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Building a Culture of Quality and Safety at UK Healthcare

Building a Culture of Quality and Safety at UK Healthcare. A Healthcare Provider’s Guide to the Nuts and Bolts of the Efforts Underway at UK Healthcare to Improve the Quality and Safety of the Care the We Provide to Our Patients. How is Quality Measured?.

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Building a Culture of Quality and Safety at UK Healthcare

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  1. Building a Culture of Quality and Safety at UK Healthcare A Healthcare Provider’s Guide to the Nuts and Bolts of the Efforts Underway at UK Healthcare to Improve the Quality and Safety of the Care the We Provide to Our Patients

  2. How is Quality Measured?

  3. The Bottom Line for Measuring Quality and Safety • There are many ways to measure Quality and Safety • There is significant overlap in the measures developed by different organizations and agencies • CMS measures are especially important because: • They provide a distillation of key metrics from several sources into a manageable and actionable list • CMS metrics are tied to reimbursement • Private insurers are following the CMS lead in tying quality and safety to reimbursement • 30% of UK HealthCare discharges are CMS patients • Performance on many CMS metrics are publicly reported

  4. Q: How Does UK HealthCare Compare Its Quality and Safety Performance to Other Academic Medical Centers?A: University HealthSystems Consortium (UHC)

  5. UHC: University HealthSystem Consortium • Based in Oak Brook, Illinois, formed in 1984 • Alliance of 107 academic medical centers and 246 of their affiliated hospitals • Represents approximately 90% of the nation's non-profit academic medical centers • Offers an array of performance improvement products and services to its members • Maintains powerful databases that provide comparative data in clinical, operational, faculty practice management, financial, patient safety, and supply chain areas

  6. UHC 2010 Top Ten Performing AMC’s • University of Utah Hospitals and Clinics, Salt Lake City, UT • University Medical Center, Tucson, AZ • Methodist Hospital of Indiana- A Clarian Health Partner, Indianapolis, IN • Lehigh Valley Health Network, Allentown, PA • Mayo Clinic, Rochester, MN • Tufts Medical Center, Boston, MA • Beaumont Hospital, Royal Oak, Detroit, MI • University of Colorado • Case Western Reserve University, Cleveland, OH • New York Univ. Langone Medical Center, New York, NY Black font= earned 2010 UHC Quality Leadership Award

  7. Charge from UK HealthCare Leadership: • Move UK HealthCare from its present position in UHC Group #4 (4th Quintile) to Group #2 (2nd Quintile) by July 1, 2011 (2009 rankings shown below)

  8. UHC Organizational Score Domains • AMI=acute myocardial infarction; CMI= case mix index; HCAHPS= Hospital Consumer Assessment of Healthcare Providers and Systems; HF= heart failure; LOS= length of stay; O/E= observed to expected; PN= pneumonia; PSI= Patient Safety Indicator; SCIP= Surgical Care Improvement Project; WI= wage index

  9. Measuring Quality and Safety atUK HealthCare • Enterprise Scorecard:

  10. Enterprise Scorecard

  11. Goals for Our Executive Leadership Team From Jeff Norton, Co-Director, Office of Enterprise Quality and Safety, Team 1 Executive Sponsor: “We hope that by the end of your project you will”: • Have learned a great deal about quality and safety measurement, and will be able to educate us • Have looked at what UK does to measure quality and safety as well as what is happening on a national level • Be able to make some recommendations of what we should do relative to measuring quality and safety now, and for the next 3 years (i.e. a progressive plan) • Develop a paper that is publication-ready

  12. Our Team’s Next Steps? • Divide and Conquer to research more about Quality and Safety measurement: • At UK HealthCare • Nationally (UHC Top 10 Performers) • Develop potential questions for further study • Develop Recommendations for UK HealthCare quality and safety measurement: • Presently • 3-Year progressive strategic plan • Develop our team’s A3T Sheet (due March 15, 2011) • Meet with Dr. Boulanger and Jeff Norton to discuss

  13. References and Resources • The Joint Commission: http://www.jointcommission.org/ • National Quality Forum: http://www.qualityforum.org/Home.aspx • CMS: http://www.cms.gov/ • AHRQ: http://www.ahrq.gov/ • NDNQI: https://www.nursingquality.org/ • American College of Surgeons NSQIP: http://www.acsnsqip.org/ • UHC: https://www.uhc.edu/cps/rde/xchg/wwwuhc/hs.xsl/home.htm • Hospital Compare: http://www.hospitalcompare.hhs.gov/ • US News and World Report Best Hospitals: http://health.usnews.com/best-hospitals • UK HealthCare Careweb: http://www.hosp.uky.edu/careweb/carehome.asp?PageName=General&Section= • Executive Leadership Development Program Home Page: https://www.ukhc.uky.edu/ldp/default.aspx

  14. LDP Project Team 1 Quality Metrics • Executive Sponsor: Jeff Norton janort3@email.uky.edu • Project Sponsor: Bernie Boulanger bboul@email.uky.edu • Coach  Susan Project Team • Chris Nelson cnelson@email.uky.edu • Sally Jones sajone2@email.uky.edu • Amanda Madden-Dyal asmadd0@email.uky.edu • Leola Hampton ljhamp2@uky.edu • Barb Thies bethie2@uky.edu • Paula “Shane” Winstead pswins0@uky.edu • Rhonda Sewell rnsewe0@email.uky.edu

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