCA) 42

43 Questions? J. Bart Rodier, M.D., Chief Quality Officer Kathy Deel, Director-Quality Management/Health Information Management 43

44 Good Samaritan Regional Medical Center Corvallis, OR Vicki Beck, Director of Quality Resources Dawn Prall, QI Review Coordinator VTE Re-Boot August 26 & 28, 2014

45 About Us GSRMC is part of a 5 hospital system spanning 3 counties in western Oregon, including 3 critical access hospitals. Recently engaged in collaboration with the local medical school taking on the role of a teaching hospital. 45

46 We used to wander aimlessly About 18 months ago, there was a patient care issue causing the CEO to ask the executives, Who is in charge of Quality? No one answered. Executives realized SHS wasn t progressing fast enough. A new director was given authority to change the direction of Quality 46

47 Our Journey SHS implemented LEAN training and teams VTE chosen as a focus Initial analysis demonstrated opportunity in several areas: Physician assessment/epic Orders SCD machine accessibility process Nursing documentation education Staff/Patient/Family education (signage) 47

48 How Are We Doing So Far? Potentially Preventable VTE % VTEs that were potentially preventable 120.0% 100.0% 80.0% 60.0% 40.0% 20.0% 0.0% Baseline Goal Good Samaritan Regional Medical Center 48

49 VTE Improvement Pearls Tackled challenges from all sides: process, resources, education. VTE LEAN Project Activities: Included MD and Nurse Champions on Project Team Designed and Implemented Screening Tool to guide ordering of prophylaxis Standardized evidence based order sets with hard stops for MDs Placed SCD equipment in every patient room and leg wraps are always available as floor stock Educated staff, patients, and families with signs on units to educate regarding the risks and expected interventions Advancing the Topic We are in the process of adopting more effective methods of monitoring compliance and engagement through in-person spot audits with rewards for compliance 49

50 What Barriers Did We Encounter? Physician resistance to completing VTE assessment Nursing training needs Availability for getting equipment to the bedside 50

51 How Did We Overcome These Barriers? Strong physician champions on LEAN team Strong nurse leadership on LEAN team Negotiated the contract to increase # of SCD machines and EVS agreed to clean the SCD s in the patient s room 51

52 What Can Others Learn From Our Journey? Success does genuinely require a team effort. Individual accountability is required and it was built in by using EHR hard stops This work is a process, not a destination!! 52

53 Questions? Dawn Prall Vicki Beck

54 Wrapping It Up What are YOUR next steps to get to 40%

55 Simple can be harder than complex: You have to work hard to get your thinking clean to make it simple. But it's worth it in the end because once you get there, you can move mountains. 55

56 Now Make a Commitment in the Chat Box 1. Name, Hospital, Commitment 2. RAISE YOUR HAND AND WE WILL OPEN YOUR LINE! 3. What will you do by next Tuesday? 56

57 VTE/HAPU Repeat Thursday August 28 Same Bat Time/ Same Bat Channel 10:30 am CT 57

58 Resources HRET Data Team Improvement Advisors Steve Tremain Kim Werkmeister Your State Hospital Association Change Packages ( Listserv 58

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60 Reminders Instructions on how to claim CEUs will be sent via . To join the Other Harm LISTSERV, log in to and click the red box in the top lefthand corner of the screen. An evaluation survey on this boot camp will appear when you close out of the WebEx platform. Please let us know how we are doing! Register now for tomorrow s session at under the Events page. 60

61 Don t change that dial! We will be back at 15 minutes after the hour! NEXT UP: HAPU 61

62 Welcome to HAPU RE-Boot! Cheryl Ruble, MS, RN, CNS Improvement Advisor Cynosure Health

63 HAPU: Where are We? 88% reporting 40.36% harm reduction!! 63

64 That means. 2,814 Stage III/IV prevented $113,967,000 estimated saved 64

65 65

66 More work to do Stage II or greater HAPU: 68% reporting 29.9% reduction 66

67 POLLING QUESTION 3 SHARE YOUR SUCCESS 67

68 Dive into that Chat Box name a barrier or struggle 68

69 69

70 Do you have % Reliability? 70

71 Look and you will find it what is unsought will go undetected ~ Sophocles 71

72 HAPU: Breaking Through to 40% Harm Reduction and Beyond Cheryl Ruble, MS, RN, CNS Improvement Advisor Cynosure Health

73 Variability in Skin Assessment Finding time for adequate skin assessment Skill at Braden or other risk tool Determining correct etiology of wounds Pressure vs moisture changes 73

74 Assessment to Action! 74

75 Myth: Education will solve it 75

76 Fact: Measurevention 76

77 Measurevention or just in time In the moment Peer to peer champions Show and tell Prevalence study Observation audits 77

78 Pressure Ulcer Delirium VTE VAE Immobility Falls HA-PA CAUTI 78

79 Fact: Engaging patients & families How can patients and families be engaged in pressure ulcer prevention through communication and information sharing? Use of whiteboard to outline skin care and mobility program Education about early warning signs of pressure ulcers Plan of care what is being done and why 79

80 Part of the care team! 80

81 How? What can they do? Family or loved one prompt staff to turn patient Participate in mobility Ask when can I get out of bed? Report early sign of skin breakdown 81

82 Physical Therapy Occupational Therapy Physicians Nurse Aides Others? PU prevention is just not about nursing What are some ways to partner with other disciplines? 82

83 HOSPITAL STORIES Janice Newton APRN, ACNS- BC Director for the WOCN service & administrative oversight for PUPP Amy Moses BSN, RN, CWON Manager of Inpatient Wound/Ostomy Department Joanna Losier MBA, BA, RN Manager of Patient Safety and Accreditation 83

84 OU Medical Center Pressure Ulcer Prevention Janice Newton APRN, ACNS- BC Director for the WOCN service and administrative oversight for PUPP

85 About Us OU Medical Center celebrated its 100 th anniversary in 2010 Largest hospital in the state with 750 beds Level 1 Trauma Center with specialized services unavailable elsewhere in the state 50,000 emergency room visits per year 5,000 outpatient and 7,000 inpatient surgeries annually 85

86 That was then 2013 Problem statement: We currently do not have a multidisciplinary team approach to pressure ulcer prevention. Our 2012 Stage III & IV pressure ulcer rates are above the current benchmark. 86

87 TEAM Members Multidisciplinary: Regina Ketts, APRN, CCNS; Letitia Breath,CWON; Sylvester Zama, WOCN; Carol Swope, CWOCN, Janice Newton, APRN, ACNS, Director Linda Yeingst, RN; Elaine Haxton, APRN CCNS; Angela Nooner,RN Oncology, Marcia Cordry, Psych nurse; Kacey Price, CVS manager; Ronda Kelly, 4E Surgical manager, Bertha Nunez,4W Nephrology manager, LindsayLindsey, Trauma manager, Amber Hawkins Medicine Specialty manager, Tamara Walker, Oncology manager Larita Haffey, 3 rd floor, Paula Whitlow, MICU/ICUW manager, Dee Cross, Supply Chain, Doug Gibson; Mitsy Martin-Davis, PT/OT Director; Sharon Cathcart,Quality; Sheryl Morsman, Dietician; Mandy Nelson CNS; Judith Sparks RN, Theresa Wyman, Education Specialist,Russell Rooms, CS ER; Linda Perron,CNS 87

88 2013 Actions/Achievements to Support Success: Nurse Residencies are having pressure ulcer training added to their learning Designed an education program utilizing the novice to expert framework Planned the education of the skin care champions on pressure ulcer prevention Skin Care Guidelines updated Two WOCNs hired Biweekly meetings: Tissue Tuesday & Tushy Thursday high-risk patients identified Potty notes 88

89 Outcomes. With these interventions we have been able to reduce the number for Stage III-IV pressure ulcers from 10 patients in 2012 to 6 patients in

90 This is now.. Define Measure Problem statement: Our 2013 Stage III & IV pressure ulcer rates are above the current benchmark. Goals/Objectives: Obtain and sustain a zero % pressure ulcer rate. Review of data: OU Medical Center 1Q14 2Q14 3Q14 4Q Total Pressure Ulcers Stage III&IV

91 Analyze Continue reducing hospital acquired pressure ulcers at OUMC. Obtain needed equipment and supplies to establish a simulation based pressure ulcer educational program 91

92 Innovative PU Education Torso simulator Foot simulator 92

93 Potty Notes New Supplies New Remedy Products 93

94 3 rd Quarter Skin care champions are assigned the Medline Pressure Ulcer Prevention (PUP) Program. The program consists of a pretest, computer-assisted learning modules, and a post-test. Once completed the skin care champions will have their skin care competencies validated by the use of the anatomical pressure ulcer simulators. 94

95 3 rd Quarter continued Once the skin care champion has been checked off they will participate in the NDNQI skin care prevalence dates. Seasoned Skin Care Champions training will include the use of pressure ulcer simulators to establish inter-rater reliability on the staging of pressure ulcers. Skin champions will be educated on photographing wounds using the NE-1 staging tool. 95

96 Thank you! Questions???? 96

97 Moving Beyond the Plateau: St. Elizabeth Healthcare, Northern Kentucky Amy Moses BSN, RN, CWON-Manager of Inpatient Wound/Ostomy Department Joanna Losier MBA, BA, RN-Manager of Patient Safety and Accreditation HRET HEN Hospital Story Monday August 25, 2014 & Thursday August 28, 2014

98 About Us St. Elizabeth Healthcare is one of the oldest, largest and most respected medical providers in the Greater Cincinnati region. We are the heart and soul of healthcare in Northern Kentucky. Our story today includes 3 Campuses totaling almost 1000 licensed beds: St. Elizabeth Edgewood St. Elizabeth Florence St. Elizabeth Ft. Thomas 98

99 Your Journey Mission Statement As a Catholic healthcare ministry, we provide comprehensive and compassionate care that improves the health of the people we serve. Wound care was set as a priority by administration to improve the care and safety for our patients. 99

100 What did we learn? Preventing hospital acquired pressure ulcers requires aggressive monitoring, education, and a multidisciplinary approach. Developed an aggressive wound care protocol with clear expectations for staff and wound care. These protocols help increase continuity of care for all wound care inpatients. Collaborated with various departments to increase awareness. The departments have developed their own protocols to support our HAPU initiative. 100

101 What barriers did we encounter? Capturing data Nursing engagement and education Multidisciplinary support Financial impact and cost Administrative Support was not a barrier because it was administration who identified this as a priority. 101

102 How did we overcome these barriers? Capturing Data No system-wide data Wound care staff note trends but not captured in a meaningful way. Implemented focus in Midas ask protocol questions, helps to identify trends. Completed by nurse manager Reviewed at multidisciplinary meeting. 102

103 How did we overcome these barriers? Nursing Engagement and Education Creation of Wound Care and CNA Committees Carefully selected RN and CNA representation from each nursing unit delegating them the role of Skin Champion Provide educational in-services on products and protocols. Participation in NDNQI pressure ulcer prevalence studies. WOC nurses in Wound Care Department work closely to frontline staff involving them in plan of care & patient/family education. Skills days Wound Symposium 103

104 How did we overcome these barriers? Multidisciplinary Pressure Ulcer Committee Reviews all HAPU every two weeks all pressure ulcers Includes members from dietary, respiratory, IT, physical therapy, and nursing staff development. Nurse managers report on the cases observed on their units. Monitor for Braden accuracy, turns q 2 hours, use of prevention techniques, equipment and supplies Review for trends devices? 67% related to devices. Identify opportunities for education for staff. Investigate new products or new interventions Bridals Extended use of Foam Border Dressings Surgery protocol Improve documentation where? 104

105 What can others learn from our journey? It takes a team. Collaboration. Supporting one another along the way. Data is driver for improvement. Nursing engagement and education Education at all levels, constant reinforcement Empowering staff Multidisciplinary support Financial impact and cost HACs Cost of care 105

106 Questions? Amy Moses BSN, RN, CWON- Manager Inpatient Wound/Ostomy Department Joanna Losier MBA, BA, RN- Manager of Patient Safety and Accreditation 106

107 Breaking Through the Barriers: Call to Action!

108 Share Struggles & Solutions Chat Box 108

109 Struggles & Barriers All but one unit is doing really well Staff do not seem interested We do it well for awhile and then it s back to old habits We have tried everything! So frustrated! 109

110 Now Make a Commitment in the Chat Box 1. Name, Hospital, Commitment 2. What will you do by next Tuesday? 110

111 Resources AHRQ Toolkit - Preventing Pressure Ulcers in Hospitals Retrieved at: AHRQ Guideline Synthesis on Preventing Pressure Ulcers Retrieved at: 78 National Pressure Ulcer Advisory Panel Retrieved at: IHI How to Guide Reducing Pressure Ulcers Retrieved at: eventpressureulcers.aspx 111

112 Resources HRET Data Team Improvement Advisor Cheryl Ruble Your State Hospital Association Change Packages ( Listserv 112

113 VTE/HAPU Repeat Thursday August 28 Same Bat Time/ Same Bat Channel 10:30 am CT 113

114 114

115 Reminders Instructions on how to claim CEUs will be sent via . To join the Other Harm LISTSERV, log in to and click the red button in the top lefthand corner of the screen. An evaluation survey on this boot camp will appear when you close out of the WebEx platform. Please let us know how we are doing! Register now for tomorrow s session at under the Events page. 115