Quality/Performance Improvement Fundamentals Getting Started Skill Building Session May 1, 2013 Pat Teske, RN,MHA pteske@cynosurehealth.org (661)755-5317
Today Agenda for Today Review ways to strengthen AIMs for your PI initiatives Discuss PI team membership Design next steps Refine AIMs Refine Team Membership Perform a Tracer Describe next webinar
Great start but We still have a way to go
Raise your hand and chat Let s try it
Please don t put us on hold
HEN Topics ADE CAUTI CLABSI EED Falls with Injury HAPUs OB Adverse events VAE VTE 8
Top 10 Improvements
#10 Use Progress Report Use CHA HEN template A P S D
Aim Statement My Hospital My Town, CA Run Charts Lessons Learned To by Why this is important to your patients and your organization Recommendations and Next Steps Changes Being Tested, Implemented or Spread Team Members List by role or title 2012 Institute for Healthcare Improvement
#9 Why is this work important? To your patients? To your organization? Use literature if available Link to your organization s strategic plan
Examples Falls are the leading cause in inpatient injuries, increasing length of stay and health care costs. HCAHPS Increase in our Scores will contribute to the Financial Stability of our hospital and continually enhance the patient care experience. Nationally almost one-fifth (19.6%) of Medicare patients are readmitted to the hospital within 30 days of discharge. Our Medicare readmission rate is XXX%. The hospital is receiving a readmission penalty of $$. Preventing unnecessary readmissions will improve our care and strengthen our reputation and financial viability. 13
#8 Be as clear as possible Reduce by 40% from to by date Include your specific data rather than saying reduce from baseline
Examples Reduce Overall Fall with Injury Rate by 50% by December 31, 2013: Falls with Injury: Reduce Rate From 0.6 to 0.3 Falls per 1000 Patient Days To have zero incidents of CLABSI in Critical Care Units by second quarter 2013 Reduce hospital readmission rates from 2012 baseline by 20% by December 2013. From baseline of 4.2% to 3.3% by 12/13 15
#7 Link AIM to Importance If preventing falls with injury is what is important to you Your AIM should address falls with injury
Examples Good Decrease inpatient injury & non-injury falls by 40% by December 31, 2013. Falls are the leading cause in inpatient injuries, increasing length of stay and health care costs. Better To increase HCAHPS scores on Pain Management by 5% by Dec. 31, 2013. Improving our patients experience with pain management will increase their satisfaction with the care, treatment, and services provided. This improves the likelihood of the patient/family to recommend us. An increase in HCAHPS scores will increase our CMS reimbursement that plays a part in the Financial Stability of the organization
#6 Know your data Before you set your AIM, know what your baseline is Make it obvious to anyone what your specific goal is Reduce by 40% of what which will get us to
Example Strong Decrease the number of Adverse Drug Events that harmed ER patients (required an invention) by 40% from 2011 baseline by December 31, 2013. Stronger Decrease the number of Adverse Drug Events that harmed ER patients (required an invention) by 40% from 2011 baseline by December 31, 2013. Include baseline Include drug classes
# 5 Clarify timeline State the start and end dates Avoid x # of months
Example OK Reduce incidence of all falls rate per 1,000 pt days by 20% 3months after the start of the project and 40% by the end of the year Better Reduce incidence of all falls rate per 1,000 pt days by 20% by September 30, 2013 and 40% by December 31, 2013 21
# 4 Focus on outcomes Outcome Usually down Process Usually up
Examples Outcome Reduce NHSN reportable Hip and Knee surgical site infections 50% by the end of Q2 2013. Process Achieve 100% in Heart Failure Education by July 2013 2012 Baseline = Hip SSI 5.2%, Knee SSI 1.5% 23
# 3 What not how Focus on what you are going to do It is not necessary to include how you are going to do it in your AIM statement
Examples What Reduce HAPU Rate to 2.0 by September 2013. How 100% of patients upon admission will receive a skin risk evaluation and score during admission assessment.
#2 Connect Team to Task Ask What are we trying to change? Which disciplines will be effected? Who needs to champion? MUST HAVE STAFF
Examples Will this team be effective? Readmission reduction Quality Dir Nurse Manager CCO PI coordinator How about this one? Sepsis ICU/ER Supervisors Infection Control RN Infectious Disease Physician champion Pharmacist Nutrition Staff Laboratory Director Chief Nursing Officer Front-line Facilitator Quality Personnel
#1 Think bout the patient How are you getting input from your patients and families about the design and implementation of your processes?
It s time to stretch
Now what? Work with your Network Facilitators Convene your teams Review and refine If you haven t already done so, start to trace your process Find your gaps Participate in the next webinar
What to do and how to do it - webinar Date 5/15/13 Time 10:30 11:30 Topics Covered Using the evidence to support your improvement efforts Understanding the driver diagram Small tests of change 32
What to do and how to do it Skill Building Skill building due to NF, Kelly and me by 5/22/13 Locate the HRET change package for their initiative(s) Read the driver diagram for their initiative(s) Describe the gaps in their current performance Send list of gaps to network facilitator, Kelly and me Plan their next PDSA cycle Send plan to network facilitator, Kelly and me Skill building post webinar call 5/29/13, 10:30-11:30 33
Any more questions?