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Broward Health Quality Improvement PlanACHPE 2015
Broward Health
Broward Health Medical Center Broward Health Coral Springs
Broward Health Imperial Point Broward Health North 2
System and Leadership
3
Five Star Values
1. Accountability for Positive Outcomes2. Valuing our Employee Family3. Fostering an Innovative Environment4. Collaborative Organizational Team5. Exceptional Service to our Community
4
Strategic PrioritiesSafety – provide quality and safe care to all we serveEvidence-based practice – ensure evidence-based practices are implemented and followedRecruit- and retain high performing staff Value – the differences in our culturally diverse workforce and communityImprove profitability – by continually identifying way to improve efficiencyCulture – promote a culture that consistently fulfills the needs of our staff, physicians, patients, families, and the community we serveExcellence – strive to be the best and work to improve performance that exceeds expectations 5
Broward Health Board Driving Quality
Change in CEO to a physician leader
Change in CEO compensation package
Change in Executive and Management staff incentive
package
Changing Employed Physician’s compensation package
Changing general staff incentive structure
6
Performance Improvement
7
Board of Commissioners(Governing Body)
Corporate Patient Care Key Group
Corporate Environment of Care Key Group
Regional Medical Councils Regional & Ambulatory Quality Councils
BHMC BHCS BHIP BHN CHS
Broward Health Quality and Patient Safety Goals
Safety/Quality Flow of Information
Quality Assessment and Oversight Committee
Region Specific Performance Improvement
8
Broward Health Board of CommissionersQuality Assessment and Oversight Committee
Outcome Indicators Mortality Rates Readmission Rates
Patient Safety Indicators Catheter Associated Bloodstream Infections Catheter Associated Urinary Tract Infections Ventilator Associated Pneumonia Class II Surgical Site Infections Mislabeled Specimens Hospital-acquired Pressure Ulcers Early Elective Deliveries Falls Adverse Drug Events Door to Balloon Compliance Nurse Vacancy Rates
Efficiency Indicators ED Throughput
Risk Management and Environment of Care9
Benchmarking:Adverse OutcomesHospital-acquired infections
Catheter Associated Bloodstream Infections
Catheter Associated Urinary Tract Infections
Ventilator Associated Pneumonia
MortalityReadmissionsCardiothoracic SurgeryObstetric Hemorrhage Initiative
Agencies Include:Society for Thoracic SurgeryPress-GaneyCrimsonAvatarAgency for Healthcare Research and Quality (AHRQ)National Database of Nursing Quality Indicators (NDNQI)American College of Surgeons Commission on CancerHospital Engagement NetworkHealth Services Advisory GroupFlorida Perinatal Quality Collaborative
External Benchmarking
10
Defining a High Reliability Organization
11Chassin, M. R., & Loeb, J. M., (2013). High-Reliability Health Care: Getting There from Here. The Joint Commission. Retrieved from http://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf
• Complex, high risk industry where mistakes can equal great harm
• “ High Reliability Organizations are organizations with systems in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors “ – Quint Studer
Minimal Developing Approaching
Leadership
Quality activities focused on regulatory requirementsStrategic importance of quality improvement not recognizedMetrics for quality goals not part of the strategic plan or incentive compensationInformation technology provides little support for quality improvementPhysicians not actively engaged in quality improvement
Chief executive officer leads proactive quality agenda•Board reviews adverse events•Organization sets a few measurable quality aims•Information technology supports some quality and safety initiatives•Physician leaders champion quality goals in some areas
• Organization commits to goal of high reliability for all clinical services
• Organization aims for near-zero failure rates in vital clinical processes
• Some services demonstrate near zero failure rates in some vital clinical processes
• Information technology integral in sustaining quality improvement
• Physicians routinely lead quality efforts
Safety culture
No program to assess safety cultureNo assessment of trust or intimidating behaviorRoot-cause analysis limited to most serious adverse events close calls not recognized or evaluated
Establishing safety culture accorded high priority by leaders at all levels•First measures of safety culture deployed •Beginning initiatives to encourage reporting and analysis of close calls
• Safety culture is well established• Measurement of safety culture is
routine and drives improvement• Regular reporting of close calls
and unsafe conditions lead to early problem resolution
Robust process improvement
No formal quality management systemExternal requirements are focus of improvement effortsNo commitment to sustainable improvement
• Organizational commitment to adopt strong quality improvement tools
• Training of selected staff beginning• Improvement tools used to achieve
gains in quality and safety in addition to routine business processes
• Robust performance improvement tools used throughout the organization
• Patients engaged in redesigning care processes
• Mandatory training of all staff in robust process improvement
• Proficiency in robust process improvement required in career advancements
TJC Reliability Model – Broward Health ProgressBroward Health Current State
12
Key Broward Health Accomplishments/ Initiatives
Leadership
• Leadership accountability for quality and safety tied to performance incentive
• Transparency of clinical processes to Board of Directors through Quality Assessment and Oversight Committee
• Demonstration of system-wide low mortality rates• High level of compliance with ORYX and core measures• Physician leadership of quality committees and key quality
initiatives throughout Broward Health• System-wide CEO led patient safety and satisfaction rounds
Safety Culture• Routine root cause analysis of near misses with corrective actions• Non-punitive reporting policy• Quarterly system-wide patient quality and safety meeting• Huddles to address quality and safety issues
Robust Process Improvement
• Process improvement/ lean/ six sigma belt training available• Well established process improvement department and utilization
of lean / six sigma tools
TJC Reliability Model – Broward Health Progress
13
Broward Health – Harm Star
14
Performance Improvement Objectives 2015
Decrease fall rates to below the NDNQI benchmark Decrease mislabeled specimen rates Early removal of indwelling urinary catheters using the HOUDINI protocol Decrease hospital-acquired infections through the Healthcare- Associated Infection (HAI) Prevention Collaborative utilizing the Health Services Advisory Group (HSAG) Improve the management and outcomes of patients with sepsis Improve ED throughput to state averages Decrease HAPU rates to below the NDNQI benchmark Decrease readmission rates at or below the Crimson benchmark Maintain potentially preventable VTE at zero Continue journey to becoming a high reliability organization
15
2015System-Wide Quality & Patient Safety Initiatives
Outcome Indicators Mortalities Readmissions
Infection Control Indicators CAUTI CLABSI VAE Surgical site infections C-difficile Compliance rates for influenza vaccine for staff and physicians Reduction of MDROs
Efficiency Indicators ED throughput Decrease number of ED patients leaving without being seen 16
2015System-Wide Quality & Patient Safety Initiatives
Patient Safety Indicators HAPU Falls Adverse Events Early Elective Deliveries Mislabeled Specimens Adverse Drug Events Management of Sepsis (new for 2015) Potentially preventable VTE
17
2015System-Wide Quality & Patient Safety Initiatives
Participated in the Hospital Engagement Network (HEN) project (2012 through 2014); Will be participating in HEN II Six Sigma Methodology implemented in all facilities Ongoing Six Sigma Training is being conducted System-wide Six Sigma Showcase was held in July 2014 to present projects and share results and best practices The Advisory Board Company Crimson Continuum of Care Program was implemented. This tool is used to identify areas of opportunity as well as benchmarking.
Participating in AHRQ Patient Safety Initiatives to decrease falls and pressure ulcers.
18
SAFETY CULTURE
19
• Key dimensions to improve quality and reduce harm:– Setting Aims
3.86
4.32
2.00
2.402.19
4.003.86
1.03
6.92
1.92
3.02
1.00
0.00
1.08 1.161.40
2.25 2.30
3.102.81
0.90
0.00
1.14 1.08 1.12
2.08
1.24
R² = 0.2425
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
Rate
of
Infe
cti
on
s
Jun-12 - Aug-14
BHMC Run Chart of Central Line Infection Associated Bacteremia (CLABSI) in the Critical Care Units: Rate per 1000 Line Days
PURPOSE: Reduce the number of CLABSI in the Adult Critical Care Units by 50%between: July 1 and December 3, 2014 as compared to January 1 andJune 30, 2014
IMPROVEMENTS:Identified and Implemented process changes in maintenance of central lines: improved insertion/cleaning methodology and periodic retraining of nurses.
RESULT: Rate of infection decreased from 1.5 in Feb to 1.03 in Aug 2014.
SAFETY CULTURE
20
• Key dimensions to improve quality and reduce harm:– Establishing and monitoring system-level measures
Catheter Associated Urinary Tract InfectionsICU
21
Medication Management
22
Medication Management Initiatives Types of technology used
Cerner Millennium Smart pumps (Hospira Plum) Barcoded medication administration Pyxis Epidural pumps/PCA pumps (Bbraun) ePrescribing – February 2015
95% implementation of Computerized Provider Order Entry (CPOE) 2013 Standardized order sets using evidence-based guidelines using PowerPlan Population specific pharmacists Reduce likelihood of patient harm by better management of anticoagulation therapy 23
Medication Management Initiatives System-wide policies and procedures
Management of high-risk medications Look alike, sound alike medications Hypoglycemic protocol Insulin therapy protocol Heparin protocol Vasoactive titration guide Standardized concentration for drips
Reporting of medication errors through RiskQual Technologies Health Advisory Series (H.A.S) program Broward Health Complete Trials and research studies
24
Infection Control Key Initiatives
Hand Hygiene Campaign Personal Protective Equipment Elimination of Hospital Acquired Infections (HAI)
Central Line Associated Bloodstream Infections (CLABSI)Catheter Associated Urinary Tract Infections (CAUTI)Ventilator Associated Events (VAE)Surgical Wound InfectionsMultidrug Resistant Organisms (MDRO)
• C-difficile, VRE, CRE, MRSA
25
Infection Control Program
CDC, APIC, AORN Guidelines Risk Assessment, Prioritization, Planning, Implementation, and Evaluation
Ongoing and annually Root Cause Analysis as needed
Targeted surveillance NHSN definitions for reporting
System-wide epidemiology meetings Standardization of plans, policies Standardization of products and best practices
MedMined computer system for surveillance and antimicrobial stewardship
26
Patient SafetyDelivery of Care Overview
27
UPDATEValue Based Purchasing
28
Delivery of Care Initiatives Interdisciplinary Provision of Care Policies and Procedures The Journey to Interdisciplinary Rounds:
DSC Programs Pain Behavioral Health Hospitalists (Pediatric and Adult) Neonatologists Intensivists Journey to Top of Licensure Practice
Interdisciplinary Communication Support Electronic Plan of Care Electronic Patient Education Record (Teachback) Decision Support and Alerts Various Screen Views to aggregate the process of care Each hospital has prioritized a sequence of hourly rounding, bedside report and shift
huddles
Focus on Standardizing Resource Systems Lexicomp®, Cerner Content, Lippincott, Ovid
29
Environment of Care
30