Successes and Challenges for CAH’s with MBQIP & HCAHPS

1. Successes and Challenges for CAH’s with MBQIP & HCAHPS Candy Fincke, MSW, MHSA Jennie Alderman, BSN, RN, CPHQ

2. The Fabulous Florida Keys

3. BHSF Our Organization • Baptist Health South Florida • largest not-for-profit healthcare organization in South Florida • 65 miles south of Miami in the Florida Keys

4. Pathway to Excellence First hospital in Florida to achieve Pathway to Excellence Designation from ANCC

5. Beyond “Basic” Services • Outpatient, Inpatient Surgery • Arthroscopic Cataract • Gastrointestinal • General • Gynecological • Laparoscopic • Orthopedic • Oncology Services • Physical Therapy • Sleep Diagnostics • Speech Therapy • Swing Beds • Wellness Center • Wound Care • Cardiac, Pulmonary Rehabilitation • Cardiac Testing • Stress • EKG • Holter • Diabetic Care Center • eICU • Gastrointestinal Procedures • Hyperbaric Medicine • Imaging Services • MRI • Bone Density • CT Scan • Digital Mammography • 24/7 Emergency Care • Laboratory

6. Hospital Statistics

7. MBQIP-What?Medicare Beneficiary Quality Improvement Project • Began September 2011, voluntary-register on Quality Net • 100% participation goal by FY 2014 • Nationwide quality improvement plan for rural healthcare • Improves access for Medicare beneficiaries served, including EMS • Voluntary CAH quality benchmarking & reporting to CMS Hospital Compare • Builds a national data base to demonstrate effect of rural quality improvement initiatives • Phase I Process measures for inpatient Pneumonia & HF • Phase II- Outpatient measures 1-7 and HCAHPS • Phase III-Pharmacy CPOE review of orders in 24 hours & ED transfer communication & report quality improvement data to state

8. MBQIP-Why do it? • Promotes accountability & public disclosure • Future of all hospital reimbursement will soon be tied to performance-Get ahead of the curve • Only statistically significant volumes will be reported (>25 cases) • Gives benchmark data to analyze and guide performance improvement • Flex funding up to $775,00 per state for special CAH needs • It’s the RIGHT thing to do ! Evidence drives improvement

9. How Mariners Achieves Success • One FTE dedicated to concurrent & Retrospective reviews (daily rounding, critical conversations with MD’s and staff) • Paperless Time management tools • Implementation of CPOE • Down-time order sets prompt MD’s for quality care initiatives • Nurse-driven immunization assessment and orders • Hardwire measure compliance into discharge forms • Pharmacy monitors orders-timely d/c antibiotics • Communication !!! Staff meetings, Monthly newsletters to staff, board and MD’s • Monthly Performance Improvement meeting

10. Quality Updates Communication

11. Abstraction Tool Concurrently abstracted on inpatients daily, then ready for entry into the reporting database

12. DischargeInstructions Prints on back of discharge instructions and meets discharge requirements for Stroke, HF, Coumadin Tx , VTE and AMI

13. Heart Failure Evaluation of Left Ventricular systolic function, usually by Echocardiogram, provides an Ejection Fraction measurement by which physicians can manage patient’s medications based on evidence to improve cardiac outputs and quality of life. Thorough discharge instructions and follow-up care improve outcomes and reduce readmissions.

14. Order Sets Order set for STEMI and Rapid response team—also for Stroke

15. Outpatient Acute MI and Chest Pain • Cardiac biomarkers (Troponin) assist in ID of myocardial necrosis and are essential for risk stratification of unstable angina and non STEMI and diagnosis of MI • Lab turnaround time for results should be less than an hour to increase ED efficiency for timely eval and treatment of chest pain/AMI patients • Efficiencies in throughput can lead to less overcrowding, less elopements, & less financial loss for the hospital • Timely ECGs assist in identifying STEMI patients and impact the choice of reperfusion strategy. • TIME = HEART MUSCLE Early reperfusion (giving thrombolytic in less than 30 minutes improves outcomes) • Aspirin provides a 25% reduction in mortality that is comparable to thrombolytic therapy and the combination provides additive benefit for patients with ST-segment elevation myocardial infarction and is also effective in patients with non-ST-segment elevation myocardial infarction. • Rapid EKG results provide better outcomes as TIME=HEART MUSCLE SAVED OR LOST

16. Post-Op Orders Post op orders address Foley cath Removal , VTE prevention & antibx Discontinuation-this is hardwired in CPOE program

17. ED Inpatient Throughput Times Reducing the time patients remain in the ED can improve access to treatment and increase quality of care. Emergency Room Staff are ready and available for trauma and medical emergencies. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.

18. Challenges-What Now and How? • Staffing • CPOE • Low volume numbers for reporting • Resources – limited budget • Share data and network (conferences, list-servs) • Many best practices and wins available on TJC site, IHI, and AHRQ • Commit to EBP, continuous process improvement with patient and family at center

19. Mariners Hospital Successes

20. HCAHPS Overview Hospital Consumer Assessment of Healthcare Providers and Systems • Survey of Patients’ perspectives of hospital care • 18-items survey instrument of the hospital experience • National standard • 2008 provided valid comparisons across locally, regionally and nationally

21. HCAHPS Goals • 1st Goal: • Standardized survey and implementation that allow objective and meaningful comparison on topics that are important to consumers. • 2nd Goal: • Public Reporting create incentives to improve quality. • 3rd Goal: • Enhances accountability in health care by increasing transparency in return public investment (Inpatient Prospective Payment System)

22. Composite Topics • Nurse Communication (3) • Doctor Communication (3) • Responsiveness of Hospital Staff (2) • Pain Management (2) • Communication About Medicines (2) • Discharge Information (2) • Care Transition (3) New

23. Individual Topics & Overall Ratings • Cleanliness of the Environment • Quietness of Hospital Environment • Overall Rating of Hospital • Willingness to Recommend Hospital

24. Mariners HCAHPS Report

25. New Care Transition Questions • *Estimated scores for patients discharged during each time period

26. Communication with Nurses Successes: • Hourly Rounding • Call button • Toileting • White Boards • Discharge Date and Time • Discharge Phone Calls • Studer/Patient Call Manager

27. Communication Regarding Medicine Successes: • Micomedex • TV Education channel • Wired MD • Dietician education • Pharmacist education • Teaching magnet on door • White Boards • Pain Medication due • Pain goal

28. Patient Information Maria Jonas Tammy Shaw CT Scan No Physical Therapy today Sit up in chair twice today. Anticipated discharge date 06/21 Pain Medication is at 2:00 pm Pain Goal is a 3

29. Quietness at Night Challenge! • Quiet signs brought out • Communication phones on vibrate • Ear plugs offered • Move patient when requested and able • Change EKG batteries & leads at a.m. shift change • Employees “sleep over” suggestions (wins) • Unit Practice Council patient survey (new)

30. Standing Signs in each unit Shhhhhhh

31. UPC Quiet Survey

32. Room & Bathroom Clean Successes: • Staff returns if patient is not in room during cleaning • Gold stickers on toilet paper • From: leaving tent cards To: “Get Well” cards • Monitoring Program/EnCompass • High touch areas with DAZO marking & black light • Ecolab Reports • By room • Area • Housekeeping tech

33. Tools of the trade What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Hunches ? Theories? Ideas? Very Small Scale Test Wide-Scale Tests of Change Implementation of Change Follow-up Tests Changes That Result in Improvement

34. Processes Examined TEAMS* REFOCUS* IMAGINE* MEASURE

35. TRIM Overview TRIMinvolves using simple tools for analyzing, understanding and redesigning work processes. The primary tools utilized in TRIM are value stream mapping and A3 problem solving. • Value Stream Mapping • A3 Problem Solving • Emphasis is on empowering front-line staff. • Management is not top-down. • Employees are considered valuable assets. • Involves very few meetings. Core Principle :Deeply understanding how work currently happens is essential before trying to fix it!

36. From This ……….

37. ………To That

38. Work place Culture Hire Happy employee = Happy patients Acknowledge/Award Tell the “Why” Clear mission and vision Set the bar of expectation Empower your staff Provide the tools Come with solution Celebrate

39. Quality is our number One Goal

40. Questions? Candy Fincke, MSW, MHSA Vice President of Professional Services candyf@baptisthealth.net 305-434-1006 Jennie Alderman, BSN, RN, CPHQ Performance Improvement/Quality jenniea@baptisthealth.net 305-434-3001