PERFORMANCE IMPROVEMENT REPORT First Quarter Fiscal Year 214 October-December, 213 Daniel Coffey, CEO 1
Executive Summary The Quarterly Performance Improvement Report summarizes the measures used to monitor and evaluate Acadia s inpatient care. It contains the results from the first quarter of the current fiscal year, October through December, 213. Hospital Based Inpatient Psychiatric Services Indicators (pages 3-7) Ongoing efforts to maintain the improvements made on completing a continuing care plan at discharge and transmitting it to the next level of care provider within five days of discharge improved to at or above the national average. Including an appropriate justification for patients discharged on more than one antipsychotic has maintained 1% compliance for five consecutive months. Acadia continues to perform better than the national average on four of the seven indicators: Admission Screening, Physical Restraint, Seclusion, and Use of Multiple Antipsychotic Medications. EMHS Zero Defects Project (page 9) Acadia increased the percent of employees receiving influenza vaccination from 8% in 212 to 92% in 213. Medication errors are the largest contributor to the total number of defects and increased from the previous quarter, primarily due to errors made by locum tenentes. In response, the orientation for temporary physicians has been revised. Patient Restraints (pages 9-1) After unusually high rates in July and August, Acadia s restraint rate has been below the national average since. When rates of restrictive intervention, which includes both restraint and seclusion, are compared, Acadia is significantly lower than the national average, even in months when our restraint rate is unusually high. Education and Training provides refresher MOAB session for all direct care staff in order to reinforce/maintain skills. Medication Errors (page 11-12) The medication error rate decreased in the past quarter after a sharp increase the previous quarter. Prescribing issues with locum tenentes remain an issue. Orientation for temporary physicians has been revised. Patient Falls (page 13-14) The fall rate rose again in recent months, with November and December both above Acadia s goal. Most adult patients who fall are already on fall precautions. Patients rarely suffer injury due to falls. Length of Stay (page 15) Overall length of stay has decreased slightly in the past two quarters. For adults, there has been a steady decrease for four consecutive quarters. 2
Executive Summary (cont d) 3-day Readmission Rate (page 1) The percentage of patients readmitted to Acadia within 3 days of discharge has been declining during the last two years; it is not significantly different from the nation average. Staff Injury (page 17) The rate of days away, restricted or transferred (DART) continues to decline from the high rate in 29. Areas continue to receive regular reports of unit-specific injury data. Patient Injury (page 18) Patient injury is usually connected to patient assault on peers, self-harm, or incidental injury during restraint. All of these are more common among our pediatric patients. Patient Satisfaction (page 18) Patient satisfaction results have been quite positive this year, and remain at or above the nation in all domains. Environment of Care (page 19) Highlights 3
Hospital-Based Inpatient Psychiatric Services Indicators (HBIPS) Admission Screening: Percent of patients who were screened, within three days of admission, for risk of violence to self and others in the past six months, history of psychological trauma, substance use in the past 12 months, and two or more patient strengths. Compliance with this indicator has been excellent. 1 HBIPS 1 - Admission Screening Acadia NRI Mean 1 1 1 1 1 1 1 1 1 1 1 1 1 Percent Compliant 8 4 2 Higher is better Hours of Physical Restraint Use: Number of hours spent in physical restraint for every 1, inpatient hours. Acadia s rate is driven by our pediatric population. Acadia s rate was below the national average for most of fiscal 213 and 214. The rise during July and August was due to a few particularly acute pediatric patients. 1.5 HBIPS 2 - Restraint Rate Acadia NRI Mean 1.25 1..93.89.75.5.25.27.44.31.24.17.27.37.5.29.23.3. Lower is better 4
Hours of Seclusion Use: Number of hours spent in seclusion for every 1, inpatient hours. Acadia does not use seclusion. 1.5 HBIPS 3 - Hours of Seclusion Use Acadia NRI Mean 1.25 1..75.5.25. Lower is better Restrictive Intervention Overall When restraint and seclusion are combined to look at overall restrictive intervention, Acadia has a significantly lower rate than the national average. Although this is not an HBIPS indicator, it s helpful to see how Acadia performs when looking at restrictive intervention overall, effectively combining HBIPS 2 and 3. 1.5 Hours of Restrictive Intervention Acadia NRI Mean 1.25 1..93.89.75.5.25.27.44.31.24.17.27.37.5.29.23.3. Lower is better 5
Multiple Antipsychotic Medications at Discharge: Of all patients discharged on antipsychotic medication, the percentage discharged on more than one. This indicator continues to be below the national average. HBIPS 4 - Multiple Antipsychotics at Discharge 1 Acadia NRI Mean 8 4 2.7 9.1.3 7.4 5. 8. 3.9 7.7 4.2 9.7 5.7 1.1 7.7 Lower is better Multiple Antipsychotic Medications at Discharge with Appropriate Justification: Percent of patients with appropriate justification for discharge on multiple antipsychotic medications. Acceptable justifications are specified and evidence-based. Acadia has very few patients discharged on multiple antipsychotics and physician performance on documentation of the rationale is inconsistent. Physicians receive compliance reports and the discharge summary template includes a prompt for this information.
Post Discharge Continuing Care Plan Created: Percent of patients discharged with a care plan including diagnosis, recommendations for next level of care, dosage and indication for all medications, and reason for hospitalization. Inconsistent compliance continues to be addressed by staff education and individual feedback to physicians, nurses, and discharge planners. Percent Compliant 1 8 4 2 HBIPS - Continuing Care Plan Created Acadia NRI Mean 98 98 1 1 95 95 95 8 82 94 1 71 97 Higher is better Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider: The care plan (with all four components of the previous measure included) was transmitted to the next provider within five days of discharge. Multi-pronged improvement efforts have led to significant changes in performance. HBIPS 7 - Continuing Care Plan Transmitted Percent Compliant 1 8 4 77 98 1 1 Acadia 91 89 NRI Mean 9 74 9 84 88 9 87 2 Higher is better 7
EMHS Zero Defects Project Medication errors contribute the largest number of defects. The proportion of employees receiving the Influenza vaccination increased this year to 92% (last year it was 8%). Medication Error Events EMHS Zero Defects - Quarterly Results NA= Not Applicable Process Errors Q1 Oct-Dec 213 wrong drug wrong dose 14 extra dose 1 missed dose 7 wrong patient 1 wrong route VTE Errors VTE Risk Level Documented # of pts without a documented VTE Risk Level within 24 hrs of admission VTE Prophylaxis Ordered # of pts assessed as high risk for VTE who did not have prophylaxis ordered Potentially Preventable Complications 1 Q2 Jan-Mar 214 Q3 Apr-Jun 214 Central Line Infections - # of occurrences NA NA NA NA Ventilator-Associated Pneumonia - # of occurrences NA NA NA NA VTE - # of DVT and PE occurrences Serious Reportable Events # of NQF serious reportable events Hand Hygiene Compliance Other Elements % of staff observed who met the hand hygiene standard 85% Influenza Vaccination - reported annually % of employees & staff who completed the screening process (i.e. either accepted the vaccine or signed a declination form) 9% % of employees & staff who received the vaccine 92% Culture of Safety Survey Rating - reported annually Two elements from the AHRQ Culture of Safety survey: "The actions of hospital management show that patient safety is a top priority." ( % of employees who "strongly agree" or "agree") "Please give your work area/unit in this hospital an overall grade on patient safety" (% of employees who answered "excellent" or "very good".) 7% 8% FY 214 Q4 Jul-Sep 214 8
Restraints per 1, patient care hours Patient Restraints Acadia s rate has been well below the national average for most of the past two years. Many hospitals continue to use seclusion to manage patients whose behavior poses a danger to themselves or others. Acadia eliminated seclusion more than 1 years ago. When rates of restrictive intervention, which includes both restraint and seclusion, are compared, Acadia is significantly lower than the national average, even in months when our restraint rate is unusually high. 9
Restraint Rate by Age Pediatric patients have significantly higher rates of restraint than adults. 3. Inpatient Restraint Rate per 1, Patient Care Hours by Age Category and Calendar Month 2.75 2.5 2.25 2. 1.75 1.5 1.25 1..75.5.25. Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 All Inpatient.33.58.4.31.17.27.38.94.91.52.3.23.3 Adults.2.9.3.3.8.21..17.14.25.4.11. Children..83.7.49.29.35.8 2.31 2.2.91.59.38.75 Percent of Patients Restrained A much higher proportion of inpatients under 18 is restrained compared to adults. 1
Medication Errors The medication error rate decreased during the last quarter as prescribing issues with locum tenentes were addressed. Wrong dose (missed or extra) continues to be the most frequent error type. Unit-specific reports are distributed monthly. 14 12 Inpatient Medication Doses in Error per 1 Inpatients Served by Calendar Quarter 11.5 Acadia Rate NRI National Rate 1.4 1 9.3 8. 9.5 8 7.1 4 2.8 3.8 2 Jan-Mar12 Apr-Jun12 Jul-Sep12 Oct-Dec12 Jan-Mar13 Apr-Jun13 Jul-Sep13 Oct-Dec13 12 12 Doses in Error Reaching the Inpatient by Type of Error from October to December, 213 1 1 8 4 2 1 1 1 11
Medication Errors (cont d) Acadia continues to be on track to have fewer medication errors than the prior year, fewer errors reaching patients, and fewer errors made that have potential to harm the patient. 12
Patient Falls Number of Patient Falls per 1, Patient Days Fall rates continue to vary from month to month, primarily due to one or two patients. Very few falls result in injury to the patient. 1 14 Acadia Hospital Inpatient and Observation Units Patient Falls per 1, Patient Days, by Fiscal Month Hospital Rate 3-month Average = 3.9 Tentative FY213 Goal: 3.8 12 1 8.2 8.4.. 4 2 3.2 2.9.5 2.1 3. 4.5 3. 4.5 2.1 2.9 3.9 2.2 2.1 4.5 2 Falls per 1, Patient Days by Age Cohort Patients 18 Years of Age and Older Patients 17 Years of Age and Younger 15 1.9 9. 7.4 7.9 7. 8.5 5.8 5 3.9 1.3 1.1 4.2 1.4 1.2 2.5 1.3 3.1 2.7 3.5 3.3 3.4 4.1..... 13
Patient Falls (cont d) 12 1 11 Falls by Contributing Factor, Fiscal October to December, 213 1 8 7 7 4 4 3 3 2 2 2 2 1 14
Length of Stay Acadia continues to experience longer lengths of stay than its national comparison group. This is due primarily to patient acuity and difficulty in securing placement for patients ready for discharge. In addition, the national average includes psychiatric units in medical hospitals. 2 Average Inpatient Length of Stay By Fiscal Quarter Acadia Inpatient 211 National Average=9.1 15 12.27 13.52 15.53 14.5 14.37 14.52 14.21 12.83 12.99 Days 1 5 3 Average Inpatient Length of Stay by Age, by Fiscal Quarter Age <18 Age >=18 25 Days 2 15 1 12.7 12. 14.3 13.1 17.8 18.1 14.3 12.97 15.5 13.79 17. 1.9 12.94 12.53 15.9 11.5 17.9 1.73 5 15
Inpatient 3-Day Readmission Rate Percentage of discharged patients readmitted within 3 days The addition of full-time discharge planners on inpatient units is partly responsible for the decrease in Acadia s 3-day readmission rates. Readmission rates vary for both pediatric and adult units. There is no distinct pattern by age group. 2 Inpatient 3-Day Readmission Rate by Calendar Quarter Acadia Inpatient NRI 15 1 5 9.4 8. 7. 5.9 4.9. 7.4 8.5 4.8.5.4 Note: Because this rate looks at readmissions within 3 days of discharge, the rate for a quarter isn t known until 3 days after the end of the quarter. Thus, the rate for calendar quarter 4, October-December, won t be known until the January data has been analyzed and reported. 1
Staff Injury Lost work time due to work-related injury The DART rate for 212-213 is the lowest it s been in several years. Units continue to receive unit-specific injury reports monthly and have created action plans to maintain or improve their rates. 1 Employee DART (days away, restricted or transferred) Cases per 2, Hours Worked by Calendar Year Acadia Hospital & Healthcare 14 12 11.9 1 9.1 9.5 8 7.8 5. 4 2 29 21 211 212 213 18 17 1 15 14 13 12 11 1 9 8 7 5 4 3 2 1 98 17 Days Away Rate* by Pay Period, Calendar Year 213 Cost in wages = $3,49 5 28 1 2 3 4 5 7 8 9 1 11 12 13 14 15 1 17 18 19 2 21 22 23 24 25 2 Pay Period 21.5 *Days away from work due to injury per 2, hours worked 17
Patient Injuries Injuries are defined as requiring diagnostic services, treatment beyond first aid, or treatment at a higher level of care. Patient injury is most commonly a result of patient assaults on peers, self-harm, or incidental contact during restraint. Acadia s rate remains above the national average. Patient Injuries per 1, Patient Days (Inpatient & POU) by Fiscal Month Acadia Paitient Injury Rate NRI National Inpatient Rate 5 4 3.9 3. 3 2 2.4 1.9 1.3 1.3 1.1 2.2 1.8 2.2 1.2 1.4 2.3 1.8 2.4 1... Patient Satisfaction and Loyalty Acadia Hospital continues to perform at or above national averages in all domains. Outcome of Care and Rights are consistently the lowest scoring domains 1% 9% 8% 7% % 71% 78% Percent of Inpatients with Positive Responses to Inpatient Consumer Survey (ICS) Domains, October-December, 213 9% 82% Acadia 7% 8% 8% 7% National Rates 73% 7% 8% 78% 7% 3% 5% 4% 3% 2% 1% % Outcome of Care Dignity Rights Participation in Treatment Facility Environment Empowerment Consumer Loyalty 18
Environment of Care Highlights December 2-3, 213 The Joint Commission performed an onsite survey which included inspection of Life Safety and Environment of Care standards by an engineer. All deficiencies from survey have been corrected or have a corrective action plan in place. The most significant finding was a Proactive Risk Assessment that identified ligature risk of the patient room bathroom fixtures, but had not been addressed. A subsequent Proactive Risk Assessment was completed and a proposal to correct was approved. All bathrooms will be retrofitted with anti-ligature fixtures to eliminate ligature possibility by end of May 214 at the cost of approximately $11,. All 213 Environment of Care Management plan evaluations were completed and approved. 19