strategies and tools for patient safety/quality improvement donald crandall, md physician...
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Strategies and Tools for Patient Safety/Quality ImprovementDonald Crandall, MDPhysician Informatics ConsultantTrinity Health, Novi, MI.
Trinity Health – Our Communities
• Fourth-largest Catholic health system in the United States
• Operating revenues of $5.7billion
• 44,950 FTEs• 7,315 physicians – 95% private
practice community hospital based
• 25 Ministry Organizations, 44 hospitals (29 owned and 15 managed), 379 outpatient clinics/facilities, numerous long-term care facilities, home health and hospice programs, and senior housing communities in seven states
The Scale of Change
• How big is Genesis?
• Project Genesis will involve:– Implementation of 20+ information systems – Across 17 Member Organizations and 23 hospitals– Redesign of 300+ business and clinical processes
Scope: Applications Installed
• CLINICAL (Cerner/Millenium)– Power Chart - Orders and results– Clin Doc - Clinical documentation– PharmNet - Pharmacy – FirstNet: Emergency Dept.– RadNet: Radiology Dept.– SurgiNet: Operating Room – Inet: ICU– Profile - HIM application– EMPI– Standard Orders– Electronic Record - Clinical functions by pt. type - Current clinical documentation forms
Copyright © 2006 Trinity Health, Novi, Michigan
Trinity Health Genesis Clin/Rev Schedule as of June 2007
MuskegonJuly 2004
Sioux CitySept 2005
F03/05
Grand RapidsOct 2004
FY06
Mason CityJuly 2005
FY07
Battle CreekFeb 2005
CompletedIn ProcessNot Started
Key:
OaklandMarch 2007
MacombApril 2005
ClintonOct 2007
DubuqueFeb 2006
LivoniaMarch 2006
FY08 FY09
BoiseJan 2009
FY10
Ann ArborJune 2009
ColumbusTB ConfirmedLate Fall 2009
HQ UpgradeAug 2006
FresnoOct 2008
South BendApril 2008
Silver SpringJuly 2008
Domain SplitJan 2007
CTTACS & CHF
Cerner UpgradeMay 2006
MC-Network Phase I
July 2007
MC-NetworkJuly 2008
MC-NetworkSept 2008
CernerUpgrade Alpha
Sept 2007
LivoniaOrtho Tot Joint
PI Pilot
ACS/CHFPI Pilot-Oakland
Mar 2007
CernerUpgrade Main
Jan 2008
FY08 Genesis Doc MngBundle
Genesis Accomplishments
• 10 ministry organizations live on in-patient system as of 7/2007• Three ambulatory clinics live on PowerChart Office• Avg. # of physicians placing orders per day (actually doing it themselves)
is >850• Orders processed per day > 300,000• Avg. chart openings per day > 160,000• Avg. HQ-Cerner ADT transactions per day > 50,000• Avg. concurrent users per day during peak hours • (08:00-16:59) > 1200• Peak concurrent users > 1500• Simultaneous synchronization to 2 data sites
Trinity CPOE Saturation – previous 13 months
CPOE Saturation % = physician entered orders + protocol orders + AHP orders / total orders
QUALITY MONITORING
The objective of I²S² is to create information from data in order to measure and improve clinical and operational performance.
AMI
Site ASPIRIN w/in 24h ASPIRIN @ DC Adult Smoking Cessation BETA @ DC BETA w/in 24h PCI w/in 120
min
Ann Arbor 97% 99% 98% 99% 93% 90% FAV
Battle Creek 86% 83% 75% 97% 86%
Boise 100% 98% 94% 93% 92% 71% FAV
Cadillac 100% 100% 82% 100% 100%
Clinton, IA 94% 93% 24% 79% 86%
Columbus East 95% UNF 99% 68% FAV 98% 98% UNF 91%
Columbus West 97% 96% UNF 86% FAV 96% UNF 99% 90%
Des Moines 98% 99% 100% 99% 99% 91% FAV
Dubuque 95% 99% FAV 89% 100% FAV 94% 63%
Fresno 97% 96% 74% 96% FAV 99% 92%
Grand Rapids 95% 93% 91% 100% 99%
Grayling 88% 100% 0 patients 90% 82%
Livingston 98% 95% 67% 100% 90%
Livonia 96% 94% 75% 93% 95%
Macomb 97% 97% 84% UNF 99% 97% 53%
Mason City 100% 98% 100% 97% 100%
Mishawaka 95% 97% 93% 100% 88% UNF 63%
Muskegon 99% 99% 86% 97% 99% 56%
Oakland 94% 96% 84% 93% 83% 78%
Plymouth 92% 100% 100% 100% 91%
Port Huron 90% 94% 100% 100% 88%
Saline
Silver Spring 99% 93% 75% 98% 93% 75%
Sioux City 100% 99% 95% 96% 90% 100%
South Bend 94% 99% 89% 94% 92% 63%
Westerville 88% 91% 20% 95% 94%
Trinity Health 96% 97% 87% FAV 97% 94% 78% FAV
Date of Data Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04CMS Top Decile 100% 99% na 98% 98% na
Green Top 25% 98% 99% 93% 98% 97%
Yellow 25-75% 97-92% 98-93% 92-73% 97-87% 96-83%
Red <25% <92% <93% <73% <87% <83%
Blue cells indicate less than 30 cases
Trinity Quality Dashboard 2004
Trinity Quality Dashboard 2007
AMI Indicators
Site Aspirin w/in 24 hrs AMI-1 Aspirin at discharge
AMI-2ACEI/ ARB at discharge
AMI-3Adult Smoking Cessation Counseling
AMI-4Beta blockers at discharge
AMI-5Beta blockers w/in 24 hrs
AMI-6 PCI w/in 90 min
AMI-8
AMI Composite
Ann Arbor 100% EP 99% 99% 99% 99% 94% 57% DNS
Battle Creek 89% 93% 100% 100% 91% 100% 84%
Boise 99% 99% 100% 100% EP 99% 99% 55% 90%
Cadillac 98% 88% 100% 100% 100% 100% 94%
Clinton, IA 94% 92% 67% 89% 87% 88% 50% 81%
Columbus East 100% EP 99% 97% 100% EP 100% EP 99% 97% EP 97% EP
Columbus West 100% EP 100% EP 97% FAV 100% EP 99% FAV 98% 76% 95%
Columbus St. Anns100% 100% 100%
100%100% 100% 100%
Des Moines 99% 100% EP 99% 100% EP 99% 98% 98% EP 97% EP
Dubuque 99% 99% 97% 100% EP 95% 94% 42% 84%
Fresno 99% 99% 100% EP 100% EP 99% 100% EP 63% 97% EP
Grand Rapids 95% 97% 93% 100% 97% 97% 50% 81%
Grayling 100% 100% 100% 100% 91% 81% 82%
Livingston 100% 100% 100% 0 pts 100% 80% DNSLivonia 98% UNF 99% 94% 100% 100% EP 97% 71% 90%
Macomb 98% 99% 100% 100% EP 99% 98% 86% 93%
Mason City 96% 99% 94% UNF 100% EP 99% 97% 64% 91%
Mishawaka 96% 100% 67% 89% 100% 100% 73% 87%
Muskegon 100% EP 100% EP 97% 100% EP 99% 100% EP 25% 89%
Oakland 100% EP 100% EP 100% EP 100% EP 99% 98% 83% 98% EP
Plymouth 100% 100% 100% 100% 100% 94% 95%
Port Huron 88% 93% 86% 100% 94% 96% 75%
Saline 100% 100% 0 pts 0 pts 100% 100% DNSSilver Spring 94% 88% UNF 100% 67% 85% UNF 86% UNF 13% 65%
Sioux City 99% 98% 92% 100% EP 99% 100% EP 81% 97% EP
South Bend 97% 99% 78% 96% 98% 93% 80% 90%
Trinity Health 98% 99% 97% 99% 98% 97% 71% 93%
Date of Data April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06
Exceptional Performance 100% 100% 100% 100% 100% 100% 86% 97%Target 100% 100% 100% 99% 100% 100% 70% 94%Above Median 99 - 96% 99 - 95% 99 - 85% 98 - 92% 99 - 95% 99 - 93% 69 - 60% 93 - 84%Median <96% <95% <85% <92% <95% <93% <60% <84%
Less than 30 cases
Targets developed from CMS data for FY 2005. When CMS data not available, other vendor data used.
FAV = Favorable 12 month regression (p<.05). UNF = Unfavorable 12 month regression (p<.05).
• We are successful with the technology.• Are we achieving our clinician goals?
6 3 3 6 6
Indicator Before
Go-Live
Disruption Pre Go-
Live
Disruption Post Go-
LiveDisruption Combined
After Go-Live
P value-Before
and After
Sig Improveme
nt Combined
Sig Improvem
ent PH
Sig Improvement Musk
Sig Improvem
ent GR
Sig Improvem
ent BCAMI-1 Aspirin on admission 95% 96% 96% 96% 94% 0.76AMI-2 Aspirin at discharge 97% 95% 98% 96% 97% 0.89AMI-3 ACEI / ARB at discharge 86% 88% 89% 89% 86% 0.99AMI-4 Smoking cessation 90% 90% 93% 91% 99% 0.02 Y yAMI-5 Beta at discharge 98% 97% 99% 98% 98% 0.77AMI-6 Beta on admission 96% 96% 96% 96% 97% 0.47AMI-8 PCI in 120 minutesHF-1 Discharge instructions 50% 45% 64% 54% 63% 0.00 Y y yHF-2 LVF assessment 93% 93% 94% 94% 96% 0.07 yHF-3 ACEI / ARB at discharge 81% 81% 84% 83% 90% 0.03 Y yHF-4 Smoking cessation 90% 86% 88% 87% 88% 0.69 yCAP - Antibiotics w/in 4 hours 71% 66% 67% 66% 77% 0.06 yCAP - Smoking Cessation 72% 80% 92% 86% 93% 0.00 Y y y yCAP - Blood C/S 82% 75% 77% 76% 77% 0.07 yCAP - Pneumococcal vaccine 47% 50% 53% 52% 58% 0.02 Y y
Chi Square Chi Square
Lessons Learned from Live Sites
CARE TRANSFORMATION
Moving from Utilization to Standardization
Copyright © 2006 Trinity Health, Novi, Michigan
Data Standards
Medication Cycle
Decision Support
ED ICU ACUTE SURG CATH
Governance
Oversight
Acute Coronary Syndrome
Congestive Heart Failure
Care Area Improvement Teams
Transformation Structure
Copyright © 2006 Trinity Health, Novi, Michigan
Decision Making TeamsPatient Centric – Zero Defects
• Care Area Improvement TeamsVenue Specific, Interdisciplinary, Workflow BasedED, Acute Care, Critical Care, Surgical, others…
• Clinical Transformation TeamsLean process, Interdisciplinary, Outcomes, Evidence Coronary, CHF, Pneumonia, Diabetes, SIP, others…
• Clinical Oversight TeamCross Venue, architecture, cross venue, and system decision making.
•Improve consistency in quality performance on key clinical indicators •Enhance the patient experience•Increase value and decrease risk in Genesis as noted in PGVA
• Evidence-based clinical practice is not embedded in many of the order sets.
• The workflow pattern has not changed much. For example even though a STAT ORDER is now instantly processed, it DOES NOT mean that the nurse sees it any earlier to do anything about it.
• We still have MO specific formularies. This means we have different ways of approaching even the highest risk drugs.
• We will embed evidence into workflow, order sets, rules, etc.
• Workflow will be optimized by embedding evidence--enhancing the overall clinical experience and care outcomes.
• Communication and efficiency improvements between all care providers and patients.
• Medication cycle and formulary will reflect evidence based use.
Current Future
Clinical Transformation
Care Transformation is a comprehensive approach to:Improve quality and safety of care, the patient care experience and improve financial stewardship Achieve zero defects by embedding evidence throughout the care processSupport acceleration of change and rapid replicationMaximize value from Genesis technology
Trinity Health’s brand name for Care Transformation is Genesis CareExperience (Genesis CareEx on second reference).
Key attributes of Genesis CareEx are:Patient focused – studies the end-to-end patient experienceDisease specific – e.g. heart failure, acute coronary syndrome, diabetesInformation and evidence driven – versus consensus opinion drivenHolistic – examines all elements of cost and quality Measurable – produces quantifiable benefitsIterative – we never stop looking for new opportunities
Care Transformation Definition Reaching a Higher Standard of Care
Genesis CareExperience Design Objectives
• Establish enterprise workflows that are actionable, flexible, patient focused and incorporates evidence throughout the care delivery process
• Ensure consideration and elimination to current provider and patient dissatisfiers• Ensure avoidance of all avoidable and predictable errors• Establish process, productivity and functional indicators• Ensure required documentation meets applicable standards• Will deliver outstanding care within financial parameters of CMS reimbursement
while maintaining alignment with our Mission • Support Genesis CareEx teams to support evolution towards system formulary• “Hardwire” into Genesis systems• Improve the patient experience
Acute MI Example Order Set from Zynx on Nexus
Best Practice EmbeddingTransformational Order Set
Designing the “Quality Heath Record”
Threats:– High cost of dictation & transcription, storage & retrieval/release of information – Fragmentation & Case Mix (lower productivity)– Continuity of Care, Handoffs, & Communication
Ongoing “Quality Health Record” projects:– Concurrent quality documentation review & dialogue with physicians, coding
and DRG assignment– Structured physician documentation templates (PN2G), including diagnosis – Standard terminology definitions for documentation and coding classification– Voice recognition & medical documentation quality review– Document management (Scanning) and Imaging– “Virtual” environment - working remote & load balancing
QUESTIONS?
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