Date Submitted: 2011-07-26

Actions required:
- Revise and update pneumococcal and influenza vaccination guidelines and standing vaccination orders
- Improve documentation by updating EMR system to include a drop down list and details list of contraindications and requirements to alert clinicians to potential vaccination candidates
- Continue Core Measure bi-monthly educational sessions to improve nursing staff knowledge and awareness
- Provide Core Measure Quick Reference Guide Cards to all staff


Timeframe for completion:
Revisions to standing orders to be completed by August 2011.

Responsible parties:
Pneumonia Physician Champions, Quality Management, Nursing Leadership, IT

Support / Resources:
Administration, Quality Department, Physician Services, Nursing Services

Evaluation of Our Progress:
Examine vaccination scores generated from vendor core measure outcome reports to identify improvement trends. Monthly reports are disseminated to Service Line, Quality Review and Performance Improvement Committees to highlight progress on vaccination metrics and identify performance improvement opportunities.

 

Date Submitted: 2011-08-20

Actions required:
Abx cessation 24 hrs and Abx selection-Order sets previously hardcopy were designed and implemented to new system. Education hours were given to both nursing and physicians for use of electronic order sets.
Pharmacy EMR set to deselect abx after two q8hr doses or three q6hr doses of abx and physicians wishing to continue abx must reorder them.
Currently physician compliance using electronic orders is voluntary.
Electronic order set must be created to check off psuedomonas risks Q211 physcians will return to hardcopy PN order sets until this order set can be created to allow easy documentation. Then education of new order set will occur.
Physicians out of compliance have their cases taken through executive session meetings, where the physician must explain reason for his variance from guidelines.
Implementation and education on new EXIT CARE program for nursing.
Physicians and nursing are trended on variances and policy was made in Q210 that disciplinary action may be taken if a nurse or physician show a trend of noncompliance
Participation on monthly basis with Mission;Lifeline on several subcommittees to help AHA improve the regions overall rates. STEMI analysis meeting held after every STEMI. Liason from EMS by invitation participates in these meetings. Tours of cath lab and outcome information sharing with EMS crews to foster cooperation for patient benefits.


Timeframe for completion:
Electronic SCIP order sets were set up and in place beginning Q211 along with MD education when the rates were noted to dip slightly.
Order sets for PN in creation with their implementation and MD education end of Q311 will be planned to evaluate process in time for fall PN season.
IT consult regarding EXIT CARE program completed Q211

Responsible parties:
Pharmacy, Physicians, Unit clerks, nursing will use order sets.
Quality will monitor use during Q211 and analyse results Q311.
IT to maintain electronic systems.

Support / Resources:
Above parties plus education nurse to teach as well as 'defined SUPERUSERS' of new system.

Evaluation of Our Progress:
Data is reported to the medical staff on quarterly basis. Rate reports are broken down to be physician specific as well as the core measure rate that goes out to HHS.gov
Small volume hospital must set goal @ 100% as one miss can pull our rate to less than the medicare compliance rate.
The progress while reported quarterly is analysed biweekly to catch errors or offenders of the new system as well as daily concurrent review to invoke immediate correction and direction of care for our patients.
Re-education using the new EXIT CARE discharge program was required r/t the nurses ability to tailor the program to the patient they would cut education that was required. While we want the nurses to have this ability we are consulting with IT on how to disable the ability to cut required guidelined patient education.
Reinstruction for nursing r/t CHF patient education has been given monthly during nursing sessions

 

Date Submitted: 2011-09-29

Actions required:
AMI Goals: Implemented "Chest Pain" certification program. Secured a Coordinator to oversee.
HF Goals: Seeing evidence that process implemented is achieving desired results
PN Goals: PI Staff rounding in September to inc awareness of Flu Vacc season; had huge employee campaign which will also inc awareness; ABx Selection: Info sent to physicians, post in lounge, put in newsletter;
SCIP Goals: PACU champion established, visits each unit every day and assesses every foley; VTE - Protocol developed, trends of non-compliance referred to VPMS
30 Day Rates - working with local NH facilities of action items
Increasing # of indicators in physican credentialling OPPE
Created a Recognition program called API PRO for physicains, nurses/staff, and departments that promote the Core Measures. Pictures posted around facility
Implementing our EMR in October; Upgrading LVN position in PI department to RN to increase ability to dialog with physicans.

Timeframe for completion:
CP Center Designation: Sept 2011
Increasing OPPE indicators October 2011
API PRO monthly/ongoing
Foley monitoring daily/ongoing
Rounding - daily/ongoing
EMR - go live date Oct 25th
Upgrade LVN position October 2011


Responsible parties:
PI Staff, ED Staff, Nurse Managers/Directors, VPMS, CNO, VP of Quality, Some Physican Contracts will include accountability for compliance
CSI committee has oversight of the entire process for the organization. This is led by the Director of PI and VP of Quality.

Support / Resources:
Support from CEO and Administrative Staff, Core Measure Success is tied to Evalualtions at the Director level and up as well as Nurse Managers. Others on an individual basis. Also monetary incentives. Cardiologists and others got on board when able to increase revenue in office based on scores.

Evaluation of Our Progress:
Achieved 100% on HF discharge instructions for 1st time ever June 2011. (We were 17% in 2006!)
Named 'top performer' by Premier QUEST Collaborative several quarters in a row. Recieved an award at the June 2011 National Meeting for our accomplishments.

 

Date Submitted: 2011-10-05

Actions required:
We are working one on one with our physicians and educating them about selecting the proper antibiotic.

Timeframe for completion:
Q3 2011

Responsible parties:
PI Coordinator for SCIP
Chief Medical Officer

Support / Resources:
QM Dept.

Evaluation of Our Progress:
Reports of our core measures weekly from UHC

 

Date Submitted: 2011-10-17

Actions required:
PHYSICIAN OUTLIER INTERVENTIONS
• Accountability via progressive discipline plan starting with November outliers. The first outlier will result in an educational letter to the provider; a second outlier will result in a phone call from a medical staff or administrative leader, the third outlier will result in an invitation to the Medical Staff Quality Committee for discussion. TIMEFRAME: Complete / in place now and on-going monthly
• An educational core measure brochure has been developed and placed in all of the Physician Lounges’.
TIMEFRAME: Complete / in place now
• At the March Medical Executive Committee meeting, the group approved the Best Care Committee recommendation to begin posting the physician outlier names in the Physician’s Lounge.
TIMEFRAME: Complete / in place now and on-going monthly
NURSING OUTLIER INTERVENTIONS
• Roll out of real-time core measure check sheets has taken place among all of the inpatient nursing units for concurrent reviews
TIMEFRAME: Complete / in place now in all nursing areas
• On-going audits and spot checks regarding appropriate use of the core measure check sheets is on going with results being e-mailed to the appropriate nurse manager, nurse director and HCID for follow-up.
TIMEFRAME: In place now and on-going weekly
• Nurse Managers will continue to receive regular communications regarding outliers identified / abstracted that took place on their unit with the expectation that they will complete a drill down analysis and bring that information to a weekly core measure meeting (every Tuesday)
TIMEFRAME: In place now and on-going daily
• Summary report of the drill down information reported at the weekly core measure meeting will be consolidated into a report card that the nursing directors or HCID will use to report outliers, root causes and process corrections at the weekly 1:00 Director Productivity Meeting (core measures will be reported every Tuesday).
TIMEFRAME: In place now and on-going weekly
• HCI worked with Access Services in accurately entering the patients’ admitting diagnosis into Meditech to facilitate improved accuracy in the daily core measure report sent out by HCI.
TIMEFRAME: Complete

PHARMACY INTERVENTIONS
• Pharmacy has worked with nursing to improve the accuracy of identifying newly admitted AMI, CHF and PNE core measure patients in the Meditech Admission History module. This report is generated every morning and refreshed each afternoon for pharmacy review. Newly admitted PNE patients will be reviewed by pharmacy for the appropriate abx selection for core measure compliance. AMI and CHF patients will have their existing medications reviewed for the presence of ASA, BB, ACE/ARB and STATIN. A progress note to the physician will be left in the record if a medication is missing, prompting their documentation of a contraindication or reminder to order.
TIMEFRAME: In place now and on-going daily.
• Pharmacy now identifies all SCIP patients for review of abx discontinuation and VTE orders.
• TIMEFRAME: In place now and on-going.
• Pharmacy has incorporated core measure compliance goals into all pharmacists’ annual performance evaluation process.
TIMEFRAME: In place now and on-going annually


Timeframe for completion:
Noted with each action above

Responsible parties:
Monthly oversight / management is conducted through the local Best Care Committee, which reports to the Medical Executive Committee.

Ongoing compliance efforts are the responsibility of the Charge Nurses on the floor, the Nurse Manager, Nurse Director, HCI Director, COO/CMO, Pharmacy Manager and Pharmacy Director.

Support / Resources:
Same as above.

Evaluation of Our Progress:
Evaluation of our processes is taking place via daily House Supervisor core measure audits with findings for follow-up communicated each morning.

 

Date Submitted: 2011-10-17

Actions required:
monthly multidisciplinary meetings to evaluate compliance duringthe previous month, focusing on areas of noncompliance and real time intervention where there are opportunities to improve

Timeframe for completion:
by 3q, 2011

Responsible parties:
Healthcare Improvement Director, Physician champions, RPh and nursing leadership

Support / Resources:
as noted above

Evaluation of Our Progress:
Monthly systems data review for internal benchmarking and hospital compare or other external sources for external benchmark comparisons

 

Date Submitted: 2011-10-17

Actions required:
AMI - Area of Focus: ACEI or ARB for LVSD.
Educated new physicians on documentation requirements. Ongoing

HF - Area of Focus: Discharge Instructions. Standardized Form
Educated staff on appropriate verbiage for follow up visits.

PH - Area of Focus: Initial antibiotic selection for CAP in immunocompetent patients.
Use Order Set.
Changed process to concurrent review; pharmacy checks on admission to ICU and discussed at rounding.

SCIP - Area of Focus:
Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision
Action: Reeducation of clinical staff including physicians. Three phases-
1 Anesthesia Time Out (physician leads)
2 Time out immediately prior to incision (physician leads)
3 Time out before leaving OR
(Circulator leads)













Timeframe for completion:
AMI, HF, PN, SCIP
All the CM's listed above: Initiated 7/2011

Responsible parties:
HealthCare Improvement Director for all the above Core Measures listed

Support / Resources:
Executive leadership is 100% supportive of changes for all of the above PIP for CM's listed

Evaluation of Our Progress:
Leading Indicator: Monitoring compliance daily thru Concurrent Review. Lagging Indicator: Compare to hospital and CMS Nat’l rates

 

Date Submitted: 2011-10-17

Actions required:
AMI- Actions have been to maintain gains and to monitor daily use of order sets for standardized care and compliance

HF - Actions have been to maintain gains and to monitor daily use of order sets for standardized care and compliance

PN - Daily monitoring of order sets has not been enough to ensure compliance. Concurrent reviews are now being implemented for all admitted patients to review for medications and vaccine administration.

SCIP - Concurrent reviews are being implemented to help facilitate compliance with antibiotic selection, timing and discontinuation.



Timeframe for completion:
For All core measues - By Dec 1, 2011 goal is to have 100% concurrent monitoring in place

Responsible parties:
Nursing and Health Care Improvement Directors and coordinators

Support / Resources:
Physician support and accountability, nursing support and HCI auditing/education

Evaluation of Our Progress:
Monthly reporting and comparison

 

Date Submitted: 2011-10-17

Actions required:
concurrent monitoring for all CM's listed above.

SCIP - Reinforce with OR staff need to verify antibiotic selection and timing during the surgical time out process. Continue concurrent review and intervention when variances identified. Academic detailing for involved MD and RN. Monthly multidisciplinary meetings to evaluate SCIP compliance during the previous month, focusing on opportunities for improvement.

HF - Concurrent monitoring by HCI with intervention when applicable.

AMI - Academic detailing for discharging MD. Concurrent monitoring by HCI with intervention when applicable.

PN - 1.) Concurrent monitoring by HCI with intervention when applicable. If vaccination status unknown on admission, SDMO will remain on the front of the chart to be completed by the next shift. Charge nurse to verify status during 24 hour chart check.
2.) Academic detailing for involved MD. Case referred to pneumonia team meeting or process review.


Timeframe for completion:
100% compliance with all-or-none bundle by 3rd Q 2011 for SCIP, HF, AMI and PN

Responsible parties:
Nursing, Healthcare Improvement director and coordinators

Support / Resources:
Physician and administrative support

Evaluation of Our Progress:
Monthly data for internal benchmarking and external data for benchmarking peer hospitals of like size and kind

 

Date Submitted: 2011-10-17

Actions required:
AMI: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. Identify trends and action plans related to any identified trends. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail
HF: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. Identify trends and action plans related to any identified trends. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail
PN: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. Task force developed to improve compliance with influenza and pneumococcal vaccines. Multiple hard wire processes have been implemented including a daily report of eligible patients with f/u from charge nurse and house supervisor. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail
SCIP: Continue monthly reporting at hospital best care, staff meetings, MEC and Board of managers. Include transparency with opportunities for improvement. Display outcomes presentation in staff lounges. Provide monthly newsletter including “Core Measure” updates. A task force was developed to improve all areas where there are opportunities to improve. Provide notification to physicians and staff when an OFI occurs. This process is through email and USPS certified mail




Timeframe for completion:
Concurrently and ongoing




Responsible parties:
Responsible Parties – HCI, Supervisors, clinical staff, house supervisors, ACNP,, pneumococcal/influenza task force, pharmacy, task force was developed to improve all areas where there are opportunities to improve.

Support / Resources:
Leadership

Evaluation of Our Progress:
Evaluations of these processes begin with staff, hospital best care, medical executive committee and the board of managers. Our results are also reviewed by the healthcare system best care and the healthcare system board of managers.

 

Date Submitted: 2011-10-24

Actions required:
AMI2, AMI5 & AMI10
Details of occurrences discussed in Department of Cardiovascular Services Committee, bi-monthly


HF - N/A

PN -
Continue concurrent audits by HCI
Education of new SDMO planned for all units
Education of new changes to include SDMO as part of the CPP planned for all units


SCIP -
Continue concurrent audits by HCI POD1 & 2 with daily email from HCI to nursing, pharmacy and surgery on each surgery patient

Physician SCIP Manual available on each unit and in surgery department

Appropriate antibiotic selections listed on Antimicrobial Prophylaxis for Surgery Order Set and available in every surgery patient chart

Physician education letter sent regarding antibiotic selection. Nursing education letters sent regarding documentation of antibiotic administration and requirements of foley removal

Poster and oral presentation In-service on SCIP requirements regarding foley removal to all nursing units, including night and weekend shifts completed.


All -
Core Measures education provided by HCI for all new nurse hires, weekly
Educational letters sent to involved Physicians and Nursing for each OFI identified with details and improvement suggestions
Details of occurrences discussed in Hospital Quality Committee, monthly
Individual counseling with bedside leaders involved in OFIs by Unit Manager




Timeframe for completion:
AMI - N/A

HF - NA

PN - concurrent audits with goal of 100% by 1q, 2012

SCIP - concurrent audits with goal of 100% by 1q, 2012

All - Ongoing for all

Responsible parties:
AMI - N/A

HF - NA

PN - Team Leads

SCIP - Team Leads

All - HCI, Physicians, Nursing and Pharmacy, Task Force Teams

Support / Resources:
AMI - Physician Champion, Nursing Champion, Unit Managers, and Cardiac Nurse Practitioner

HF - Physician Champion, Nursing Champion, Unit Managers, and Cardiac Nurse Practitioner

PN - Physician Champion, Nursing Champion, pharmacy, Unit Managers, Supervisors, Acute and Critical Care Directors

SCIP - Physician Champion, Nursing Champion (surgery director), pharmacy, Unit Managers and Supervisors

All - Physician and Nurse Champions, Unit Managers, and Cardiac Nurse Practitioner

Evaluation of Our Progress:
AMI - Department of Cardiovascular Services and Hospital, bi-monthly and Quality/Best Care Committee using Midas reports and data

HF - Department of Cardiovascular Services and Hospital, bi-monthly and Quality/Best Care Committee using Midas reports and data

PN - Physician Champion and Nursing Champion

SCIP - SCIP Committee Meeting, monthly and Hospital Quality/Best Care Committee using Midas reports and data

All - Hospital Quality/Best Care Committee using Midas reports and data

 

Date Submitted: 2011-10-24

Actions required:
SCIP -
Interventions: Recovery unit (PACU) placing an Anesthesia End Time Sticker on post-op order sets so that pharmacy can better time medications. Also a process for stickers on the front of the charts for surgical patients that serve as a visual cue for completing interventions in a timely manner.HF -
AIM: Achieve 95% or greater compliance with all HF measures by June 30, 2011.

AMI - Interventions: Continue to monitor performance.


HF - Interventions: Implementation of a Heart Failure checklist sticker that is placed on the front of the patient’s chart. This serves as a reminder for both physicians and nursing. Also, stressing importance of Physician Discharge Summary reconciliation with the patient’s Medication List at time of discharge through hospitalist emails and during new physician orientation.

PM - Interventions: Charge Nurses follow a process for identifying pneumonia patients in the Emergency department, and determining that all areas of importance have been addressed prior to the patient transferring to the floor. This is accomplished with a thorough handoff communication between units. Also, the House supervisors have a checklist that is completed every shift as well.


Timeframe for completion:
See Above

Ongoing for all

Responsible parties:
for All

Team Leads, HCI, Physician champions, Nursing champions

Support / Resources:
Physician champions, HCI

Evaluation of Our Progress:
Midas reports
Hospital Compare and other public benchmarking

 

Date Submitted: 2011-10-25

Actions required:
AMI -
Issue to Hospitalist group – education regarding consistency of dictating discharge summary along with the Medication Reconciliation form to prevent inconsistencies between the two.
All opportunities for improvement are taken to Physician Peer Review for review and discussion by the committee and education of the individual physician.

HF - Continue monthly meetings with Hospitalists, Physician Champion and HCI department. Physicians in both Hospitalist groups agreed to meet with nursing prior to discharge and review the Medication Reconciliation form for accuracy. Physicians agreed to dictate discharge summary (medications pt. is going home on) with Medication Reconciliation form to ensure both are accurate.
There has been improvement in compliance – continue the momentum.
ACEI or ARB for LVSD. Have met target for this quarter but does not appear to be hard wired. Continue to take do Peer Review for discussion and education of Physicians


PN - Opportunities revolve around 1 – 2 patients - ED evaluating each case for areas presenting delays. Identified an issue with delay in timing of radiology reporting back to ED. Working with both areas to decrease that time.
Standing Delegated order for both Influenza and Pneumovac Education as to documentation required if pt. is not a candidate for vaccine.
Epidemiologist follows up with each physician not using appropriate combination of antibiotics. Pneumonia order set changed to reflect TJC antibiotic combinations recommended.
Unit based educators working with staff to educate new global SDMO - standing delegated medical order.


SCIP - Postop serum glucose: Modified insulin infusion protocol in OR and
Order set modified – change from regular insulin to humulog . Recommendation to Thoracic/Cardiovascular department to consult the new Diabetologist early (pre-op) in potentially difficult patients. Insulin infusion used for the first 24 hours post op along with insulin sliding scale

Stamp developed to remind Physician of the need to remove Urinary Catheter by POD 2 or give reason catheter needs to remain.
Hand-off Process developed between surg ical ICU and receiving floor – basically check off list to ensure catheter removal. Nursing staff following –up with communication flow sheet from ICU to floor to remind receiving floor to remove catheter by POD #2 if still remains on transfer.



Timeframe for completion:
AMI - By end 3rd quarter 2011

HF - By end of 2nd quarter – met target but will continue with previous efforts to ensure hard wiring

PN - Increased compliance but continue to have opportunities for maximizing goal

SCIP - Results continue to present opportunities to improve.


Responsible parties:
AMI - Physicians, AMI team

HF - Accountability physicians and nursing staff

PN - Physicians, Nurses, Pharmacy input.

SCIP - Accountability Physicians, Nursing staff


Support / Resources:
AMI - Strong Admin support - Chiefs of Cardiology and Internal Medicine Physician and Physician Champions

HF - Strong Administrative, Physician Champion, Best Care Council and Nursing support.

PN - Strong Administrative, Physician Champion, Best Care Council and Nursing support.

SCIP - Administrative support, Physician and nurse managers


Evaluation of Our Progress:
AMI - All or None bundle had been 97% end of Year 2010 – Statin had been 100% - Reeducation of Cardiologists, Internal Med MD’s and Nurses

HF - Progress is evaluated monthly at BUMC Best Care Council. (multidisciplinary council) Strategies for improving process discussed and accountability assigned.

PN - Progress is evaluated monthly at BUMC Best Care Council. (multidisciplinary council) Strategies for improving process discussed and accountability assigned.
Nurse managers where appropriate invited to Best Care to discuss action plans for unit.


SCIP - Progress is evaluated monthly at BUMC Best Care Council. (multidisciplinary council) Strategies for improving process discussed and accountability assigned.

 

Date Submitted: 2011-10-26

Actions required:
For all of our Core Measures, we implemented a new corporate wide initiative. Starting in July, as our 2Q 2011 data was made available, corporate instituted a new process to help us begin hardwiring our processes for consistent and successful results. We have corporate wide monthly phone calls with 22+ other acute care facilities where each hospital has time to discuss struggles and share successes. This helps provide best practices and collaboration development of practices for increased chance of success when implemented. We are now measuring our progress through rapid cycle improvement, implementing “test changes” weekly. Our hospital wide teams were all reevaluated and reconstructed to make sure all of the necessary areas were represented for effectiveness. We are in the process of developing standardized order sets for each of our core measures, to be implemented within the next quarter. Our intent is that these order sets and the weekly test changes will provide the needed hardwiring for consistency, trying to eliminate the element of human error.

Timeframe for completion:
Due to our reorganization, we are now measuring our progress on a weekly basis through rapid cycle improvement helping to monitor our target completion dates for weekly “test changes.”

Responsible parties:
The Core Measure Coordinator/Nurse will oversee the re-evaluation of the processes on a monthly basis and report any issues to the Director of Quality and the CEO. Our Core Measure Teams meet monthly and the members responsible for implementing the weekly test changes communicate daily as needed. Additional team leader oversight of weekly initiatives have been added as content experts to help drive process changes and ensure hardwiring of processes.

Support / Resources:
-Core Measure Team members/content experts
-Director of Quality
-CEO, COO, CMO, and CNO are very active and provide support and feedback
-Directors for units are very engaged with Core Measures.
-As of 2Q 2011, we are restructuring our Patient Advisory Council and developing a Hospital Performance Improvement Committee. This committee will be the oversight to ensure progress in our Core Measures, HCAHPS, Infection Control, Regulatory and Accreditation initiatives.
-Medical Executive Committee provides a team of physician champions willing to meet with physician outliers to devise appropriate action plans for improvement. The physician peer review process has an accountability structure for physicians with Core Measure compliance issues.
-Board of Governors is provided a monthly report with our struggles and successes for their involvement, leadership oversight and support.
-Corporate Quality Department



Evaluation of Our Progress:
We are now focusing on data on a weekly, concurrent basis rather than monthly or quarterly to impact the trends sooner, rather than later. NWTHS has seen a positive culture shift related to Core Measures that is evident in the increased compliance with practices and accountability.

 

Date Submitted: 2011-10-26

Actions required:
Training staff and identify non compliant staff for 1 on 1 training.

Talk/ re-educate medical staff about blood cultures


Timeframe for completion:
We strive for accuracy next quarter

Responsible parties:
Nursing administration

Support / Resources:
Medical staff and nursing administration

Evaluation of Our Progress:
Not at 100% compliance. will strive to reach that goal.

 

Date Submitted: 2011-11-01

Actions required:
Concurrent Progression of Care Rounding on each unit began in April/May of this year, this activity remains our focus to assure that concurrent charts are being monitored daily and that outstanding action steps are being highlighted to front line staffing as well as physicians. We continue to provide focused efforts in certain areas such as ICU for foley removal; SCIP committee to implement new order sets for Orthopedic and Colorectal surgeries regarding best practice for antibiotic start and stop timing; Emergency department physicians regarding pneumonia measures.

Timeframe for completion:
At this point there is not a completion date, we are ever vigilant in our follow-up and where we need to re-educate to improve.

Responsible parties:
We maintain that all levels of care share the resposibility. If nursing, techs, physicians are not following up on the chart notations provided to them to complete or document a reason for a measure not being met, this information if forwarded up the chain of command for corrective action.

Support / Resources:
We have support from administration, shared governance, nursing leadership, and physician champions. Results are reported monthly to the above committees as well as the medical staff committees so everyone is aware of our current state and where the mishaps fall.

Evaluation of Our Progress:
We are certainly sharing our results with all pertinent committees and levels of staffing within the facility. Benchmarking and comparisons are shared with nursing and physicians alike. Physician specific data is brought to each monthly medical staff committee and made available to the medical staff services office for re-credentialing reports with peer comparisons by specialty. We continue to strive toward our new computer conversion project which is on schedule for early summer 2012. The new system will bring us an EMR and help resolve some of the charting issues that plague our current system.

 

Date Submitted: 2011-11-07

Actions required:
PN 5c - ER staff to identify patients with possible dx of pneumonia and assure the timeliness of antibiotic administration in the ER
PN 6 - ER Evidence Based Order sets include antibiotics for patient with immunocompetent risk to guide the physician in ordering the correct antibiotics
SCIP Inf 1 - It is the responsibiblity of the OR circulator to assure a antibitic is given timely in the OR.
SCIP 3 - CEO and physician advisor in discussion with surgeons related to practive using antibiotics appropriately in patients without evidence of infection.
SCIP Inf 4 - ICU nurse and Cardiothoracic surgeon monitoring blood sugars ongoing to maintain a therapeutic range / control.

Timeframe for completion:
PN 5 C - 3rd Qrt 2011
PN 6 - 3rd Qrt 2011
SCIP Inf 1 - 3rd Qrt 2011
SCIP 3 - 3rd Qrt 2011
SCIP Inf 4 - 3rd Qrt 2011

Responsible parties:
PN 5 - ER Triage, Physician and ER bedside Nurse
PN 6 - ER bedside Nurse, ER Physician, and Pharmacist
SCIP Inf 1 - OR nurse circulator & Anethesia
SCIP 3 - Physician, CEO and Physician Advisor
SCIP inf 4 - ICU bedside Nurse and Cardiovascular Surgeon

Support / Resources:
PN 5 - Administrative Leadership, ER Physician Group, Nurse Leadershipt DON, ER director
PN 6 _ Administrative Leadership, ER Physician Group, Nurse Leadershipt DON, ER director
SCIP Inf 1 - OR Director, DON and Department of Surgery
SCIP 3 - CEO and Physician Advisor, Department of Surgery, Evidence Based Medicine Committee
SCIP inf 4 - ICU director, DON and Cardiac Care Committee

Evaluation of Our Progress:
Data is reviewed ongoing in daily core measure meetings and in the administrative flash report each morning(action occurs at this meeting).Data is covered weekly in the Administrative Operations meeting. Quarterly data is reported at Patient Care Committee, Quality Council, Medical Executive Committee and Board.

 

Date Submitted: 2011-11-08

Actions required:
AMI - Continue to Monitor

HF - 1 pt did not have medications reconciled appropriately. Medication Team re-established to identify potential gaps in the current process. Continue to review requirements and profile data during Hospitalist Meeting.
Added Med. Rec. requirement to Hospitalist Contract performance measures… awaiting approval to implement. Continue to monitor concurrently for compliance.


PN - 1 patient did not receive antibiotic within time requirement. Provided reminder cards for ED physicians that are attached behind name badges to remind them of requirements. Nurses also instructed to Stop the Line to check for antibiotic given if pt is in ED > three hrs. Notify unit nurse of antibiotic administration due time. 1 patient did not get appropriate antibiotic selection due to delay in diagnosis of pneumonia. Continue monitor concurrently for compliance.

SCIP - Opportunities involved 2 patients.
Provided reminder cards for SCIP evidence based care to surgeons that are attached behind name badges to remind them of requirements. Posted list of antibiotics in OR.
One physician was concerned about pt. due to history and poor immune response that he was acting in her best interest to continue antibiotics. Literature provided to this physician. Continue to monitor concurrently for compliance when possible.


Timeframe for completion:
AMI - Ongoing effort to maintain - reevaluate if needed

HF - Completed by 10/31/2011

PN - Completed 10/14/2011

SCIP - Completed 10/14/2011

Responsible parties:
AMI - ED physician champion, hospitalist, ED staff, HCI

HF -
HCI Staff and clinical coaches will provide just in time staff education
Nurses and Social Workers will reconcile medications at discharge when available. HCI will continue to monitor and provide feedback to staff, physicians and Managers.


PN - Emergency Department physician orders the appropriate initial round of ABX utilizing the Transition of Care Order Set. The Hospitalist or other Admitting physician will order the appropriate initial Antibiotic as recommended on the Pneumonia Order Set. The nurse giving report will inform unit nurse of time requirement if antibiotic is not given in ED.

SCIP - Surgeons are responsible for compliance with evidence based practices. HCI distributed SCIP reminder cards for name badges

Support / Resources:
AMI - Physician champion, HCI, Nurse manager, Hospitalists

HF - CNO, Physician Champion, Unit Nurse Managers


PN - HCI, Administration, Physician champions,Nurse Manager, nursing leadership

SCIP - Surgery champion, Nurse manager, HCI Staff

Evaluation of Our Progress:
AMI - Ongoing

HF - Ongoing

PN - 100% since implementation of Order Sets. Review data monthly using Best care Reports to compare with other facilities

SCIP - 100% since implementation of new process and revised form. Review data monthly using Best care Reports to compare with other facilities

 

Date Submitted: 2011-11-10

Actions required:
Hands on work in system, inservices and reminders for nurses and physicians on quality measures

Timeframe for completion:
CPOE September 12 install; other work ongoing

Responsible parties:
Nursing adminstration

Support / Resources:
Admin

Evaluation of Our Progress:
Staff/vendor evaluation of progress on work in system. Cart tools, HQA preview reports on compliance.

 

Date Submitted: 2011-11-14

Actions required:
HF-1 Discharge Instructions - goal to reach 100% compliance

Physician driven electronic discharge med list - piloted once and corrections made to system; now being tested again - plan to have implemented by Jan 1 2012

PN - Immunization Measure - revamp electronic immunization screen - automatically triggers order if vaccine needed - plan to implement by Dec 1 2011
Antibiotic Selection - addressed on computerized protocols

SCIP - Antibiotic stop within 24 hrs - hardstop in electronic system
Catheter removal on POD1 or POD2 - hardstop in electronic system
BetaBlockers for surgical patients - revamped anesthesia record (paper) to include BB and place for contraindication

Readmissions - Improve transitions of care to appropriate level, appropriate transitions to Hospice with earlier referrals to Palliative/Supportive care

Mortality Rate - Coding review for appropriate coding; review appropriateness of care vs Hospice; Implemented full-time Social Worker in ER to assist with appropriate care level for end-of-life patients


Timeframe for completion:
HF- 1 - Discharge instructions - Goal Jan 1, 2012

PN - Dec 1, 2011

SCIP - Dec 1, 2011

Readmissions - ongoing

Mortality Rate - ongoing

Responsible parties:
Performance Improvement Teams, Physician Champions, Nursing, Pharmacy, Medical Management (Case Managers/Social Workers, IT



Support / Resources:
Senior Director of Quality and Safety, Director of Case Management, Nursing Directors/Managers, IT, Business Intelligence, Chief Medical Officer, Physician Champions

Evaluation of Our Progress:
ThomsonReuters Data/Hospital Compare preview reports reviewed with leaders at LDI and staff at staff meetings

VBP reports also reviewed with leaders/staff

 

Date Submitted: 2011-11-14

Actions required:
PNE measures: Letters of non-compliance to staff & Director. It was discovered that staff were profiling Pneumovax as one time medication, which fell to the bottom of the MAR. Pharmacy now profiles for 2 hours after arrival.
HF Measures: Discharge Medications were not matching Discharge Summary medications. Process now in place to have 2 nurses / pharmacists to verify Home Medication Reconciliation is complete at discharge.
SCIP measures: Urinary catheter Removal on POD 1 or 2. Process now in place to stamp the physician's progress notes with daily reminder about Urinary Catheter Daily Line Necessity for documentation that the catheter is still needed and reason why.

Timeframe for completion:
Completed during Qtr 2 2011.
Since that time, all PNE measures have been 100% incl Pneumovax, HF Discharge Instructions have been 100%, all SCIP measures have been 100% incl Urinary Cath removal on POD 1 or 2.

Responsible parties:
Responsible parties are CMO, CNO, Quality Director, Pharmacy Director.

Support / Resources:
CMO & CNO have been instrumental in their support.

Evaluation of Our Progress:
Since the processes above have been implemented, all PNE measures have been 100% incl Pneumovax, HF Discharge Instructions have been 100%, all SCIP measures have been 100% incl Urinary Cath removal on POD 1 or 2.

 

Date Submitted: 2011-11-15

Actions required:
Data collection slipped to retrospective review in the first quarter; then compliance fell. Retrospective review does not allow us to catch missed interventions, and correct it before hte patient goes home. Therefore, we refocused our attention in getting back to concurrent reviews, with the abstractor making daily rounds on the units to ensure all the appopriate care was given and documented. We also made concurrent phone calls to physicians regarding LVF assessments and received better cooperation from them.

Timeframe for completion:
Return to concurrent review started April 1st.

Responsible parties:
THe RN abstractor for heart failure and penumonia.

Support / Resources:
The Vice President of Patient Care Services was supportive in ensuring that the staff responded to the abstractor. The involved nurse would be notified of the intervention needed, if it wasn't done the clinical manager and director would be notified, and there was a third notification, a copy would go to the VP and the mgmt staff would have to respond with an action plan for improving.

Evaluation of Our Progress:
Improvement was noted right away, and our scores went up this quarter. In June, we were 100% compliant with all heart failure and pneumonia measures.

 

Date Submitted: 2011-11-15

Actions required:
Pneumonia:
*Attend the Medical Section meetings to raise awareness regarding patients presenting to the hospital without orders and the need for timely initial antibiotic orders with special focus on hospitalist group.
*Identify Core Measure nurse champion for areas that are high risk for potential outliers.
*Provide positive feedback to areas that are reaching the target.
*Provide Core Measure updates to Core Measure Oversight Team, Patient Care PI Committee, Physician Leadership and the Board.


SCIP:
Streamline our process to use the “out of OR time” as the point of reference to ensure timely discontinuation of prophylactic antibiotics.
*Utilize the kardex as a place to document “out of OR time” and discontinuation time to provide a visual to staff nurse.
*Place green stickers on the kardex to provide a visual during hand-off communication.
*Add notification bar to the patient's profile to serve as a visual reminder on the eMAR system.
*Nurse Champion in each unit serves as a resource on measure criteria for Nursing.


Timeframe for completion:
Pneumonia and SCIP: Begin initiatives June 2011 with timeframe for completion at the end of 3rd Quarter 2011.


Responsible parties:
Pneumonia:
The multidisciplinary team consisted of the following:
 Admitting Department
 Oncology Unit
 Express Admit Unit
 Core Measures PI Coordinator
 Hospitalist Service
 Nursing Supervisor
 Pharmacy Department

SCIP:
The multidisciplinary team consisted of the following:
 Pharmacy
 Surgical Services (OR, PACU)
 Women Services Department (GYN)
 Medical/Surgical Unit
 IT&S


Support / Resources:
CEO, CNO, CMO, and CFO, President of Medical Staff (Overall Core Measure Physician Champion), Medical Director of Core Measures (Hospitalist), VP of Clinical Performance Improvement, Quality Director, PI Supervisor, Pneumonia and SCIP Team, Concurrent Reviewers, Clinical Support Staff Leaders/Directors


CEO meets biweekly to review all Core Measure outliers.

Evaluation of Our Progress:
After implementing the action items for Pneumonia, we have seen an increase in our compliance with the antibiotic administration within 6 hours of hospital arrival indicator. We have increased our percentage from 94.2% in 1Q11 to 95.8% for 2Q11.
We saw a decrease initially in our compliance with the antibiotic discontinued within 24/48 hours from 99.1% for 1Q11 to 96.9% for 2Q11. Once the process changes migrated to key areas, we began to see tremendous improvement. Our preliminary result for 3Q11 is at 100%. Our plan is to maintain our 100% compliance rate for antibiotic discontinuation in 3Q11 with the action items put in place 2Q11. Physician engagement and awareness has increased as well as accountability. We will continue to make accountability a high priority for all levels of our facility. Leadership has been very supportive of all efforts put in place to provide the best quality of care for our patients.

 

Date Submitted: 2011-11-15

Actions required:
Initiative Type: Improve upon existing system
SCIP:
- Mandatory education for nursing staff for SCIP
- VTE Risk Assessment and Order form to be implemented for all admissions
- Post-op order sets will be revised to include a check-list of contraindications for pharmacological VTE prophylaxis for physician reminder / order.
- Daily review of current SCIP core measures on nursing units with nursing staff
- Monthly medical staff meetings for core measure discussion

HF:
- 1:1 nursing education regarding the discharge process
- Daily review of current HF core measures on nursing units with nursing staff
- Monthly medical staff meetings for core measures discussion


Timeframe for completion:
SCIP:
- April 2011: VTE Risk Assessment / Order form implemented as part of admission
process for all patients
- May 2011: Post-op order sets revised to include an area to document a
contraindication to pharmacological VTE prophylaxis
- June 2011: Mandatory nursing education to include SCIP measures

HF:
- May 2011: 1:1 nursing education regarding HF discharge process began,
continues as new employees are hired


Responsible parties:
SCIP:
- Admitting nurse responsible for completion of VTE risk assessment; Physician
responsible for completion of order or documenting contraindication
- Quality Analyst (Concurrent Reviewer) and Pharmacy staff are responsible for revising / updating Post-op order sets as necessary
- Quality Director led mandatory SCIP education
- Quality Analyst (Concurrent Reviewer) responsible for daily education

HF:
- Quality Analyst responsible for ongoing education


Support / Resources:
- Quality Analyst (Concurrent Reviewer)
- Director of Quality
- Physician Champion
- Core measure reference “badge” cards (created June 2011)



Evaluation of Our Progress:
- Improvement noted: we had a total of 10 SCIP failures during the months of April and May. There were no failures in the last month of the quarter.
- There was a significant improvement with HF discharges, scoring 100% for the quarter.

 

Date Submitted: 2011-11-17

Actions required:
Heart Failure Discharge Instructions: Through chart review, it was found that with the system changeover to the Exit Care system for discharge teaching there was a need for more nurse user education and specific facility wide updates to the program. On the user level, education was provided to the nursing staff responsible for discharging patients. This was provided through monthly staff meetings available to all shifts and through training with the IT nurse. The core measure requirements for heart failure discharge teaching were posted at the nurse's station and a macro was created in Exit Care for the nurses to select when printing the discharge teaching material. The IT nurse worked individually with nurses to create user specific details saved into Exit Care that they wanted included in their discharge instructions.

CAP guidelines: The CAP guidelines were reviewed with physicians during Medical Staff meeting. The QI nurse reviewed the recommendations per the specifications manual. Laminated pocket cards with the approved antibiotic regimens were distributed to all physicians and were also placed in the ED and at the doctor's dictation stations. Any charts not meeting CAP guidelines were brought to the attention of the physician Chief of Staff and to the attending physician for the patient. The physicians were then able to review the electronic patient record and collaborate with the QI team.

Antibiotic timing: Patient charts were reviewed and results shared with physicians, ED nurse manager, and Medical-Surgical nurse manager. During Medical Staff meetings physicians were urged to order initial dose of antibiotics for PN while patient is in the ED. The ED nurse manager posted memos for ED staff to request a physician order for antibiotic selection prior to the patient being transferred to the Medical-Surgical floor to reduce the possibility of a delay in antibiotic administration.

Timeframe for completion:
Heart Failure Discharge Instructions: Completion timeframe July 2011. Updates and training with the Exit Care system were completed.

CAP guidelines: Completion timeframe September 2011.

Antibiotic Timing: November 1, 2011. Action was taken immediately when second quarter charts were completed to change the process of starting antibiotics ASAP.

Responsible parties:
Heart Failure Discharge Instructions: Nursing staff providing patient care and discharge teaching were involved in the process. The IT nurse assisted with Exit Care training and program settings. The Nurse Manager began reviewing discharge instructions as part of her departmental QI that is is reported to the QI department for the hospital. This allowed charts to be identified quickly and counseling to be performed with the responsible nurse or practitioner if necessary.

CAP guidelines: The QI staff communicate specifications manual updates to Physicians. The Physicians are responsible for overseeing mid-level practitioners for hospital admission orders.

Antibiotic Timing: Physicians, ED staff, and floor staff were reminded of the goal start times for antibiotics for PN patients.

Support / Resources:
The primary support and resource personnel for accomplishing our target goals are the physician Chief of Staff and nursing administration for the ED and Medical-Surgical units. The QI department reviewing charts notifies the appropriate practioners and provides the information needed to physicians and nursing administration to meet the measures.

Evaluation of Our Progress:
Progress toward these goals is evaluated through reports reflecting current process. Antibiotic timing has improved to 100%, current heart failure discharge instructions have improved to 100% and CAP guideline compliance is currently trending at 100% of charts reviewed since second quarter. The quality processes implemented to specifically target these areas has successfully improved our scoring.

 

Date Submitted: 2011-11-30

Actions required:
1) RN staff education completed. Beta blocker last dose date and time must be documented on the medication reconciliation for complete abstraction.

2) Discussion during MEC meeting for surgeon champion, and anesthesia representative team leader to heighten awareness.



Timeframe for completion:
Education completed July 2011

Responsible parties:
PreOp Mgr, Director of Quality, Anesthesia team, PACU Mgr

Support / Resources:
Medical executive committee, administration

Evaluation of Our Progress:
Improvement already seen during month of August