Agenda
• BMC FY13 Quality goals• Current QI initiatives
– Mortality Reduction • Sepsis
– Patient Experience– DOM Quality Leader projects– Residency QI curriculum
• Future Directions• Your input
BMC Quality Goals• Mortality:
– Achieve a University Health Systems Consortium (UHC) observed/expected mortality of 0.84, (top 30% of hospitals)
• Patient Satisfaction:– Inpatient: Increase the HCAHPS percent of patients who give
BMC a 9 or 10 on "Overall Rating of Hospital" to 70%– Outpatient: Increase the composite Outpatient surveys score*
for the question “Likelihood to Recommend” to 75% • Access:
– 70% of new primary care patients seen within 14 days– 45% of new specialty care patients seen within 14 days
Mortality Reduction: Why Focus on Sepsis?
• Volume of cases– Top cause of excess deaths at 2013 mortality goal– Of 444 deaths at BMC in 2012, 31% had a diagnosis of sepsis coded
• Opportunity for improvement– A previous review of 50 hospital‐acquired sepsis deaths at BMC identified delayed recognition and delayed time to antibiotics as possible contributors
Mortality Reduction: Why Sepsis?
• Volume of cases– Top cause of excess deaths at 2013 mortality goal– 31% of 444 patients who died in 2012 had sepsis coded
• Opportunity for improvement– A previous review of 50 hospital‐acquired sepsis deaths at BMC identified delayed recognition and delayed time to antibiotics as possible contributors
2012 BMC Sepsis POA vs Not POA
707, 80%
175, 20%
Sepsis POA (ICD‐9 995.91, 995.92, 785.52)
Sepsis Not POA (ICD‐9 995.91, 995.92, 785.52)
Expired Sepsis Patients‐ POA vs Not POA
96, 68%
45, 32%
Sepsis POA Expired (ICD‐9 995.91, 995.92, 785.52)
Sepsis Not POA Expired (ICD‐9 995.91, 995.92,785.52)
Mortality Reduction Initiative: Sepsis3 components
• Decrease time to appropriate antibiotics in sepsis on the medical/surgical floors. – Kevin Horbowicz, pharmacy, and Karin Sloan, MD, Medicine.
• Improve timely recognition of sepsis on the medical/surgical floors.– Kate Mandell, MD, surgery, Nahid Bhadelia, MD, ID, and Tamar Barlam, ID.
• Increase compliance with early goal‐directed therapy for severe sepsis and septic shock in the ED/ICU– Willie Baker, MD, ED, and James Murphy, MD, Pulmonary/Critical Care.
Group 1: Decrease time to antibiotics
• Process Improvement group was convened• Process maps of current and target state completed• Metrics defined
– Time to broad spectrum antibiotic– % with blood cultures drawn prior to antibiotics
• Solutions were identified in these categories:– Ordering– Pharmacy– Communication– Administration
• Pilots to begin on 6W Menino in near future
Group 2: Improve recognition of sepsis
• Group convened and recognition tool was drafted to pilot
• Management protocol being drafted• Process improvement group to meet soon
– Need to do initial and target state, decide on metrics, identify solutions
• Coming soon: pilots on recognition tool and other changes on 6W Menino and on 2 housestaff teams staffed by Hospitalist attgs
Improve management for severe sepsis/septic shock in ER/ICU
• Management protocol being drafted• Process improvement group to meet soon
– Need to do initial and target state, decide on metrics, identify solutions
• Future: possible teams‐training Simulation with learning objectives around recognition and management of sepsis
Inpatient services
• Resume exit interviews with service attendings– Review deaths, complications, improper triage, morbitidies with goal of identifying opportunities for improvement, systems issues
• Beginning discussions with Risk Management on how to better collaborate on investigating and feeding back issues identified in STARS reporting system
• Attending involvement ‐ CALL• Attending daily notes
2013 Patient Experience: QUEST Goals
Outpatient Composite: Achieve a 75 percent top box rating score for the question “Likelihood to Recommend” (Very Good) on composite outpatient surveys. Composite is based on a weighted average of percentage of patients who select “Very Good” for “Likelihood to Recommend.” Includes all three instruments‐ Ambulatory Surgery; Outpatient – Radiology; Med Practice
Formula‐ (AS% Top Box score X AS N) + (MP % Top Box Score X MP N) + (OP % Top Box Score X OP N) ÷ (AS N) + (MP N) + (OP N)
Med Practice Questions Highest Correlation to “Likelihood to Recommend”
Outpatient Questions: Ambulatory Surgery survey, Outpatient survey and Medical Practice survey
• Information about delays• Wait time in clinic‐ when >15’• Sensitivity to patient’s needs‐ comfort, concerns etc.• Response to complaints and concerns• Explanations given by staff‐ including explanations of visit,
procedures and follow up care• Staff worked well together to care for patient‐ information
hand‐offs
Patient Experience Initiatives• 1000 front end staff ‐ 2 hour patient experience training
– Case scenarios/simulations• RESPECT ‐ behavioral standards ‐ designed by staff• Scripting• Time about delays
– Offer to reschedule – earlier on in process– Coupon to use while waiting
• Distractions – Care Channel, CNN, Patient Education on TV in waiting room – set by Practice Manager
• Future initiatives: – Pre‐provider visit work
• e.g. Refills– Optimize pre‐registration– likely downstream effect on no show rate
Primary Care Press Ganey results
Press GaneyQuestion
October ’12‐Mean
Rank‐All Sites database
November ’12‐Mean
Rank December ’12‐Mean
Rank
Overall Assessment‐N=142
86.9 6% 88.6 10% 94.2 64%
Staff worked together N=140
86.4 4% 89.3 12% 93.6 55%
Likelihood of Recommending the Practice N=138
86.8 6% 88.1 9% 94.6 65%
Residency QI Curriculum
• Course Directors: Winnie Suen, Gouri Gupte, Craig Noronha, Karin Sloan
• Resident/MPH student teams working on 16 QI projects with faculty sponsors
• January 18 to May 3, teams meet for 1.5h every 4th Friday am
Resident QI projects• Pod 1/Blue:• 1. Improving management of chemotherapy‐induced nausea and
vomiting ‐Mark Sloan, Radhika Sane• 2. Decreasing time to antibiotic delivery in sepsis ‐ Karin Sloan, Kevin
Horbowicz, Stephanie Martinez• 3. Preventing Inpatient Hypoglycemia ‐Marie McDonnell• 4. Increasing Spontaneous Breathing Trial rates in the MICU ‐ James
Murphy•• Pod 2/Yellow:• 1. Testing for Hepatitis C in the suboxone program ‐ Jane Liebschutz• 2. Improving post‐discharge followup in Shapiro Suite 6A ‐ Dan Chen,
Henri Lee, James Hudspeth• 3. Improving ICU family meeting rates ‐ Sandhya Rao• 4. Team care for DM and hyperlipidemia population management on
Shapiro 6B ‐ Karen Lasser•
• Pod 3/Purple:• 1. Smoking Cessation Program ‐ Rob Sokolove• 2. Access to Behavioral Health Services ‐ Christine Pace• 3. Point of care processes for DM and hyperlipidemia on Shapiro 5A
‐ Tara Dumont• 4. Resident Continuity Clinic experience in Shapiro ‐ Craig Noronha•• Pod 4/Red:• 1. Appropriate Use of Blood Transfusions ‐ Karen Quillen, Carlos
Arellano• 2. Early Inpatient Discharge ‐ Ashish Upadhyay• 3. Improving Cellulitis Management ‐ Rachel Simmons• 4. Improving results management in the outpatient setting ‐ Karin
Sloan, Ramon Cancino
DOM Physician Quality Leaders
• Cardiology: George Philippides
• Endocrine: Sara Alexanian• Geriatrics: Winnie Suen• GI: Brian Jacobson• GIM: Karen Lasser
• Heme‐Onc: Gretchen Gignac
• ID: Nahid Bhadelia• Pulm/CC: James Murphy
• Renal: Andrea Havasi• Rheum: Mike York
DOM Major Quality Projects AY12‐13
• Cardiology– Improve lipid control for patients with CAD in cardiology clinic– Improve 30‐d readmission rate for AMI– Improve Door to Balloon time for STEMI
• Endocrine and GIM– Improve LDL and A1c screening and control in diabetics in
endocrine and primary care clinics• Geriatrics
– Improve osteoporosis screening and treatment in geriatrics clinic
• GI– Improve compliance with Hep A and B vaccine in Hep C patients
and PVX and influenza vaccine in IBD patients in GI clinic
DOM Major Quality Projects AY12‐13
• Hematology‐Oncology– Improve process for elective chemotherapy admissions, decreasing time to first dose
• ID– Decrease CLABSI rate for floor patients
• HD and sickle cell floors as targets
• Pulmonary‐Critical Care– Increase compliance with sedation vacation in mechanically ventilated patients on
continuous sedation– Improve PVX and flu vaccine rate for COPD patients in pulmonary clinic
• Nephrology– Increase number of CKD patients in renal clinic who are Hep B immune
• Rheumatology– Increase PVX and flu vaccine rate and increase education re: live vaccines being
contraindicated in immunosuppressed patients in rheumatology clinic
More to come…
• Improving our AQC performance– Leakage– Quality Metrics
• Readmission reduction initiative• Ongoing patient experience work• Population management• Incorporating quality in EPIC