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Nebraska HIMSS 2018 Spring Meeting 1
Nebraska Medicine: A Davies JourneyTammy Winterboer, PharmD, BCPSDirector, Clinical Effectiveness & [email protected]
April 23, 2018
Clinical Effectiveness and DaviesMicah Beachy, DO, FACPMedical Director, Clinical Effectiveness
Charlotte Brewer, BSN, RNCoordinator, Clinical Effectiveness
The mission of the Clinical Effectiveness team is to reduce variability of care through the development and implementation of evidence-based best practices to realize cost savings and develop programs, while improving patient quality, safety, and outcomes.
Clinical Effectiveness Mission
Analytics
Quality
Application/ Informatics
CE
Clinical Effectiveness Core Team Structure
Nebraska Medicine Advisory Board
Board Quality Committee
Patient Safety & Quality Steering
Core Event Review Team
Patient Experience
Patient OutcomesCommittee
Clinical Effective-
ness
Education & Practice Support
Bellevue Medical Quality
Committee
Nursing Quality
Physician Quality
Committee
Medical Staff
Peri-Op Quality
Committee
Ambulatory Care
Committee
Quality Governance
Clinical Value Bundle (CVB) TeamPhysician
ChampionsNurse/Clinical Team Leads Epic Analysts Integrated
Functions SMEs
CE Working Group
CE Medical Director, Program Director & Coordinator Analytics/Data Analyst College of Public Health
Partners
CE Steering Committee
Executive Sponsor Key Enterprise Leaders
Nursing RehabEMS IT Lab PharmacyStaffEducation
PatientEducation
PalliativeCare VNA
Clinical Effectiveness Program Structure
Wave 3
Code Sepsis Team Drug Utilization Lab Utilization Inpatient QMCs
“Sprint” 2
Frequently Admitted Patients
Wave 2
Sepsis - Early Treatment Mobility Heart Transplant/VAD ACR Select
Sprint 1
Telemetry
Wave 1
Sepsis - Early Identification Heart Failure Complex ICU/ECMO
Clinical Effectiveness Initiatives
Clinical Effectiveness Sepsis Program
Clinical Effectiveness (CE) program partnership with multi-disciplinary sepsis operational team focused on reducing variability in sepsis care• Implemented tools and processes to improve early
identification• Standardized documentation for outside transfers to
assist with screening• Developed education and ongoing marketing
campaign• EHR improvements implemented to assist with core
measure adherence
Despite improvements in early identification of sepsis patients at Nebraska Medicine, early treatment strategies remained variable and compliance with evidence based timely interventions (3 & 6 hr bundle) was suboptimal.
Why a Code Sepsis Team?
• Frequently changing definitions & treatments make it difficult to keep large number of staff up to date
• Ensured sepsis is treated with urgency at the time of recognition
• The large rotating, membership of the Rapid Response Team made it difficult to ensure consistency of expertise in sepsis recognition and treatment
• Best practice requires adherence to time sensitive treatment strategies (3 & 6 hour bundle)
Code Sepsis Team (CST) Pilot
November 2016 –January 2017• 2 Medical/Surgical
Units
Team Members• Hospitalist advanced
practice provider• ICU lead nurse• Critical care
pharmacist
Training• Workflow• Team member responsibilities • EHR tools & resources available• Clinical case reviews for
providers
Metrics • Workflow feedback/refinement• Time needed per team member• Adherence with 3 and 6 hour
bundle (CMS core measure)
Code Sepsis Team Activation from EHR
• Automated activation Triggerso abnormal lactateo nurse sepsis screen resultso low blood pressure
• Team members dispatched to patient’s bedside to evaluate and treat the patient in collaboration with the primary team
© 2017 Epic Systems Corporation. Confidential.
Code Sepsis Tools: Chart Review
© 2017 Epic Systems Corporation. Confidential.
Code Sepsis Tools: Documentation
© 2017 Epic Systems Corporation. Confidential.
CST Pilot: Sepsis Core Measure
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016
% C
ompl
ianc
e
Calendar Year Quarter
Overall Compliance Sepsis Core Measure -Nebraska Medicine Compared to Vizient Median
NMC Sample Pop
Vizient Median
CST Pilot
CST Pilot: Sepsis Core Measure
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Initial lactate Broad spectrumantibiotics
administered
Blood culturesdrawn prior to
antibiotics
Repeat lactatewithin 6 hours
30ml/kg fluidresuscitation
Vasopressoradministration
Reassessment ofvolume status and
perfusionfollowing IVF
% C
ompl
ianc
e
NMC Sample PopQ3 2016NMC Sample PopQ4 2016CST Pilot
Target
Sepsis Program Current Initiatives
• Code Sepsis Teamo Launched at NM Bellevueo NM Main campus implementation planned 2018o ED specific workflow
• Sepsis Screeningo Optimized ED screening alertso New screening workflow for infusion centero ED, IP and infusion workflows live at all
Community Connect sites• Integrating Predictive Analytics
Wave 3
Code Sepsis Team Drug Utilization Lab Utilization Inpatient QMCs
“Sprint” 2
Frequently Admitted Patients
Wave 2
Sepsis - Early Treatment Mobility Heart Transplant/VAD ACR Select
Sprint 1
Telemetry
Wave 1
Sepsis - Early Identification Heart Failure Complex ICU/ECMO
Clinical Effectiveness Initiatives
CE Program Lab Utilization Initiatives
• Reason for actiono Need for improved visibility to cost with the
transition to value based contractso Hardwiring appropriate use guidelines
• Partnered with Lab Utilization Committee to identify opportunities
• Initiatives to dateo GI Pathogen Panelo Displaying inpatient lab costso Respiratory Pathogen Panelo Indicating “send out” tests
Lab Utilization – GI Pathogen Panel
Go Live
30%
© 2017 Epic Systems Corporation. Confidential.
© 2017 Epic Systems Corporation. Confidential.
Lab Utilization – Displaying Cost
© 2017 Epic Systems Corporation. Confidential.
© 2017 Epic Systems Corporation. Confidential.
© 2017 Epic Systems Corporation. Confidential.
Acknowledgements
Sepsis Team Past & Present• Lisa Ablan • Meredith Hellman • Dara Schlecht• Mike Altschuld • Sara Hooper • Lisa Schlitzkus• Nate Anderson • Jo Jameson • Michelle Schulte• Ozgur Araz • Brandi Johansen • Megan Skryja• Lorena Baccaglini • Brandon Jordon • Christopher Smith• Aaron Barksdale • Dan Kalin • Sue Stensland• Nancy Bernard • Katie Kerrigan • Jessica Strickler• Justin Birge • Maria Lander • Karen Townsley• Kelly Cawcutt • Anna May • Melanie Tuamoheloa• Kellie Clapper • Amy Mead • Jana Uryasz• Sandy Crites • Jenny Nano • Trevor Vanschooneveld• Tracy Diehm • Jennifer Nguyen • Suzanne Watson• Val Driscoll • Greg Peitz • Adam Wells• Dave Gannon • Craig Reha • Kirstin Woodbury• Jodi Garrett • Kiri Rolek • Wes Zeger• Ashley Gay • Jamie Rudd • Qin Zijian• Emilie Goldsberry • Todd Sauer
Lab Team Members• Amy Crismon• Paul Fey• Jodi Garrett• Susan Griffith• Caitlin Murphy• Lauren Hood• Jason Shiffermiller• Trevor Vanschooneveld• Kirstin Woodbury
HIT Successes For Quality ImprovementNicole Turille, BSN, RNDirector, Quality & Patient [email protected]
April 23, 2018
CAUTI:• Modification of Indwelling Urinary Catheter Indications• Provider Decision Support Tools
Additional Quality Metrics Improvements:• CLABSI• Violence Prevention
Ongoing Optimization
Indication Modifications:• Evaluating Input & Output Frequency
• Every 1- 3 hours vs. every 4 hours• Utilization of decision support tools to aid in catheter
selection
CAUTI OptimizationHow Health IT is continually Used
Utilization of a Female External Urinary Catheter:• Evaluating Input & O1utput Frequency
CAUTI OptimizationHow Health IT is continually Used
© 2017 Epic Systems Corporation. Confidential.
Quality Metric Checklist:
Quality ImprovementHow Health IT is continually Used
© 2017 Epic Systems Corporation. Confidential.
Violence Prevention Project:• Standardized Screening Tools
Staff Safety OptimizationHow Health IT is continually Used
© 2017 Epic Systems Corporation. Confidential.
Violence Prevention Project:• Decision Support Tools
Staff Safety OptimizationHow Health IT is continually Used
© 2017 Epic Systems Corporation. Confidential.
© 2017 Epic Systems Corporation. Confidential.
Violence Prevention Project:• Encounter Based Flags
Staff Safety OptimizationHow Health IT is continually Used
© 2017 Epic Systems Corporation. Confidential.
© 2017 Epic Systems Corporation. Confidential.
Applications, Logic and Integration for DaviesDavid Cloyed, MS, RN-BCApplications Manager, Enterprise Clinical Applications
Clinical Decision Support Backbone
Point of Care Alerts
Care Opportunity
Reports
Enterprise Dashboards
Regulatory Reporting Alphabet Soup
Making sense of the governing bodies
Boone, K. (2012, November 12) Hashtag Soup: Relating QDM, HQMF, eMeasures, QueryHealth, QRDA, SIFrameworkand MeaningfulUse Stage2. Retrieved from http://motorcycleguy.blogspot.com/2012/11/hashtag-soup-relating-qdm-hqmf.html
Nebraska Medicine eCQMCycles
Sept• VSAC publishes value
set updates
Jan/Feb• Vendor releases value
set updates
Feb-March• NM SDLC
April – December• New Measure
Deployment• Performance
Monitoring• Alert Optimization
Testing ImperativeFunctional
Regression
Integrated
Production Validation
Lessons Learned• Attribution is everything• Be prepared to build Decision
Support based on clinical best practice logic when eCQM logic does not fit with Point of Care presentation
• Validate that Lab testing procedures align with clinical best practice and LOINC codes
• Be agile when addressing bugs• Partner with vendor
IntegrationBidirectional NESIIS Transactions- Enables reconciliation with patients chart- Support eCQMs via CVX
- CMS147 - Preventive Care and Screening: Influenza Immunization- CMS127 - Pneumococcal Vaccination Status for Older Adults
