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It’s one of those cases where the focus is distinctly on the cup half-full: More than 1,200 hospitals, or just about 37% of those accredited by The Joint Commission, achieved Top Performer status on 2013 accountability measure data. That’s an increase of more than 11% from last year. This is good. But it still means that just about two-thirds of the hospitals The Joint Commission accredits don’t meet that mark.
Quality is, indeed, a long journey.
According to The Joint Commission’s 2014 annual report, Top Performers must “1) achieve cumulative performance of 95% or above across all reported accountability measures; 2) achieve performance of 95% or above on each and every reported accountability measure where there are at least 30 denominator cases; and 3) have at least one core measure set that has a composite rate of 95% or above, and (within that measure set) all applicable individual accountability measures have a performance rate of 95% or above.”
One of the interesting things about meeting high quality standards is the feeling of confidence the public has in large academic institutions despite the relative difficulty they seem to have in meeting the high expectations. There are 35 academic medical centers among the Top Performers. That’s up from 24 last year, and just 4 in 2011, which sounds like a vast improvement until you remember there are 125 of them reporting.
Forty-four hospitals went above and beyond and reported on at least five measure sets, rather than the required four — only one of which is an academic medical center, and none is among the places most people think of when they think about where they’d go if they were rich and famous and had a dread disease.
Hospital Peer Review talked to three of these 44 hospitals about what they did — and do — that makes them stand out, and what other facilities can learn from them.
At Renown Regional Medical Center, a 538-bed facility in Reno that serves northern Nevada, 2013 data submission included children’s asthma, and next year will include perinatal care. For the 2016 submission, the hospital’s quality team is already working on sepsis, says Laura Latimer, director of performance improvement at the hospital.
Latimer says that the heart failure 1 measure offered the most “opportunity for enhancement” over the last year. “One key component we focused on was ensuring all patients with a diagnosis of heart failure scheduled a follow-up appointment with their primary care provider or cardiologist prior to being discharged from the hospital,” she says. “We were able to achieve compliance on this measure through setting standard processes and integrating with key programs we already had in place.”
The following were among the key initiatives, according to Latimer:
accurately identifying heart failure patients through a tool in the electronic health record, quality consultant staff, and nurse navigator collaboration;
ongoing education and training for nursing staff, hospitalist staff, and medical residents;
interdisciplinary rounds with hospitalist staff and discussion around follow-up appointments;
encouraging nurses to schedule the follow-up appointment soon after admission, rather than waiting until the day of discharge. (“The patient’s appointment date and time is then included in their discharge instructions,” she notes.);
increasing utilization of home health visits and the community paramedic program;
daily rounding by the heart failure nurse navigator and real-time tracking of all heart failure patients to ensure follow-up appointments are scheduled;
providing ongoing feedback for continuous process improvement at weekly core measure meetings.
Across the country in Florida, Baptist Hospital of Miami was another one of the 44 that turned in more data than it had to. “We didn’t wait for the government to tell us what to look at,” explains Miriam Serrano Robles, RN, BSN, performance improvement manager of the facility. “We are early adopters, and we don’t just settle for the minimum.”
The facility had been looking at the issue of venous thromboembolism for more than 10 years — “It’s a hospital-acquired condition” — and had also been working to become a stroke center. So adding those two measure sets seemed a no-brainer. They also added immunization to the mix for a whopping seven measure sets.
Next up they are thinking of adding tobacco use to the list. “We started looking at that two years ago,” Robles notes. “We have an action plan and processes in place and start training in January.” There is an assessment in the electronic records, and once a patient is identified as a user, someone from the respiratory therapy department is cued to come in and provide smoking cessation education to the patient. The patient is also sent home with a program for quitting.
The pilot of the program was being completed at press time, and Robles expected some tweaks before a final was rolled out.
Like Renown, they are also working on sepsis, as well as blood management and elective deliveries. On the latter, they have gone from 30% five years ago to 0% currently. “The biggest issue around that was changing the culture and getting the physicians involved,” says Robles. “There used to be this idea that in South Florida, you could pick when you had your kids. We got the head of the department and everyone at the table. We showed the doctors the data. If you want an early delivery, the head of the department will have to approve it.”
Does Robles worry about complacency? “You can’t ever stop. You are always looking at the data, reviewing it continuously, and looking at the research for the next thing,” she says, adding like any true A student: “We have to ensure we are always moving forward.”
At the University of Kentucky Hospital, setting the bar high is just what they do, says Kristy Deep, MD, MA, FACP, enterprise quality director and residency program director at the Lexington-based hospital. “We pride ourselves on a robust quality improvement program, and we collect a lot of data,” she says. “Much of what we submit is what we are already doing anyway. Submitting for these annual measures is something we can do, confident in our performance.”
She says that none of the quality “wins” are taken lightly, even the ones that have been relatively easy. “That just means that there has been low-hanging fruit, that our performance has not been what we wanted it to be and there are no-brainer things that lead to improvement.”
Deep gives an example of iatrogenic pneumothorax. “When you use ultrasound, your risk of giving a pneumothorax goes down,” she says. “So we invested in more ultrasound machines. We trained our staff and physicians, and we had a lot of improvements in our numbers. Those are easy, process of care wins.”
Things like giving heart attack patients aspirin — those are completely in the control of the hospital, Deep says. Those kinds of core measures are simple. What is harder are the measures that are outside the control of the hospital. “Patient-level variables or clinical decision-making by a large number of providers, or outcomes measures like readmissions and mortality — those are the much harder wins, and much harder to tackle — as we continue to see.”
Still there are a couple of quality projects that she has extreme pride in. Both relate to healthcare-acquired infections, and thus are on most people’s radar and are extremely gratifying to solve. First, there was urinary tract infections. There was a high historical rate at the hospital. One thing they wanted to do was do some accurate benchmarking to clarify opportunities to improve, Deep says.
“In addition to The Joint Commission, we are a member of the University Health Consortium and so we had a lot of data, and we knew that even among our peers, we had higher rates than we would have liked.”
Deep and her team looked for ways to reduce the use of catheters. Every day, every patient with a catheter has a chart prompt asking if the catheter can be removed. Every patient is assessed to see if he or she should have one to begin with. If the patient has a catheter, there are nursing-driven protocols — what Deep calls “standard work” to care for the site, ensure it is kept clean, and to be sure that when it is removed there are no repercussions. Patients and families are encouraged through signage to ask if a catheter is needed or can be removed, and physicians are educated to reduce their use and reliance on them unless it is warranted.
While Deep says the rates are declining — “we are chipping away at the iceberg” — there is still a ways to go.
With central-line infection — another piece of indwelling plastic that Deep says is always a potential for problems with patients — there has also been a multipronged approach to reduce rates. A bundle including a drape, ultrasound guidance, provider shielding, gloves, gown, effective skin decontamination and continued cleaning with chlorhexidine all have worked to reduce infections. “It’s just more standard work,” Deep says. However, insertion site preparations represent just a small portion of infections. Maintenance of the site is another big problem, she says. The pediatric ICU led a project that introduced hub scrubbing and had significant improvements from that. “It is all a hard-wired process now — catheter maintenance, clean dressings, and de-devicing. We ask daily, is this something I can remove? Because if they don’t have it, there is zero risk of infection.”
Healthcare-acquired conditions are still important, Deep says. “You want to get to zero on these, and you want to stay there. We may all understand that this isn’t attainable in the real world. But it has to be our mind set. So we have robust goal setting. We look at different domains of quality and safety and the intersect of importance, impact and ease of change.”
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