quality15 Cure Me-A Systematic Approach to Transforming ... · PDF fileDevelop criteria for when to initiate NGT feeding and/or GT Key Drivers ... Create feeding checklist to be completed

March, 2015

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Cure MeA Systematic Approach to Transforming Clinical Outcomes

Wallace Crandall, MD – Medical Director, QIS

Brian Joy, MD – Director of Quality, The Heart Center

Anup Patel, MD – Associate Medical Director, Partners for Kids

March, 2015

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“The Cost of Doing Business”

Transformational Thinking

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Goal: = 0 events per year 2014: 0 events

1 VAP in 5 years

What About Outcomes?

“The biologic ceiling for remission in IBD is 63%.” (paraphrased)

-An unnamed leader in the field, circa 2009

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………………..……………………………………………………………………………………………………………………………………..

QUALITY / SAFETY / SERVICE PATIENT & FAMILY MEDICAL CARE JOURNEY

Prematurity Preven on

Asthma Behavioral

Health Be er Baby

Zone (HNHF)

Diabetes Obesity

Do Not Harm Me Heal Me Cure Me

Treat Me With Respect

Navigate my Care Access ‐ Flow

Keep Us Well

ELIMINATE PREVENTABLE

HARM

Zero HeroSM

TRANSFORM The Outcome of One or

More Acute or Chronic Illnesses

2009 ‐ 2018

IMPROVE throughput by improving:

Access Discharge

Planning Prevent or

Reduce Unplanned Readmits

Care Coordina on

TRANSFORM The Pa ent

Experience by Re‐engineering

How We Interact with Families and Other Staff

………………..……………………………………………………………………………………………………………………………………..

QUALITY / SAFETY / SERVICE PATIENT & FAMILY MEDICAL CARE JOURNEY

Prematurity Preven on

Asthma Behavioral

Health Be er Baby

Zone (HNHF)

Diabetes Obesity

Do Not Harm Me Heal Me Cure Me


Navigate my Care Access ‐ Flow

Keep Us Well

ELIMINATE PREVENTABLE

HARM

Zero HeroSM

TRANSFORM The Outcome of One or

More Acute or Chronic Illnesses

2009 ‐ 2018

IMPROVE throughput by improving:

Access Discharge

Planning Prevent or

Reduce Unplanned Readmits

Care Coordina on

TRANSFORM The Pa ent

Experience by Re‐engineering

How We Interact with Families and Other Staff

March, 2015

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Transformative Goals:

“Important” Problems

Relatively common

Significant morbidity or mortality

Impaired quality of life

Transformative Goals:“Important” Outcomes

Remission

Survival

Decreased total hospital days

Improved QOL

Prevention

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Cure Me - Goals and Expectations

Provide the highest level of care available anywhere in the world in order to dramatically improve outcomes

Document current outcomes

Re‐define and achieve the best possible outcomes anywhere (establish benchmarks)

Share our experience with others (publish)

Key PrinciplesStructured, systematic approach

Focus on proactive, reliable care

Transparency

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Cure Me: The process

Identify the chronic illness

Identify an important problem to work on

Establish a QI team around that illness

Define process and outcome measures

Establish a Key Driver Diagram

Develop a data collection / reporting system with baseline data if available

Rapid cycle testing of interventions

Cure Me GoalsOverall goal is typically multi-year

In addition, each section develops yearly interval goals

Interval results of primary outcome goals

Implementation of important process measures

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AccountabilityEach section:

Sends monthly update to the Medical Director

Reports to the CMO, Associate CMO, CNO and Medical Director twice yearly

Reports to the Quality Committee yearly

May begin giving updates in section chief meetings as well

Example Cure Me Focus Areas

Heart Center‐ Hypoplastic Left Heart

Neonatology‐ BPD

Gastroenterology‐ IBD, Celiac Disease

Infectious Diseases‐ Pneumonia

Neurology – Epilepsy

Heme/Onc‐ Cancer Care Index

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Neonatology‐ BPD







Neonatology‐ BPD





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Improving Quality of Care in Hypoplastic Left Heart Syndrome

Brian Joy, M.D.Assistant Professor of Pediatrics Divisions of Pediatric Cardiology & Critical CareDirector of Patient Safety & Quality Improvement,

The Heart Center

Hypoplastic Left Heart Syndrome

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Ohye RG et al NEJM 2010

Hypoplasia of left heart and the aorta

Undergo three stage reconstruction (palliation) culminating in Fontan procedure

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Palliative Options for HLHS

• Traditional Norwood • Norwood Stage I Palliation (Newborn)

• Bidirectional Glenn (~6 months)

• Fontan Procedure (~2 years)

• Hybrid • Hybrid Stage I Palliation (Newborn)

• Comprehensive Stage II (~5 months)

• Fontan Procedure (~2 years)

• Compassionate care

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Hybrid Procedure

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Galantowicz M et al. The Annals of Thoracic Surgery. 2008.

Stage I (~4-7d)

Comprehensive Stage II (~5 months)

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Resource Utilization

• Stage I Palliation (Traditional Norwood)– Median LOS: 28 days

– Median Hospital Charges: $280,909

– Mortality Rate 18%

• One year transplant free survival: 69% – Rate of serious adverse events: 37-46%

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Dean PN, et al. Pediatrics. 2011.

Ohye RG, et al. N Engl J Med. 2010.

Resource Utilization

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Schidlow DN, et al. Pediatr Cardiol. 2014

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Specific Aim

Increase the percentage of HLHS patients from 50% to 70% that will have

a total hospital days before their first birthday ≤ 60 days

Included patients:

•Hybrid Stage I and Comprehensive Stage II at NCH

•Not listed for transplant before 1st birthday

•Are still alive at 1 year of age

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………………..……………………………………………………………………………………………………………………………………..

Journey Board Utilization H4A

Fellow/Resident education/acknowledgment

Conduct RN Education Days

Key Drivers

Specific Aim

Interventions

Roles & Responsibilities

Education

We will increase the compliance with completion of

Journey Boards in the Heart Center

inpatient population from 0% to 50% by

12/31/12 and be sustained for 6

months

CTICU Education

Staff Engagement

Systems/Process Measures

Implement Goals Sheet with Journey Board cues

Family Engagement

Define roles/responsibilities within process

Incorporate Journey Board into family orientation

Incorporate in RN orientation

Education on appropriate Journey Board to use

Implement EPIC Smart Form for shift change documentation

Incorporate Journey Board discussion at shift change

Incorporate education in Welcome folder

Incorporate education in Fetal Outpatient folder Reduce 30-day readmission rate

Global Aim

Change labeling for better differentiation of Journey Board type

Last revised: 4/11/13

Physician Champion: Brian Joy

………………..……………………………………………………………………………………………………………………………………..

Develop criteria for when to initiate NGT feeding and/or GT

Key Drivers

Process Measure Aim

Interventions

Accountability

Feeding Guidelines

To decrease hospital feeding days from 7 per 100 interstage days in 2013 to

4 per 100 interstage days

in 2014


Case Management

Nurses

Standardization

Discharge Planning

Identify a champion in the disciplines of physician, nurse, dietician, and case manager

Ensure patients are at full feeds for 24 hours prior to discharge

Begin feeding issues discussions at prenatal visits; include possibility of NGT or GT

Create buy-in with staff regarding NGT/GT feed indications and timing

Develop an outpatient feeding clinic for single ventricle patients

Reduce Interstage Feeding-Related Admissions

Total hospital days for HLH patients < 60 days by patient’s first birthday

Cure Me Aim

Create feeding checklist to be completed by team prior to discharge

Dieticians to meet with parents minimum of twice a week during entire hospitalization

Ensure families room in with patients 24 hours prior to first discharge

Not initiated or established

Initiated but needs improvement

Established, supported and/or effective

Increase collaboration with GI team

Physician Champions: Brian Joy, Rick Fernandez

………………..……………………………………………………………………………………………………………………………………..

Immediate feedback to staff when components are missed

Key Drivers

Process Measure Aim

Interventions

Process Simplification

Documentation

Increase compliance with rooming in for

“functional” single ventricle patients at first discharge from 50% in 2013

to 75% by December 31,

2014


Accountability

Nursing Education

Case Manager Engagement

Incorporate rooming-in education into house staff orientation

Track and measure rooming in data

Discuss rooming-in requirements for near-term discharges during rounds

Work with bedside RNs to facilitate completion of return demonstration forms

Ensure rooming in is part of new hire orientation and ongoing Skills Days training

Routine results sharing at staff meetings

Rooming In Compliance

Total hospital days for HLH patients < 60 days by patient’s first birthday

Cure Me Aim

Physician Champion: Omar Khalid

Implement EPIC smartforms for each checklist

Reinforce need for completion of return demonstration forms

Scan completed checklists into EPIC




Conduct return demonstration quizzes with families Family Engagement

………………..……………………………………………………………………………………………………………………………………..

Develop testing protocol, birth – 24 months

Key Drivers

Specific Aim

Interventions

Measurement

Protocol & Process To increase

neurodevelopmental assessment compliance* in single ventricle patients from birth to age 24 months from 0% to 75% by December 2014


Accountability

Leadership Identify physician champion

Ensure ownership and accountability within each protocol step

* Compliance includes: • Newborn: TIMP / OT / PT / ST • 3m : TIMP tes ng at 3 mos • 12m : Bayleys • 18m: Speech evalua on • 24m: Bayleys

Neurodevelopmental Assessment Standard of Care Protocols

Physician Champion: Omar Khalid




Ensure process for data collection and analysis is established

Communication

Establish protocol for patients with identified disabilities

Collaborate with education liaisons

Family Support

Establish Neurodevelopmental Team

Establish email group and reporting format for appointments

Ensure new patients have an enrollment email on admission and discharge

………………..……………………………………………………………………………………………………………………………………..

Key Drivers

Specific Aim

Interventions

PA Surveillance

To increase compliance* with the Stage II protocol in single ventricle patients from 0% to 75% by December 2014

Finalize protocol for the hypoxemic patient


Procedure Timing

Hypoxemia Recommendations

Provide patient family with Comp Stage II OR date upon Stage I discharge

Establish protocol for surveying pulmonary arteries post Stage II

Establish EPIC smartphrase that references anticoagulation, imaging, and cath plans

* Compliance includes: • Following hypoxemia guidelines • OR date given upon ini al discharge

• Exit angio performed • U liza on of smartphrase containing imaging / cath plans

• Planned surveillance procedure date given on discharge

Stage II Protocol Standard of Care Protocols

Standardize patient age to 5 months for Comp Stage II procedure

Physician Champion: Cliff Cua




Perform exit angio

………………..……………………………………………………………………………………………………………………………………..

Key Drivers

Specific Aim

Interventions

To increase compliance* with medical management of single ventricle patients during their first procedure from 0% to 75% by December 2014

Discuss feeding protocol during transfer from CTICU to H4A


Communication of Feeding Protocol

Standardization of Care

Standardize home going medications at time of 1st discharge

* Compliance includes: • Ini al surgical / cath procedure between 4‐ 7 days of life

• BAS within 10 days of 1st procedure (if app)

• Echo within 24 hrs of 1st procedure

• Discharge medica ons: Single RV home on digoxin / ASA

• Compliance with SV lab bundle • Psychology consult

Ensure copy of feeding protocol is affixed to patients’ bed at transfer

Medical Management of 1st Procedure Standard of Care Protocols

Standardize timing of initial surgery/cath

Physician Champion: Christina Phelps




Standardize surveillance testing

Data Measurement Establish tools for data collection, measurement, and analysis

Leadership & Accountability

Identify physician champion

Family Support Inpatient psychology consult

Key Driver Diagrams

Compliant Components

18 8 24 8 6 7 16 15 7 22 12 21 29 6 8 22 15 16 22 8 21 34 6

Total Components 24 8 24 8 8 8 16 16 8 24 16 24 40 8 8 24 16 16 32 8 40 48 8

………………..……………………………………………………………………………………………………………………………………..

Ini ated SV protocol

GOOD

GOOD

………………..……………………………………………………………………………………………………………………………………..

Compliance with Process Measures

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Compliant Components

18 8 24 8 6 7 16 15 7 22 12 21 29 6 8 22 15 16 22 8 21 34 6

Total Components 24 8 24 8 8 8 16 16 8 24 16 24 40 8 8 24 16 16 32 8 40 48 8

………………..……………………………………………………………………………………………………………………………………..

Ini ated SV protocol

GOOD

GOOD

………………..……………………………………………………………………………………………………………………………………..

Compliance with Process Measures

“In God we trust, all others bring data”W. Edwards Deming

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To increase compliance with medical

management of single ventricle patients during their first

procedure from 0% to 75% by December

2014

Specific Aim

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………………..……………………………………………………………………………………………………………………………………..

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HLHS Hospital LOSFirst Year of Life

Length of Stay 47%

Hospital Charges 27%

Year # of Patients Average Median (IQR)2012 6 117.8 88 (31‐293)2013 6 76.5 67 (39‐132)2014 9 52.6 47 (43‐79)

Hospital LOS

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Inpatient Cardiology

Newborns with Critical Congenital Heart Disease

Single Ventricle

HLHS

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Inpatient Cardiology

•Journey Board Compliance

•Feeding Protocol Compliance

•Parent/caregiver Rooming in•Reduce InterstageReadmissions

•Medical management Stage 1•Medical Management Stage 2•Neurodevelopmental Assessment

•Stage 2 Anticoagulation Protocol

Newborns with Critical Congenital Heart Disease

Single Ventricle

HLHS



Neonatology‐ BPD





March, 2015

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Decreasing Total Hospital Days for Epilepsy Patients

Anup Patel, M.D.Assistant Professor Neurology and PediatricsAssociate Medical Director Partners for Kids

NCH QI epilepsy team

Anup Patel, MDDebbie Terry, CNPJayne Pacheco‐Phillips, MSWJacy Sale, MSWKathy Moellman, RN, MSNChristina Waibel, RN, BSN

Daniel M. Cohen, MDJustin Cole, PharmDEric Wood, IE, MBAKatie Van HornPeter Robinson, MS IVChristopher Allen

March, 2015

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2014 Neurology QI InitiativesPATIENT & FAMILY MEDICAL CARE JOURNEY

ED and unplanned hospitalization reduction (sustain)

Do Not Harm MeHeal MeCure Me


Navigate my CareAccess ‐ Flow

Keep Us Well

Inpatient DC order time

Neurology 7‐day readmissions

Clinic wait time: new patients

Chart closure time

Reduce ADEs to zero by 2013 and sustain

Reduce PU to zero by end 2013 ‐ sustain

Status epilepticus: ED initiative

Reduce total hospital days: epilepsy

Inpatient DC order time (sustain)

8 y/o girl with epilepsy that started in 2006

ED 4 times in one year2 of those hospitalizations

Brianna

• Developed depression

• Missed a lot of school

• Family missed many appointments

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Uncontrolled patients: $10,000/year

Controlled patients: $2,000/year

Costs not included: special ed., lost work, school, transportation, etc.

US statistics: 2.3 million patients with epilepsy cost $12.5 billion

Manjunath R, Paradis PE, Parise H, Lafeuille MH, Bowers B, Duh MS, et al. Burden of

uncontrolled epilepsy in patients requiring an emergency room visit or hospitalization.

Neurology 2012;79:1908–16.

Yoon D, Frick KD, Carr DA, Austin JK. Economic impact of epilepsy in the

United States. Epilepsia 2009;50:2186–91.

Cost of epilepsy

Poor seizure control is very costly Disproportionate amount of overall costs

Only 30 % of cost is medications

Majority of cost = ED visits and hospitalizations

Opportunity for improvement

Pallin DJ, Goldstein JN, Moussally JS, Pelletier AJ, Green AR, Camargo Jr CA. Seizure

visits in US emergency departments: epidemiology and potential disparities in

care. Int J Emerg Med 2008;1:97–105.

Cost of epilepsy

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Cost to family

Lost hours from work and school

Increase risk of infection from hospital

Family disruption

Kids can stay sick in the hospital

Loss of normalcy in life

Epilepsy Cure Me

Reduce total hospital days per month for patients with epilepsy seen at NCH on H10B from 34.5 to 27.6 (20%) total hospital days on average per month by 12/31/15 and sustain for 1 year

Reduce total hospital days per month for patients with epilepsy seen at NCH on H10B from 34.5 to 27.6 (20%) total hospital days on average per month by 12/31/15 and sustain for 1 year

Increase in patient seizures

Patient and family co-morbidities and beliefs

Access and necessary resources for families and staff

Need to enhance education between providers and families

p

Develop system with ED to reduce admissions for patients that can be seen as outpt.

Decrease ED visits for patients with epilepsy from 53.1 to 42.5 (20%) visits per month by 12/31/14 and sustain for 2 years

Decrease ED visits for patients with epilepsy from 53.1 to 42.5 (20%) visits per month by 12/31/14 and sustain for 2 years

Decrease # of unplanned hospitalizations for epilepsy patients on H10B from 21.3 to 14.9 (30%) cases per month by 06/30/15 and sustain for 1 year

Decrease # of unplanned hospitalizations for epilepsy patients on H10B from 21.3 to 14.9 (30%) cases per month by 06/30/15 and sustain for 1 year

Med Related – due to side effects of medication

System and communication issues with care within Neurology

System and communication issues with care outside of Neurology

Reduce LOS for inpatients receiving ACTH treatment with infantile spasms from 5.2days to 4.2 (20%) days by12/31/14 and

sustain for2 years

Reduce LOS for inpatients receiving ACTH treatment with infantile spasms from 5.2days to 4.2 (20%) days by12/31/14 and

sustain for2 years

Investigate/standardize protocols for EMS pre-hospital treatment for seizuresDevelop Epic tx dosing guide & alert to ensure proper dosing of tx & have PharmD monitor compliance

Identify high risk patients for ED visits/hospitalizations and assign social services to assist

Implement care management checklist for high risk pts with use of care manager

Improve process of IS treatment delivery with home supply & use of bridge medication

Improve parents & provider ability to assess urgent neurology care as outpt.

Develop standardized work-up & tx algorithm for infantile spasms

Design Changes or Interventions (How)

Key Drivers (Contributing Factors)

Specific AimDevelop a Seizure Action Plan for epilepsy patients that is simplistic

Work up and treatment algorithm Enroll complex epilepsy patients

into medication trial

Develop data analysis tool qlikview for established epilepsy population

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Data analysis tool for entire epilepsy population

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Epilepsy Cure Me – ED visits

System and communication issues with care outside of Neurology

Develop and implement Seizure Action Plan for Epilepsy patients that is simplistic

Improve parents & provider ability to access urgent Neurology care as outpatient or ED consultation

Decrease ED visits for patients with epilepsy from 53.1 to 37.2 (30%) visits per month by 06/30/14 and sustain for 1.5 years

Specific Aim

Key Drivers (Contributing Factors)

Design Changes or Interventions (How)

System and communication issues with care within Neurology

Lack of access and necessary resources for families and staff

Patient and family co-morbidities and beliefs

Need to enhance education between providers and families

Investigate/standardize pre-hospital treatment of seizures and communication of EMS with Neuro

Develop Epic tx dosing guide & alert to ensure proper dosing of tx and have PharmD monitor compliance

Identify high risk and rising risk patients for ED visits / hospitalizations and assign social services to assist

Implement care management checklist for high risk patients

Enroll complex epilepsy patients into medication trial

Magnets for use of abortive medicines in families homes

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Epilepsy Decision Tree for Disposition from the ED

Discharge (Routine F/U)

Brief/few self-resolved seizuresReturn to baseline ~4 hours from rx

Seizures resolved with 1 or 2 doses of anti-seizure treatment

*Including: benzodiazepines, VNS magnet, fosphenytoin or other

Patient/Caregiver comfortable with Neurology , ED/UC seizure action plan

Caregiver prefers home observation for seizure care

Discharge (Epilepsy Urgent Care)

Caregiver:--Change --High anxiety--Education for seizure action plan, including reason(s) for ED/UC visit

Compliance/Recidivism:1. >= 2 ED/UC visits

within 30 days for seizures

2. No show appointments

3. Non-adherence to anti-seizure therapy

4. No current neurology provider

Patient sent by: school, outside facility, specialist or PCP for seizures

Significant intracurrent illness

(Consider admission to Hospital Pediatrics/PICU)

ADMIT

Ongoing significant epileptic seizures

*Red flag: prior ICU

Not at baseline in ~4 h hours

Need for seizure mapping by LTM for surgery or spell characterization

Ongoing status epilepticus; suspicion for subclinical SE; new infantile spasms

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Epilepsy Cure Me Next Steps

• Continued partnership, communication and liaison with NCH ED

• Continued work with Columbus Fire to increase % of patients receiving optimal pre-hospital tx of abortive sz medications

• Predictive Modeling

• Identify rising and high risk population*

• Applying care coordination checklist*

• Expand use of seizure action plan

* supported by a research grant from the Pediatric Epilepsy Research Foundation (PERF)

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Neonatology‐ BPD





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Goal-Increase the Rate of Remission Symptom free and no complications

ImproveCareNow

Pediatric IBD QI Collaborative

> 70 centers, goal of increasing remission rates

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Learning Healthcare System

• Patients and providers work together to choose care based on best evidence

• Drive discovery as natural outgrowth of patient care

• Ensure innovation, quality, safety and value

• All in real-time

Electronic Health

Records

Registry Database

Comparative Effectiveness

Research

Registry Applications

Patients and Families

Clinicians

Point of Care

The Learning Engine

Identify Uncertain

Management Practices

Identify New Gaps in Care

Standardize ProcessReduce Variability in

ProcessCustomize Process to

Patient Needs

Patient Outcomes

Copyright 2013 by Christopher B Forrest. For permission to reuse, contact Chris Forrest at [email protected]

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A week in the life of a learning health system….

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Monday- Clinic(and Tuesday, and Wednesday…)

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Electronic Health

Records


Clinicians

Point of Care

The Learning Engine


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Tuesday- Data Uploads

Historically: Data Recorded Three Times

Encounter Abstraction Data Entry

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Data Capture at Encounter

“Research Grade Data”

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“Data-in-Once”

Structured data is extracted from the EHR

Structured data is extracted from the EHR

AnalysisEncounterReporting

Electronic Health

Records


Clinicians

Point of Care

The Learning Engine


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Electronic Health

Records

Registry Database


Clinicians

Point of Care

The Learning Engine


Wednesday-Download Reports

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March, 2015

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Exceptions Report

Enhancing Data Quality

Drill Down Capabilities

March, 2015

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March, 2015

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Electronic Health

Records

Registry Database


Clinicians

Point of Care

The Learning Engine


Electronic Health

Records

Registry Database



Clinicians

Point of Care

The Learning Engine



Patient Needs

Patient Outcomes


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Thursday-QI Meetings

QI and PM Meetings

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Electronic Health

Records

Registry Database



Clinicians

Point of Care

The Learning Engine



Patient Needs

Patient Outcomes


Electronic Health

Records

Registry Database



Clinicians

Point of Care

The Learning Engine

Identify Uncertain





Patient Needs

Patient Outcomes


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Friday (PVP and Research)

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March, 2015

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REACH Replication

Determine whether real-world data from the ICN registry database can be used to estimate treatment effects comparable to efficacy estimates produced by the the REACH study (Hyams, 2007)

REACH = Efficacy Estimate

ICN = Effectiveness Estimate

Using data for research as well as QI: Simulated trial

Outcomes ImproveCareNow n=96; REACH n=112

NS

NS

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Electronic Health

Records

Registry Database



Clinicians

Point of Care

The Learning Engine

Identify Uncertain





Patient Needs

Patient Outcomes


Electronic Health

Records

Registry Database

Comparative Effectiveness

Research



Clinicians

Point of Care

The Learning Engine

Identify Uncertain





Patient Needs

Patient Outcomes


March, 2015

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Electronic Health

Records


Clinicians

Point of Care

The Learning Engine


March, 2015

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86%86%

Nationwide Children’s Remission Rate

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Cure Me: A Systematic Approach to Transforming Clinical Outcomes

Presentations

www.childrenshospitals.org

Presenter Contact InformationWallace Crandall, MD

Nationwide Children’s Hospital

[email protected]

Documents

quality15 Cure Me-A Systematic Approach to Transforming ... · PDF fileDevelop criteria for when to initiate NGT feeding and/or GT Key Drivers ... Create feeding checklist to be completed