ISSUE TWO | 2012
Celebrating Quality 2011 DRIVE FOR EXCELLENCE
In This Issue Leading and Community Transparency..................... 1
PHS Quality Plan.....................................................1
Aligning Forces for Quality.....................................2
PHS Goal: Best Clinical Quality..............................2
Reducing Hospital Mortality and Harm..................... 3
Hospital Mortality Reduced by 151 Lives...............3
Patient Safety..........................................................3
Collaborating to Reduce Harm...............................4
Fall Prevention Summit...........................................4
The Power of an Integrated Delivery System........... 5
Patient Centered Medical Home ~ Best Clinical Quality and Care Models...................5
Presbyterian Home Healthcare receives $24,000 recognition..................................5
Community Health..................................................6
Journey to Electronic Health Record ~ Best Clinical Quality and Care Models...................6
Evidence Based Medicine......................................7
Dear Colleagues, Welcome to Celebrating Quality at Presbyterian, which is published annually to highlight achievements driven by the PHS Quality Plan and accomplished by a caring and committed workforce. This is intended to draw your attention to a sampling of the outstanding achievements accomplished on our Quality Journey inspired by our Drive for Excellence. We are especially proud of several of our key performance results and how we stack up to external, national and regional comparisons. Presbyterian Hospital was selected as one of the 65 safest hospitals in America by Leapfrog. Our American Hospital Assocation (AHA) Health System comparison ranking improved 112 spaces in three years, placing us in the top 100 out of 250-300 systems, and Presbyterian Medical Group’s (PMG’s) Patient Centered Medical Home program received NCQA accreditation, validating the effectiveness of this care model. PMG also exceeded national performance on selected ambulatory measures and led New Mexico on others. We have also made progress on the use of quality tools to improve clinical results, evidence based medicine and evidence based care design, all central to our future success. Significant progress has been made in building the infrastructure, notably the implementation of the Ambulatory Electronic Health Record (EHR) and the decision to invest in Epic for all inpatient and emergency departments. As we reflect on our accomplishments of 2011, we continue to be inspired by the level of dedication, skill and compassion each one of you brings to the work of improving the health of those we serve. It is our great privilege to work with you as we continue on this journey, our Drive for Excellence. Thank you. With our appreciation and warmest regards,
Kathleen D. Davis, RN, MBA Sr. Vice President and Chief Nursing Officer
Hoda Asmar, MD, MBA Sr. Vice President and Chief Medical Officer
Leading and Community Transparency PHS Quality Plan | 2010 - 2015
In 2010 we approved and began to deploy the PHS Quality Plan which shares our plan to provide care that is evidence based and effective, relentlessly responsive to individual and collective needs and respectful of customer values and preferences. This 5-year plan serves as a clear roadmap to achieve the goal of Best Clinical Quality. The Quality Plan was the driver behind many of the initiatives and success stories reported in this annual report. The Quality Plan consists of 5 goals that align with and are critical to achieving all three of the PHS goals. Leads and teams have been identified for each goal and annual objectives and implementation plans developed. Guided by the Quality Plan, the Drive for Excellence embodies our spirit and passion to reliably deliver the highest levels of quality care and customer experience at the lowest cost. As an integrated delivery system, Presbyterian is positioned to be a role model for innovation in models of care designed to improve outcomes and lower cost. This Drive uses external feedback to transparently convey performance, clarify and focus on strengths and opportunities. This work is and will continue to be challenging; we know that together, with shared values and goals embodied in the PHS Egg we will achieve success.
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The five goals are: 1. Provide care that is safe, eliminating harm to patients from the care that is intended to help them. 2. Optimize effectiveness of care through the use of standardization, evidence based care, and technology. 3. Improve the health of the customers we serve, leveraging integration to proactively design care models that engage customers and align incentives. 4. Deliver an excellent service experience for every customer, across all of their interactions with Presbyterian. 5. Lower the cost of health care delivery by re-designing care models, maximizing process efficiency and eliminating waste.
CELEBRATING QUALITY 2011 | 1
Aligning Forces for Quality Presbyterian is leading the way for quality efforts and results transparency in New Mexico through its participation in key state and national quality initiatives. Since 2009 Presbyterian has been one of 17 sites nationally to participate in a Robert Wood Johnson Foundation initiative called “Aligning Forces for Quality.” PMG along with First Choice, University of New Mexico and First Nations are leading transparency efforts through publicly reporting provider clinical quality performance data. PMG participates in this program because of our physician’s commitment to provide quality care to patients. It is with great pleasure that we applaud PMG for exceeding the national averages for all of the measures we reported for all three populations studied (Medicare, Medicaid, and Commercial): • Blood pressure control • Breast cancer screening • 5 different diabetes control measures PMG exceeded national averages in other measures for selected populations in the following measures: • Cervical cancer screening • Testing of heart patients for cholesterol
112
We know the quality of care provided is more than a score in a report, and we are pleased that this data is able to identify our strengths, as well as outline those areas in which PMG can improve the care it provides. We will continue to use this report to identify successes and share lessons learned so we can continue to improve the health of the patients, members and communities we serve.
The lower ranking is better with PHS improving 112 places in 3 years.
2008 201 2009 133 2010 89
PHS Goal: Best Clinical Quality Along with 250-310 systems, Presbyterian was ranked on the following dimensions: clinical process measure scores using CMS core measures, patient satisfaction using HCAHPS, risk-adjusted readmission and risk-adjusted 30-day mortality. This transparency and external validation challenges our priorities and pace and has allowed us to say, “YES, we have accelerated clinical quality.” Without question, this represents the great work of the whole system – PHS Boards, providers, staff and leaders.
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Reducing Hospital Mortality and Harm Hospital Mortality Reduced by 151 Lives These results are due to the tremendous efforts of our clinical staff throughout PHS who have applied process improvements to patient care processes, such as: • Emergency department sepsis identification and resuscitation • Adherence to Team Training elements in Surgery and OB/GYN • Aspiration pneumonia prevention in post-surgical patients • Adherence to CMS Core Measure Bundles • Early identification of and rapid response to patient condition changes • Improved End of Life Care planning, placement and use of Palliative and Hospice services Plans are in place in 2012 to reduce mortality to 1.1 percent (the 90th percentile), equating to an additional 68 lives.
IHI Acute Care Inpatient Mortality Rate All Facilities for 1/2007-12/2011 Quarterly Rules Tested
Summary
2.3
2.0
+3 sigma
1.8 1.6 1.5 -3 sigma
1.3
1.0 Q12008
Q22009
Q32010
Q42011
Jan 3, 2012 09:14:28
Patient Safety Presbyterian Hospital was recognized by The Leapfrog Group as one of the 65 safest hospitals in the country in 2011. This recognition is a huge validation of hard work and process focus across our organization. This is one of the most competitive national hospital quality awards in the country, and recognizes hospitals that deliver the highest quality care by preventing medical errors, reducing mortality for high-risk procedures and reducing hospital readmissions for patients with certain conditions. The Leapfrog survey is used to guide and improve patient safety and quality performance.
The Leapfrog survey focuses on three critical areas of hospital care: • How patients fare • Resources used to care for patients • Management practices that promote safety and quality
Selected Patient Safety Results 48% Reduction in National Quality Forum Serious Reportable Events 24% Reduction in Surgical Complications 4% Reduction in Quality Indicators such as falls 15% Increase in Healthcare Acquired Infections
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94%
Collaborating to Reduce Harm The Partnership for Patients is a public/private partnership that brings together physicians, clinicians, leaders and patient advocates along with federal and state governments in a shared effort to make hospital care safer, more reliable and less costly. Presbyterian will participate in an Intermountain Healthcare-led network to accomplish two goals:
A multidisciplinary team of physicians, pharmacists, and care coordinators worked together to automate the identification and monitoring of inpatients on anticoagulation management. This resulted in an increase in the number of patients leaving the hospital with a scheduled outpatient appointment from 54 percent to 94 percent.
• Keep patients from getting injured or sicker • Help patients heal without complications This Centers for Medicare & Medicaid Innovation project will focus on ten conditions of preventable hospital-acquired conditions and complications to reduce harm and readmissions.
5%
Pressure ulcer incidence rates remained best-in-class at below 5 percent.
Fall Prevention Summit
PH Pressure Ulcer Incidence Study Rate Q3 2007 - Q4 2011
30.00% 25.00% 20.00% 15.00% 10.00%
Pressure Ulcer Prevention implemented at PH Q4 2008
Target is 5% or Less
5.00% 0.00%
Hospital Acquired Pressure Ulcers
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 2007 2007 2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010 2011 2011 2011 2011
Quarter / Year
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Reducing patient falls has been a challenge for many organizations, including Presbyterian. In December, Presbyterian held its 3rd Clinical Summit, bringing together healthcare team members from all facilities with the goal of reducing inpatient falls and inpatient falls with injury. More than 60 colleagues convened for one day to review the current status of our fall prevention program, identify key characteristics of patients at-risk for falling and for risk of injury from a fall and to consider best practices in developing our plan for reducing falls. The summit identified key areas of focus for improved management of this key patient safety concern.
The Power of an Integrated Delivery System Patient Centered Medical Home ~ Best Clinical Quality and Care Models Presbyterian Medical Group achieved two key milestones in the development and implementation of the Patient Centered Medical Home (PCMH). This care model has been deployed to all 10 primary care locations in the Albuquerque metropolitan area and all have received National Committee for Quality Assurance (NCQA) Level 3 accreditation. PCMH utilizes a Primary Care physician-led expanded care team responsible for all of a patient’s health needs. The care team in the PMG model may include: a pharmacy clinician, behavioral health clinician, diabetes educator, promotora or a community health worker, care and case managers, health coach, and the clinician team which includes assistants, nurses, nurse practitioners and physician assistants. Using the My Chart patient portal, and innovations such as group visits, telephone appointments, nurse visits and group educational sessions, care is tailored to meet the patient’s individual needs. Funding from PHP has supported the development of this innovative care model.
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Timeliness of returning patient calls in the Pain and Spine clinic improved from four days to four hours. Satisfaction with the promptness in returning calls improved from the 7th percentile ranking to the 30th percentile. Providers and staff accomplished this through their commitment to meet the needs of patients and members.
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Through the efforts of the Radiology Nursing Team in collaboration with physicians and bedside nurses, the number of Central Line Associated Blood Stream Infections in patients with Peripherally Inserted Central Catheters reduced from 15 in 2010 to only one in 2011.
Early results demonstrate improved preventive screening and chronic care management and reduced emergency department visits and hospitalizations. This care model is a critical element to our future success in improving the quality of care and lowering the cost.
Presbyterian Home Healthcare receives $24,000 recognition Presbyterian Home Healthcare (PHHC) Statewide Network was recognized by the Premier Healthcare Alliance for serving highrisk infants and toddlers at high risk of contracting or experiencing severe outcomes due to respiratory syncytial virus (RSV). RSV is a major cause of respiratory illness in young children. The Synagis Program has been supported by Presbyterian Health Plan and PHHC and has served children across New Mexico since 2004. PHHC has demonstrated a reduction in the percent of drugs discarded, maintained greater than 80 percent compliance with the recommended course of prophylaxis treatments and reduced hospitalizations of at-risk infants.
Presbyterian Home Healthcare receives $24,000 recognition. From left: Susan Devore, Premier, Kathie Winograd, PHD, PHS Board Chair, Antoinette Vigil, PHHC, Scott Shannon, PHHC, Jennifer Thomas, PHS Board, Jim Hinton, PHS. Back row: Premier staff, Peter Winograd, Dave Thomas
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Community Health In 2011, Presbyterian embarked on an assessment of community health needs. Using national, state and county data as well as feedback from all of Presbyterian’s Community Boards and Committees system-wide community health priorities were selected. The priorities are: healthy eating, active living and tobacco cessation. In 2012, forums will be conducted to gain community and subject matter expert feedback that will help drive interventions.
Journey to Electronic Health Record ~ Best Clinical Quality and Care Models Presbyterian has made significant progress in the deployment of the Ambulatory Electronic Health Record (EHR). The system has been deployed to 71 percent of our primary and specialty care areas. Currently, we are in a cycle of stabilization and optimization. This effort is focused on clarifying team roles and responsibilities and ensuring efficiency and effectiveness in practice. In 2011, the Discharge Phone Call Center completed more than 42,000 calls to discharged patients across New Mexico.
The patient component of the EHR, known as My Chart, is in use by approximately 5,000 patients with plans to grow this method of patient engagement and communication. Also in 2011, following an extensive review, PHS made the decision to replace our multiple inpatient EHRs with Epic, a single integrated EMR that will span the care continuum across the Presbyterian Delivery System. This investment rivals the investment in the Rust Medical Center, exceeding $150 million over several years, and is a tangible illustration of Presbyterian’s commitment to integrated, evidence based care, across the statewide delivery system.
30 Day Acute Care Readmission Rates for All Causes CDS
14%
RDS
12% 10% 8% 6% 4% 2%
Rate
2011
2010
2009
2008
2007
2006
2011
2010
2009
2008
2007
2006
0%
50th Percentile
Collaboration across our Integrated Delivery System promotes best in class hospital readmission rates. 6 | CELEBRATING QUALITY 2011
We are grateful that the PHS Board expressed its recognition of the importance of this investment and their confidence in us to transform the organization. Over time, this investment in technology will enable us to produce the highest quality of care and transparency, and identify opportunities to improve chronic and acute care management using evidence to address overuse, misuse and underuse of resources. This commitment is possibly the most important step Presbyterian has taken in our Drive for Excellence.
Evidence Based Medicine
Evidence Based Medicine Process
Presbyterian defines Evidence Based Medicine (EBM) as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Various foundational mechanisms were established in 2011 to fulfill the intent of this position. Components essential to an effective EBM approach include: • Availability of evidence in a variety of forms • Provider education about the concepts and benefits of reduction in practice variation • A means for peer review and consensus building regarding the application of evidence to practice • Structures to integrate the evidence into practice, including measurement and feedback mechanisms regarding the effectiveness of the approach and subsequent care provision The EBM Process illustrates the elements and cyclical nature of the approach. This process follows Lean Six Sigma methodology and is facilitated through the Process Excellence department in collaboration with Central Delivery System (CDS) Service Line and medical staff leaders. In 2011 the focus was on osteoarthritis, diabetes care, coronary artery disease and the Women’s birthing process.
Active My Chart users Number of trained providers Number of trained clinical staff Number of training hours
5,975 475 580 26,084
• Osteoarthritis In 2011, the Orthopedic Guidelines Committee gained consensus on 23 clinical guidelines for the treatment of osteoarthritis of the hip and knee. Three examples of the implemented guidelines are: 1) the number of and indications for the use of corticosteroid injections to reduce inflammation, 2) the number and indications for the use of hyalaronate injections to “cushion” joints when the cartilage has deteriorated, 3) the criteria for the use of MRIs vs. plain films.
Presbyterian physicians harness the power of technology to facilitate evidence based medicine. Order set templates are created and then consensus gained electronically among physicians to build a standard order set in EHR.
These guidelines provide for safer and less expensive care for our patients and members. CELEBRATING QUALITY 2011 | 7
• Diabetes Care The Guideline Committee gained consensus on the 24 clinical guidelines for the care of diabetic patients. The guidelines encompass screening criteria, the D3 Bundle, (hemoglobin A1c, blood pressure, and cholesterol), criteria for Certified Diabetes Educator and Endocrinology referrals and a Medication Treatment Algorithm. The medical staff approved these guidelines in December 2011 and they will be built into the Electronic Medical Record this summer.
100%
Referral to Cardiac Rehabilitation for postoperative CABG patients increased from 19 percent to 100 percent. 100 percent of CABG patients on the clinical pathway have met CMS SCIP Core Measure Insulin Management Requirements.
3% The Women’s Service Line’s Evidence Based Care Design project implemented the Institute for Healthcare Improvement’s Elective Induction Bundle. As a result, the number of elective inductions was reduced from 25 percent to 3 percent by December 2011.
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• Coronary Artery Bypass Graph Evidence Based Care Design Project The Heart Service Line Coronary Artery Bypass Graph (CABG) Evidence Based Care Design (EBCD) Process Excellence Project started work in February 2011 with a cross-functional team that included employed and affiliated cardiac surgeons, nurses, pharmacists and other clinical experts. Through the work of three subteams, protocols, order sets, and one clinical pathway were developed and implemented. The teams also implemented processes to consistently meet the best practice guidelines from the Geisinger Health Systems 40 Points of Proven Care for CABG patients. These care improvements span preoperative, operative, inpatient and post hospital phases of care.
Participation of physician and clinical subject matter experts is critical to the work. Many thanks to the providers, clinicians and process experts who worked on these guidelines committees to gain consensus on the evidence and standard practices.
Susan Dezavelle, PHP Clinical Informatics Director named one of Modern Healthcare’s top 25 Clinical Informaticists
CELEBRATING QUALITY 2011