Report on Quality in Maryland s Hospitals

Hand Hygiene Sepsis Healthy Mothers and Babies Readmissions/ Care Coordination Central Line- Bloodstream Catheter- Urinary Tract Ventilator- Pneumonia Surgical Site Report on Quality in Maryland s Hospitals 2014

LETTER FROM MHA S PRESIDENT & CEO, CARMELA COYLE The buzz is everywhere, and it is palpable. Throughout the nation, hospitals and other health care providers are talking about and taking steps toward the concept of volume to value. This pursuit is based on the idea that hospitals ought to be compensated based not on how many patients they treat, but rather on how well they treat their patients. This is leading hospitals on a path of holistic care of patients and communities, a path of keeping people healthy before they get to the hospital, so that they receive the best care, at the right time and in the right place. It s an endeavor that aims to treat the entire person rather than simply treat an illness. In many ways, what s old is new. Hippocrates, the father of western medicine, espoused a similar philosophy roughly 2,500 years ago: It s more important to know what sort of person has a disease than to know what sort of disease a person has. This brave new world is built on the foundational principle that the foremost priority of hospitals is to provide safe care. That principle is intrinsic for all of Maryland s hospitals, and they are guided in its pursuit by a unique agreement between the federal government and the state that enables the rates for hospital services to be set by an independent statewide commission. The agreement lays out aggressive quality improvement goals. Among these are a 30 percent reduction in health careacquired infections and a significant reduction in readmissions by 2019. This report highlights some of the efforts to improve quality and provides insight and information into those programs, their effectiveness, and where hospitals go from here to keep Maryland healthy. Fewer errors, infections and care complications lead to: Better patient outcomes, fewer deaths Fewer avoidable hospital readmissions Shorter hospital stays Lower costs WORKING TOGETHER TO PROVIDE THE HIGHEST QUALITY CARE Maryland Hospital Association The Maryland Hospital Association, founded in 1970, is the advocate for Maryland s hospitals, health systems, and their patients before legislative and regulatory bodies. Its membership is comprised of community and teaching hospitals, health systems, specialty hospitals, veterans hospitals, and long-term care facilities. The association helps hospitals and health systems serve their communities by providing them leadership, advocacy, education, and innovative programs and services. Maryland Patient Safety Center The MPSC was established by the state legislature in 2003 with the singular goal of making health care in Maryland the safest in the nation. The center accomplishes this in part by convening health care providers to improve their practices to prevent avoidable harm. Maryland hospitals work with the center on the following initiatives: Maryland Hospital Hand Hygiene Collaborative Perinatal/Neonatal Learning Network Falls Prevention The Armstrong Institute for Patient Safety and Quality The Armstrong Institute for Patient Safety and Quality aims to reduce preventable harm, improve clinical outcomes and experiences and reduce waste in health care delivery. The institute s work focuses on: Eliminating medical errors and complications of care Enhancing clinical and patient-reported outcomes for all patients Delivering patient- and family-centered care Ensuring clinical excellence Improving health care efficiency and value Eliminating health care disparities Creating a culture that values collaboration, accountability and organizational learning

COMMITTED TO QUALITY Maryland s hospitals are involved in many initiatives to improve the quality of care delivery. Each hospital is committed to quality, and it is up to each organization to decide how to best improve its care for patients. This section offers a closer look at their efforts. While most people understand that washing one s hands helps prevent the transmission of disease, for health care workers things aren t so simple. Within a single encounter with a patient, there can be several times when hand hygiene should be performed, and must be performed properly. In health care settings, hand hygiene can prevent potentially fatal infections from spreading from patient to patient, from patient to health care worker and vice-versa. Hand Hygiene Background: Hand hygiene is the most fundamental way to reduce the spread of infections, and the Maryland Hospital Hand Hygiene Collaborative, the first statewide hand hygiene effort of its kind in the nation, launched in 2009. The collaborative utilizes trained, unknown observers secret shoppers to report compliance with proper hand sanitizing procedures. The collaborative includes 44 acute care hospitals and one specialty hospital. Where we stand: As a result of the collaborative s efforts, hand hygiene performance is at an all-time high. In 2014, hospitals hand washing compliance rate improved beyond the effort s goal to more than 90 percent with 480 hospital units reporting data. For the month of December 2014, the statewide compliance rate reached its highest rate of 91 percent. Maryland s hand hygiene Average compliance rate 71% 2010 75% 2011 82% 2012 87% 2013 90% 2014 Central Line- Bloodstream 90 percent of the 150 participating hospital units report zero infections each month Catheters, or hollow tubes that are inserted in the body s large veins in the neck, chest or groin, are used to administer medicine, fluids, or blood, and perform medical tests quickly. caused by improper insertion or management techniques are usually serious and typically cause a prolonged hospital stay. They can be prevented through proper insertion techniques and management of intravenous catheters. Background: In late 2010, Maryland s hospitals joined a nationwide initiative to eliminate serious bloodstream infections. The volunteer effort, On the CUSP: Stop BSI, was developed by Dr. Peter Pronovost of Johns Hopkins Medicine and is coordinated by the Maryland Hospital Association. It uses a combination of safety checklists, staff education, and ongoing expert consultation to reduce the number of central line-associated bloodstream infections occurring in hospitals. These infections are a leading cause of health care-associated infections in acute care hospitals, with an estimated 250,000 occurring each year nationwide. Where we stand: Maryland s hospitals, which had among the highest participation rates of any state in the nation at 90 percent (the rest of the country averaged 24 percent), are building on the impressive gains made during the program s run. Quality Matters 1

Catheter- Urinary Tract Urinary tract infections are the most common type of health care-associated infection. Among urinary tract infections acquired in hospitals, about 75 percent are associated with a catheter (a tube inserted into the urinary tract). Ensuring that a catheter remains in use only for the appropriate length of time is a key factor in reducing the number of infections. Background: Maryland s hospitals joined an 18-month national effort in 2011 to reduce catheter-associated urinary tract infections. During the initiative, 68 hospital units participated, a number that has since grown to about 130 units. The program focuses not only on reducing infection rates, but also on ensuring that the catheters are used only when necessary. Where we stand: In 2014, hospitals continued to sustain the improvements made through this initiative and share best practices with their peers. Eighty-three percent of participating units are reporting zero infections each month. The mean rate remains steady at about two infections per 1,000 days that catheters are in use. Above: University of Maryland Midtown Campus 83 percent of participating hospital units report zero infections each month Ventilator- Pneumonia These infections develop when germs enter a ventilator breathing tube and end up in patients lungs. To prevent this, health care providers can keep patients heads elevated at appropriate angles, clean the inside of patients mouths, and make sure ventilators (machines used to mechanically breathe for people unable to do so on their own) are not used excessively. Background: Hospitals in Maryland and Pennsylvania have piloted the effort to reduce ventilatorassociated pneumonia, again serving as pioneers in patient safety. Launched in October 2012, this three-year initiative relies on a partnership among the Maryland Hospital Association, The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, and the Hospital Association of Pennsylvania. This project uses a series of best practices to prevent this often fatal complication. Based on their gains through 2014, nine Maryland hospitals were selected to participate in a learning network to share best practices with each other and national peers. Where we stand: Twenty-seven of Maryland s hospital units, predominantly intensive care units, participate in this effort. In 2014, the number of ventilator-associated complications declined by 55 percent from the previous year. The participating units also report nearly 100 percent compliance in ensuring appropriate positioning of patients upper bodies and heads when ventilators are used. For every 1,000 days patients used a ventilator, there was less than one day of ventilator-associated pneumonia 2 2014 Quality Report 0.57 ventilafor every 1,000 days patients used a ventilator, there was less than one

These infections can occur after surgery and can be superficial, involving the skin only, or more serious, involving organs or implanted materials like pacemakers. Preventive techniques include proper hygiene, wearing appropriate masks and gowns, and cleaning the surgical site with special soap. Background: This two-year project began in February 2013 and helps surgical teams improve safety in complex, high-pressure environments. This is accomplished through regular sharing of best practices. The national effort is funded by the U.S. Agency for Healthcare Research & Quality (AHRQ) and is led by a partnership of experts from AHRQ, The Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, The American College of Surgeons/National Surgical Quality Improvement Project, The University of Pennsylvania, and the World Health Organization Patient Safety Program. Where we stand: Eighteen Maryland hospitals are participating, with a focus on colon surgical site infections. Two-thirds of the hospitals are reporting zero colon surgical site infections per month. The number of surgical site infections statewide decreased by two-thirds in 2014. Surgical Site Two-thirds of participating hospitals are reporting zero colon surgical site infections per month Above: Calvert Memorial Hospital Sepsis, the inflammatory response to infection, has been identified as the cause of as many as half of in-hospital deaths nationwide. It is among the top 10 most common potentially preventable complications across Maryland s hospitals and one of the leading causes of readmission. Sepsis Background: This program, a joint initiative from the Maryland Hospital Association and the Maryland Patient Safety Center, began in July 2014 to create opportunities for hospital staff to learn about the prevention and treatment of sepsis. Regular meetings include information on early recognition and assessment processes, standardized treatment, and coordinated communication to help with patient flow between the emergency department and other areas of the hospital. Where we stand: Ten hospitals are participating in the initiative s first coordinated effort, scheduled to end in 2016. Another 12 hospitals will begin the second cohort in April 2015, ending in 2017. Data collection on sepsis mortality rates has recently begun as the program is less than a year old; as best practices are disseminated and implemented, hospital quality leads expect significant declines in the mortality rate. Quality Matters 3

Mothers and Babies In the past decade, Maryland s infant mortality rate has declined by more than 22 percent. Maryland s hospitals deliver nearly 70,000 babies each year. But injuries can occur to mothers and babies during labor and birth due to human and system errors. According to the Joint Commission on Accreditation of Healthcare Organizations, poor communication was the leading cause in 42 serious events involving infant death across the nation. Background: There are two important metrics hospitals use to gauge obstetric safety hemorrhage and laceration. Postpartum hemorrhage is the leading cause of maternal mortality and lacerations not only cause patient harm, they can also significantly increases the cost of patient care. Hospitals regularly review data on these complications and work to improve best practices to reduce their frequency. Where we stand: From 2013 to 2014, occurrences of obstetrical hemorrhage dropped by over 20 percent, while the number of obstetric lacerations fell by 14 percent. With 82 percent of American adults taking at least one medication and 29 percent taking five or more, accidents are a serious problem. Nationally, 700,000 emergency department visits and 120,000 hospitalizations are due to these complications each year, with $3.5 billion spent on the resulting extra medical costs. Background: The Maryland Patient Safety Center, in partnership with the Institute for Safe Medication Practices, began offering the Institute for Safe Medication Practices Medication Safety Survey to Maryland s hospitals in 2001. Analysis takes place over the summer and fall and the findings are presented at an annual conference on medication safety. The goal of the conference is to provide an assessment of practices regarding the safe use of medications. Between 40 and 45 hospitals participate annually in the survey. Medication Safety Where we stand: Over the past 14 years, hospitals have shown steady and continuous improvements in their medication safety scores. Through a regular survey administered by the Institute for Safe Medical Practices, hospital medication safety practices have been refined. In the past three years, hospitals ratings from the Maryland Patient Safety Medication Survey for communication of drug orders and other drug information have increased by 15 percent. 4 2014 Quality Report

One in six patients returns to the hospital within a month of leaving after receiving medical care. One of the pillars of Maryland s modernized Medicare agreement is to reduce hospital readmissions, an effort that requires partnerships with doctors, nursing homes, other care providers, and community service organizations, as well as new initiatives from hospitals that focus on care coordination and population health management. Among the tools available to aid in this work are the state-sponsored Health Enterprise Zones, which aim to reduce health disparities among racial and ethnic minority populations and among geographic areas, improve health care access and health outcomes in underserved communities, and reduce health care costs and hospital admissions and readmissions. Background: As they should be, the best care coordination and population health efforts are locally driven and intensely personal to each patient. In March 2013, the Maryland Hospital Association launched the Transitions: Handle with Care campaign, in which hospitals partner with family doctors, nursing facilities, and community organizations to reduce avoidable readmissions. A practical guide for how to implement the principles of this campaign, MHA s Readmissions Reduction Playbook was released in 2014 to help hospitals navigate this initiative. In this effort, teams of health care providers review causes for readmissions and develop strategies to address them at the local level. At the state level, the Maryland Care Transitions Steering Committee works to identify and eliminate statewide barriers to readmission reduction. Where we stand: Thirty-six acute care hospitals and one specialty hospital participate in this campaign. The readmission rate for the state s hospitals dropped by more than 4 percent from 2013 to 2014. Care Transitions and Avoidable Readmissions Understanding Readmissions A measure, not of hospital care, but of the overall capability and quality of the entire health system and how well it works together for patients. Above: Anne Arundel Health System Rehospitalization is a system issue and the problem does not lie with one organization or one provider, but with the community and the local health care system. Addressing this issue will require organizations and providers to work together. Anne-Marie Audet, vice president, The Commonwealth Fund Maryland has avoided more than 5,000 readmissions from 2013 to 2014. Quality Matters 5

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