Quality and Safety. Why Quality and Safety? Why Quality and Safety? Leadership Development Institute

Transcription

1 Quality and Safety Leadership Development Institute February 26, 2010 Why Quality and Safety? We are here for our patients. It s all about the patient Every patient, every time It s the right thing to do It s what I d want for me or for one of my family members 2 Why Quality and Safety? We are healthcare providers. Substandard care is unacceptable I refuse to be below average I want to work in a great place that t provides great care, not a great place that provides lousy care 3 1

2 Quality and Performance Improvement OU Medicine believes: Quality ensures that patient care is safe, efficient, timely, effective and patient- centered Quality is a continuous process Quality is evidenced-based Quality occurs at all levels 4 Quality and Safety Critical Success Factors Leadership Commitment Executive Committee EXCEL Pillar Institutional Readiness Current successes LDIs Programmatic Leadership Chief Medical Officers Physician Commitment Department Chairs Meeting Medical Executive Committee Staff Commitment PI Projects OUP and OUMC 5 Patient Safety Create an organizational culture of safety that: Focuses on patient safety and the prevention of errors Is aware and knowledgeable about patient safety and error prevention Focuses on improvement and prevention rather than blame Fosters collaboration and communication between departments, teams and individuals Provides organization-wide patient safety education and policy development that includes practitioners, staff, patients and families Recognizes unexpected outcomes and medical errors through data collection and analysis with appropriate reporting, follow-up and action 6 2

3 Quality Chronology Early Years JCAHO Process Oriented Patient Satisfaction Press-Ganey Industry Costs over outcomes 7 Quality Chronology Middle Ages Alphabet Soup AHRQ NCQA JCAHO/TJC IHI IFCC Inflection Point(s) IOM To Err is Human IOM The Quality Chasm Pay For Performance 8 Quality Chronology Recent Years to Present Process to Outcomes Never Events Hospital Acquired Conditions Readmissions i Reduced Pay for Poor Outcomes Public Reporting Credentialing and Privileging 9 3

4 Quality Cycle 10 Implementation Model for Lean Six Sigma (DMAIC) Define - What is the business case for the project? - Identify the customer - Current state map - Future state map - What is the scope of the project? - Deliverables - Due date Control - During the project, how will I control risk, quality, cost, schedule, scope, and changes to the plan? - What types of progress reports should I create? - How will I assure that the business goals of the project were accomplished? - How will I keep the gains made? Measure - What are the key metrics for this business process? - Are ethe metrics valid dand reliable? abe - Do we have adequate data on this process? - How will I measure progress? - How will I measure project success? Improve - What is the work breakdown structure? - What specific activities are necessary to meet the project's goal? - How will I re-integrate the various sub projects? Analyze - Current state analysis - Is the current state as good as the process can be? - Who will help make the changes? - Resource requirements - What could cause this change effort to fail? - What major obstacles do I face in completing the project? 11 Lean Six Sigma: What Is It? Lean Six Sigma: An improvement methodology with a focus on two critical principles 1. Elimination of waste (Lean) defined as anything that does not add value to the patient (includes WAITING) 2. Elimination of variation of outcomes (Six Sigma) utilizing the DMAIC (Define, Measure, Analyze, Improve and Control) model for continuous improvement Variation = undesirable outcomes (i.e., off target) 12 4

5 Components of Quality Program Monitor activities system-wide Provide education in quality improvement Promote awareness of quality initiatives Oversee clinical activities in a consultative (non-punitive) manner Promote initiatives that can be either organization-wide or clinic/specialty/service/department focused Create and/or utilize best practices and shares throughout organization Ensure robust peer review 13 Monitors - OU Physicians Clinic site reviews Clinical quality and patient safety indicators Accreditation standards National Committee for Quality Assurance (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC) Incident reports Patient complaints/compliments Key Indicator report regarding Operations Medical record review Disruptive and impaired practitioner and staff Dismissal of patients Clinical competency (clinical orientation, assessment of skills) Communicating test results Satisfaction surveys Patient Physician Employee 14 OU Physician's Overall Scores 80 OVERALL PATIENT SATISFACTION ALL FACILITIES PERCENTILE RANK 70 king Percentile Rank 60 Began 50 monitoring results 40 through Press- Ganey Partnered with Studer Group. Launched EXCEL to leadership at first LDI Completed AIDET training in outpatient clinics i 10 0 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Standards Rolled out to employees GOAL = Improve Patient Satisfaction Scores to 60th %tile 15 5

6 AAAHC Accreditation CATEGORIES Patient Rights Governance Administration Quality of Care Quality Management and Improvement Clinical Records and Health Information Facilities and Environment Diagnostic and Other Imaging Services Pharmaceutical Services and Medications Pathology and Medical Lab Services Dental Services Medical Home Surgical and Related Services Anesthesia Services Health Education and Health Promotion Behavioral Health Services 16 AAAHC Accreditation 47 clinic sites in 15 buildings surveyed 98.4% substantial compliance of standards resulting in a full 3 year accreditation 140 policies over 6 years 17 GROUPPERCENTILE RANKING EASE OF OBTAINING TEST RESULTS e Rank Percentile Q1 07 Q3 07 Q1 08 Q3 08 Q1 09 Q3 09 QTD Q

7 OU Physicians Comprehensive quality and safety clinic site surveys Must achieve a passing score 90 sites reviewed Assess, remediate, achieve Developed clinic manager tool kit with best practice procedures NCQA credentialing site visits 110 completed successfully 19 OU Medical Center Core Measures HCAHPS Never Events Hospital Acquired Conditions PI Initiatives 20 Core Measures Process Measures AMI, HF, PN, SCIP, Childhood Asthma Every patient every time Hardwire into the organization Bar gets higher New measures get added Universal Acceptance evidencedbased 21 7

8 Core Measures OU MEDICAL CENTER REPORT Composite Scores Top25% Top 10% 1Q09 2Q09 3Q09 4Q09 AMI 99.02% 100% 96.99% 100% 100% % Heart Failure 95.86% 98.36% 92.86% 98% 98.8% 97.85% Pneumonia 95.20% 97.30% 99.16% 99% 96.75% 96.86% SCIP 96.37% 97.77% 97.01% 95% 96.07% 95.62% Out-Pt SCIP (HCA Benchmark until CMS Available) 94.20% 95.78% 97.75% 97.93% Results with "no color" are not yet publicly reported so there is no Top 10% comparison data Green=Top10% Yellow=Top25% Red=Below 25% Benchmark 2Q08-1Q09 22 HCAHPS 4Q 09 HCAHPS Domains 4Q 06 1Q 07 2Q 07 3Q 07 4Q 07 1Q 08 2Q 08 3Q 08 4Q 08 1Q 09 2Q 09* 3Q 09 preliminary Nursing Communication 60% 64% 61% 64% 65% 66% 59% 57% 56% 65% 79% 79% 79% Physician Communication 71% 68% 72% 67% 75% 73% 69% 68% 66% 73% 84% 82% 84% Responsiveness 47% 46% 50% 51% 47% 54% 45% 49% 39% 58% 66% 59% 61% Pain Management 61% 59% 67% 63% 57% 66% 62% 57% 46% 60% 75% 74% 78% Medication Communication 51% 48% 52% 54% 56% 56% 46% 50% 48% 55% 66% 66% 65% Cleanliness 57% 59% 55% 49% 58% 55% 59% 47% 52% 56% 65% 60% 60% Quietness 49% 52% 55% 46% 52% 46% 56% 46% 44% 58% 72% 67% 72% Discharge Information 75% 82% 82% 74% 75% 81% 76% 76% 74% 80% 85% 88% 90% Overall Rating (% top 2 box) 46% 52% 42% 49% 53% 65% 53% 52% 48% 55% 66% 67% 72% Would Recommend 56% 53% 56% 51% 59% 62% 56% 56% 56% 63% 74% 76% 77% Sample Size * Change in HCA survey tool to include: incorporating HCAHPS survey into all IP surveys (includes pediatric population), telephone administration, increased sample size. Data beginning 2Q 09 is not adjust for telephone administration and case mix. 4Q06 1Q09 is adjusted and does not include pediatric patients 23 Never Events Things that should NEVER happen Wrong-sided surgery Wrong surgery Wrong patient Retained foreign body Fall with injury 24 8

9 Hospital Acquired Conditions These are all PREVENTABLE VAP Ventilator-associated pneumonia CAUTI Catheter-associated UTI CLASBI Central line-associated bloodstream infection PU Pressure ulcers (Stage III, IV) 25 Never Events and Hospital Acquired Conditions Hospital Acquired Conditions Goal Q09 2Q09 3Q09 4Q Never Events (Air Embolism, Retained Foreign Body, Blood Incompatibility) 0 NA Surgical Site Infection (Orthopedics only) 0 NA Vascular Catheter Associated Infection Catheter Associated Urinary Tract Infection Fall with Injury Pressure Ulcers - Stage III and IV 0 NA Glycemic Control 0 NA DVT/PE following total knee/hip 0 NA OUMC CLASBI OUMC CLABSI CLASBI 1/08-12/09 6 UCL= PER THOUSAND LINE DAYS CL=1.61 Data Points UCL +2 sigma +1 sigma Average -1 sigma -2 sigma LCL Linear (Data Points) 1 0 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Date/Time/Period/Number 27 9

10 OUMC Adult CAUTI OUMC ADULT CAUTI 7/08-12/09 12 UCL=11.22 PER THOUSAND CATHE ETER DAYS CL=4.71 Data Points UCL +2 sigma +1 sigma Average -1 sigma -2 sigma LCL Linear (Data Points) 0 Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec Date/Time/Period/Number 28 OUMC Ventilator Assoc. Pneumonias OUMC VENTILATOR ASSOCIATED PNEUMONIAS 1/07-12/ UCL=13.41 PER THOUSAND VENTIL LATOR DAYS CL=6.04 Data Points UCL +2 sigma +1 sigma Average -1 sigma -2 sigma LCL Linear (Data Points) 0 Jan-07 Mar-07 May-07 Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Date/Time/Period/Number 29 Risk Adjusted Mortality xpected Actual/Ex Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q

11 Plans for 2010 FPPE and OPPE Credentialing/Privileging Peer Review Clinical Pathways Development Utilization Outcomes measurement Patient and Family Centered Care AAAHC Recertification 31 Patient and Family Centered Care GUIDING PRINCIPLES It s all about partnerships Providers are visitors in the care of the patient and family Care is CENTERED on the patient and family, not FOCUSED Providers are expected to understand that the patient and family are the purpose for their professional activity KEY CONCEPTS People are treated with dignity and respect Health care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful Individuals and families build on their strengths by participating in experiences that enhance control and independence Collaboration among patients, families, and providers occurs in policy and program development and professional education, as well as in the delivery of care 32 Performance Improvement Initiatives Hospital-wide Risk Adjusted Mortality Index (RAMI) Core Measures HCAHPS Bed Management Patient and Family Centered Care Specific Projects (departments, services) 33 11

12 Quality and Safety Toolkit Studer and EXCEL Initiative LDI LEM Performance Improvement PDCA Six Sigma Lean Six Sigma 34 People Service Research QUALITY Growth Education Finance Peer Review Credentialing Plii Policies & Procedures Utilization Review Audits Length of Stay Safety Efficiency Patient/Family Centered Care Quality Communication Patient/Family Centered Care P.I. Process (Six Sigma ) E POM Clinical Pathways Information Systems Human Resources Education/Training Team STEPPS Data Analysis FPPE and OPPE National Patient Safety Goals Core Measures HCAHPS RAMI Never Events Hospital Acquired Conditions AAAHC NCQA TJC 35 Quality and Safety Leadership Council CHARTER This multidisciplinary group will develop a collaborative and coordinated enterprise-wide approach to quality and patient safety that fosters a culture of quality improvement and bolsters the vision for OU Medicine. The council will determine specific areas of focus for our quality and patient safety programs. It will target specific goals to be achieved and the timelines for which to achieve them. The council will identify the technology and other resources necessary to meet those goals

13 Quality and Safety Leadership Council Doug Folger, MD - co-chair Curt Steinhart, MD - co-chair Cameron Mantor, MD Tim Mapstone, MD Frank Lawler, MD Ed Overholt, MD Tom Hennebry, MD Kris Wallace Kathy Jost Michele Reading Pam Birdwell Holly Adams Tim Schoelen 37 QUALITY and SAFETY 38 13