BHCS Health Care Improvement and ABC Baylor Success

1. BHCS Health Care Improvement and ABC Baylor Success

2. Examples of Baylor Health Care System National Quality Awards HEALTHTEXAS PROVIDER NETWORK RECEIVES PRESTIGIOUS NATIONAL HONOR American Medical Group Association (AMGA) presents:  The Preeminence Award to HealthTexas, Recognizing Excellence in Leadership and Patient Care HealthTexas was honored, March 20th at the AMGA 2010 Annual Conference in New Orleans, as this year’s recipient of the Medical Group Preeminence Award by the Executive Committee of the American Medical Group Association (AMGA).  2 2 2

3. Baylor Health Care System Quality Performance and Ranking Note: the American Hospital Association decided to stop publishing the rankings due to complaints from members that did not rank favorably. Source: Hines S, Joshi MS. Variation in Quality of Care Within Health Care Systems. Joint Commission Journal on Quality and Patient Safety. 2008;34(6):326-332. 3

4. BHCS Process Excellence: Heart Failure Order Set • Standardized heart failure order set at Baylor Health Care System has led to improved outcomes, reduced costs of care, and increased adherence to evidence-based processes of care • Standardized heart failure order set use was associated with significantly increased core measures compliance and reduced in-patient mortality • Direct cost for initial admissions alone and in combination with readmissions were significantly lower with order set use • $2 billion cost reduction and 2,000 lives mortality reduction opportunity annually across U.S. • Ballard DJ, Ogola G, Fleming NS, Stauffer BD, Leonard BM, Khetan R, Yancy CW. Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care. Int J Qual Health Care. 2010 Dec;22(6):437-44

5. International Society for Quality in Health Care • International Journal for Quality in Health Care article 2nd place 2011 Peter Reizenstein prize • Ballard DJ, Ogola G, Fleming NS, Stauffer BD, Leonard BM, Khetan R, Yancy CW. Impact of a standardized heart failure order set on mortality, readmission, and quality and costs of care. Int J Qual Health Care. 2010 Dec;22(6):437-44

6. Evaluating the Pneumonia Order Set: Cost Effectiveness Results • Mean difference (standard error) in in-hospital mortality and costs were estimated at 1.67(0.62)% and $383(207) respectively, with both showing a benefit with order set use • From the estimates of mortality and cost differences, the incremental cost-effectiveness ratio (ICER) =-$22,882 per additional life saved • Potential life years saved, based on adjusted life expectancy calculations for all patients in the study population who died, discounted based on the 5 year survival reported for pneumonia patients, was estimated at 12 years per patient Fleming NS, Ogola G, Ballard DJ. Implementing a standardized order set for community acquired pneumonia: impact on mortality and cost. Jt Comm J Qual Patient Saf 2009 Aug;35(8):414-21.

7. Evaluating the Pneumonia Order Set: Cost Effectiveness Results • For every 60 patients who received the order set, 1 additional life was saved (1/.0167) • For every 60 patients who received the order set, $23,000 were saved (60 x $383) • For the approximate 2,000 patients receiving the order set, 33 lives were saved and $766,000 were saved Fleming NS, Ogola G, Ballard DJ. Implementing a standardized order set for community acquired pneumonia: impact on mortality and cost. Jt Comm J Qual Patient Saf 2009 Aug;35(8):414-21.

8. PDCA Efforts to Improve Revenue: Outpatient Recurring Accounts • Aim: to reduce by 50% the final unbilled dollar value of Baylor All Saints Infusion Center outpatient recurring accounts that were > 90 days old through the implementation of regular shared tracking, audit and account maintenance processes • The team’s goal was to see a reduction of outstanding final unbilled balances from $1,191,554 to $595,777 by March 31, 2010

9. PDCA Efforts to Improve Revenue: Outpatient Recurring Accounts

10. ABC Baylor Expansion • Because of ABC-Baylor success, we are now teaching it elsewhere in the US and abroad: • Texas small and rural hospitals • Hazleton and Meadville, Pennsylvania • Willis-Knighton Health Care System (Shreveport, Louisiana) • Sentara (Norfolk, Virginia) • Mexico • Possibly Kunming City, China

11. Health Care Quality Domains • Safe – avoiding injury to patients from care that is intended to help them • Timely – reducing waits and harmful delays • Effective - providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding overuse and underuse) • Equitable - providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographical location, and socioeconomic status • Efficient – avoiding waste • Patient Centered - providing care that is respectful of and responsive to individual patient preferences, needs, and values Source: Institute of Medicine. Crossing the Quality Chasm. Washington, D.C.: National Academies Press; 2001.

12. STEEEP Focus: Safe Project Title: Increasing Hand Hygiene Compliance Background: Hand washing is the number one most important part of preventing the spread of infections. Hand Hygiene compliance at the facility was 83.57% over a seven month period. This lack of compliance leads to preventable infections in hospitalized patients. AIM Statement: By May 31, 2008, the facility will improve the hand hygiene compliance rate from 73.13% to 90% through the implementation of a strong educational and awareness program, proper locations for foam dispensers and hand hygiene stations, and pocket hand sanitizers provided to staff. Results: The “You Bugged Me” program was established to hold staff accountable for proper hand hygiene practices. This program, along with the proper placement of the foam dispensers and hand hygiene stations, increased hand hygiene compliance rates to 91.69% over an eight month period which helped prevent infections in hospitalized patients. The “You Bugged Me” program was adopted a second facility, along with the visual management poster campaign “Got Foam.” This second facility increased hand hygiene compliance from 69.7% to 98%. Additionally, through the adoption of these standards, BHCS has increased hand hygiene compliance rates from 85.31% in July 2008 to 97.41% in July 2011.

13. STEEEP Focus: Timely Project Title: Push to Full: Improving Admission to Exam Time in the Emergency Department (ED) Background: In April 2007 it was taking 63 minutes for an ED patient to get examined in the ED. The facility implemented methodology to get the patient from door to exam in 48 minutes. Subsequently the ED Council has tracked this and other measures to improve timely ED care. AIM Statement: Over the next 10 weeks, staff will reduce door-to-exam time in the Emergency Department by 20% by implementing the strategies of direct-to-bed triage, expedited bedside registration and immediate notification of physicians when patients are placed in a treatment room. Results: Target of 48 minutes was exceeded with 36 minutes being the average lowest monthly time from April 2007 to March 2008. From March 2010 to August 2011 had only one month (February 2011) where the average time from door-to-exam exceeded 30 minutes.

14. STEEEP Focus: Effective Project Title: Medication Reconciliation Improvement Background: Medication Reconciliation is a Joint Commission National Patient Safety Goal requirement. In fiscal year 2010, the facility medication reconciliation all-or-none bundle score was 69.4%. AIM Statement: The facility will increase the medication reconciliation all-or-none bundle score from a rate of 69.4% to 86% by January 31, 2011. Results: Through execution of a hospital wide daily auditing process of all discharge/transfer patients standardized medication reconciliation forms and standardized training materials, the facility increased the medication reconciliation all-or-none bundle rate from 69.4% to 90%. For FY11, this was the highest improvement across the Baylor Health Care System.

15. STEEEP Focus: Efficient Project Title: “Let Me Catch My Breath” Background: Patients at the facility currently receive therapeutic duplicates of medications (DuoNeb and Spiriva) that treat COPD and asthma. The continuation of this practice results in sub-optimal outcomes for the patients, increased cost for pharmacy, increased out-patient medication costs, and wasted effort by the respiratory therapy staff. AIM Statement: By November 17, 2010, facility physicians, pharmacists, and respiratory therapists will reduce the incidence of patients receiving Spiriva and DuoNeb therapeutic duplications from 100% to 50% throughout the hospital by using physician education, therapeutic auto-interchange, and patient therapy monitoring. Results: Through integration of best practices, collaborative efforts, and standardized education, the facility decreased the incidence of patients receiving Spiriva and DuoNeb therapeutic duplications by 55%, exceeding their goal. Through the elimination of wasteful rework, the project team saved $19,708.14.

16. STEEEP Focus: Equitable Project Title: Collect Every Patient’s Race, Ethnicity, and Primary Language Designation Background: Identifying ethnic and minority groups for all patient visits helps recognize gaps in the rates of preventive services received by advantaged groups. The facility identifies this information 38.5% of the time for all patients. AIM Statement: By June 8, 2011, the facility will increase the percentage of electronic health records with patient designated race, ethnicity, and primary language identified from 38.5% to 50% for all patient visits. Results: Through easily accessible and standardized forms, the facility increased the percentage of identified patients from 38.5% to 54.5% (as of September 2011).The project team continues to improve the process to reach Kaiser Permanente’s benchmark of 86%.These ongoing improvements will help identify additional areas for improvement to ensure we are providing the same care for all patients.

17. STEEEP Focus: Patient Centered Project Title: Family Centered Care in the NICU: Open Access and Bedside Reporting Background: There have been numerous complaints from families as a result of being asked to leave the NICU for various reasons. This directly influences the Press Ganey score of “NICU was Family Friendly” which is currently at 82.5% (<10th percentile). AIM Statement:The facility Neonatal Intensive Care Unit (NICU) will increase its “NICU was Family Friendly” Press Ganey mean score from 82.5% to 91.1% by June 30, 2011 by implementing 24 hour access for parents and beside change of shift report with family inclusion. Results: Through the development of a standardized training program, display of visual management informational posters, and weekly rounding with families to obtain the voice of the customer, the facility increased the Press Ganey score of “NICU was Family Friendly” from 82.5% to 100%. As a result of this project, the facility Neonatal Intensive Care Unit was awarded with a grant from the NICU Helping Hands Foundation for $300,000 to fund “Project NICU.” The interventions from the project were adopted across the Baylor Health Care System as a best practice and was shared at the National NICU Leadership Forum in Las Vegas.