Broward Health Quality Improvement PlanACHPE 2015

Broward Health

Broward Health Medical Center Broward Health Coral Springs

Broward Health Imperial Point Broward Health North 2

System and Leadership

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Five Star Values

1. Accountability for Positive Outcomes2. Valuing our Employee Family3. Fostering an Innovative Environment4. Collaborative Organizational Team5. Exceptional Service to our Community

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Strategic PrioritiesSafety – provide quality and safe care to all we serveEvidence-based practice – ensure evidence-based practices are implemented and followedRecruit- and retain high performing staff Value – the differences in our culturally diverse workforce and communityImprove profitability – by continually identifying way to improve efficiencyCulture – promote a culture that consistently fulfills the needs of our staff, physicians, patients, families, and the community we serveExcellence – strive to be the best and work to improve performance that exceeds expectations 5

Broward Health Board Driving Quality

Change in CEO to a physician leader

Change in CEO compensation package

Change in Executive and Management staff incentive

package

Changing Employed Physician’s compensation package

Changing general staff incentive structure

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Performance Improvement

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Board of Commissioners(Governing Body)

Corporate Patient Care Key Group

Corporate Environment of Care Key Group

Regional Medical Councils Regional & Ambulatory Quality Councils

BHMC BHCS BHIP BHN CHS

Broward Health Quality and Patient Safety Goals

Safety/Quality Flow of Information

Quality Assessment and Oversight Committee

Region Specific Performance Improvement

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Broward Health Board of CommissionersQuality Assessment and Oversight Committee

Outcome Indicators Mortality Rates Readmission Rates

Patient Safety Indicators Catheter Associated Bloodstream Infections Catheter Associated Urinary Tract Infections Ventilator Associated Pneumonia Class II Surgical Site Infections Mislabeled Specimens Hospital-acquired Pressure Ulcers Early Elective Deliveries Falls Adverse Drug Events Door to Balloon Compliance Nurse Vacancy Rates

Efficiency Indicators ED Throughput

Risk Management and Environment of Care9

Benchmarking:Adverse OutcomesHospital-acquired infections

Catheter Associated Bloodstream Infections

Catheter Associated Urinary Tract Infections

Ventilator Associated Pneumonia

MortalityReadmissionsCardiothoracic SurgeryObstetric Hemorrhage Initiative

Agencies Include:Society for Thoracic SurgeryPress-GaneyCrimsonAvatarAgency for Healthcare Research and Quality (AHRQ)National Database of Nursing Quality Indicators (NDNQI)American College of Surgeons Commission on CancerHospital Engagement NetworkHealth Services Advisory GroupFlorida Perinatal Quality Collaborative

External Benchmarking

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Defining a High Reliability Organization

11Chassin, M. R., & Loeb, J. M., (2013). High-Reliability Health Care: Getting There from Here. The Joint Commission. Retrieved from http://www.jointcommission.org/assets/1/6/Chassin_and_Loeb_0913_final.pdf

• Complex, high risk industry where mistakes can equal great harm

• “ High Reliability Organizations are organizations with systems in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors “ – Quint Studer

Minimal Developing Approaching

Leadership

Quality activities focused on regulatory requirementsStrategic importance of quality improvement not recognizedMetrics for quality goals not part of the strategic plan or incentive compensationInformation technology provides little support for quality improvementPhysicians not actively engaged in quality improvement

Chief executive officer leads proactive quality agenda•Board reviews adverse events•Organization sets a few measurable quality aims•Information technology supports some quality and safety initiatives•Physician leaders champion quality goals in some areas

• Organization commits to goal of high reliability for all clinical services

• Organization aims for near-zero failure rates in vital clinical processes

• Some services demonstrate near zero failure rates in some vital clinical processes

• Information technology integral in sustaining quality improvement

• Physicians routinely lead quality efforts

Safety culture

No program to assess safety cultureNo assessment of trust or intimidating behaviorRoot-cause analysis limited to most serious adverse events close calls not recognized or evaluated

Establishing safety culture accorded high priority by leaders at all levels•First measures of safety culture deployed •Beginning initiatives to encourage reporting and analysis of close calls

• Safety culture is well established• Measurement of safety culture is

routine and drives improvement• Regular reporting of close calls

and unsafe conditions lead to early problem resolution

Robust process improvement

No formal quality management systemExternal requirements are focus of improvement effortsNo commitment to sustainable improvement

• Organizational commitment to adopt strong quality improvement tools

• Training of selected staff beginning• Improvement tools used to achieve

gains in quality and safety in addition to routine business processes

• Robust performance improvement tools used throughout the organization

• Patients engaged in redesigning care processes

• Mandatory training of all staff in robust process improvement

• Proficiency in robust process improvement required in career advancements

TJC Reliability Model – Broward Health ProgressBroward Health Current State

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Key Broward Health Accomplishments/ Initiatives

Leadership

• Leadership accountability for quality and safety tied to performance incentive

• Transparency of clinical processes to Board of Directors through Quality Assessment and Oversight Committee

• Demonstration of system-wide low mortality rates• High level of compliance with ORYX and core measures• Physician leadership of quality committees and key quality

initiatives throughout Broward Health• System-wide CEO led patient safety and satisfaction rounds

Safety Culture• Routine root cause analysis of near misses with corrective actions• Non-punitive reporting policy• Quarterly system-wide patient quality and safety meeting• Huddles to address quality and safety issues

Robust Process Improvement

• Process improvement/ lean/ six sigma belt training available• Well established process improvement department and utilization

of lean / six sigma tools

TJC Reliability Model – Broward Health Progress

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Broward Health – Harm Star

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Performance Improvement Objectives 2015

Decrease fall rates to below the NDNQI benchmark Decrease mislabeled specimen rates Early removal of indwelling urinary catheters using the HOUDINI protocol Decrease hospital-acquired infections through the Healthcare- Associated Infection (HAI) Prevention Collaborative utilizing the Health Services Advisory Group (HSAG) Improve the management and outcomes of patients with sepsis Improve ED throughput to state averages Decrease HAPU rates to below the NDNQI benchmark Decrease readmission rates at or below the Crimson benchmark Maintain potentially preventable VTE at zero Continue journey to becoming a high reliability organization

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2015System-Wide Quality & Patient Safety Initiatives

Outcome Indicators Mortalities Readmissions

Infection Control Indicators CAUTI CLABSI VAE Surgical site infections C-difficile Compliance rates for influenza vaccine for staff and physicians Reduction of MDROs

Efficiency Indicators ED throughput Decrease number of ED patients leaving without being seen 16

2015System-Wide Quality & Patient Safety Initiatives

Patient Safety Indicators HAPU Falls Adverse Events Early Elective Deliveries Mislabeled Specimens Adverse Drug Events Management of Sepsis (new for 2015) Potentially preventable VTE

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2015System-Wide Quality & Patient Safety Initiatives

Participated in the Hospital Engagement Network (HEN) project (2012 through 2014); Will be participating in HEN II Six Sigma Methodology implemented in all facilities Ongoing Six Sigma Training is being conducted System-wide Six Sigma Showcase was held in July 2014 to present projects and share results and best practices The Advisory Board Company Crimson Continuum of Care Program was implemented. This tool is used to identify areas of opportunity as well as benchmarking.

Participating in AHRQ Patient Safety Initiatives to decrease falls and pressure ulcers.

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SAFETY CULTURE

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• Key dimensions to improve quality and reduce harm:– Setting Aims

3.86

4.32

2.00

2.402.19

4.003.86

1.03

6.92

1.92

3.02

1.00

0.00

1.08 1.161.40

2.25 2.30

3.102.81

0.90

0.00

1.14 1.08 1.12

2.08

1.24

R² = 0.2425

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Rate

of

Infe

cti

on

s

Jun-12 - Aug-14

BHMC Run Chart of Central Line Infection Associated Bacteremia (CLABSI) in the Critical Care Units: Rate per 1000 Line Days

PURPOSE: Reduce the number of CLABSI in the Adult Critical Care Units by 50%between: July 1 and December 3, 2014 as compared to January 1 andJune 30, 2014

IMPROVEMENTS:Identified and Implemented process changes in maintenance of central lines: improved insertion/cleaning methodology and periodic retraining of nurses.

RESULT: Rate of infection decreased from 1.5 in Feb to 1.03 in Aug 2014.

SAFETY CULTURE

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• Key dimensions to improve quality and reduce harm:– Establishing and monitoring system-level measures

Catheter Associated Urinary Tract InfectionsICU

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Medication Management

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Medication Management Initiatives Types of technology used

Cerner Millennium Smart pumps (Hospira Plum) Barcoded medication administration Pyxis Epidural pumps/PCA pumps (Bbraun) ePrescribing – February 2015

95% implementation of Computerized Provider Order Entry (CPOE) 2013 Standardized order sets using evidence-based guidelines using PowerPlan Population specific pharmacists Reduce likelihood of patient harm by better management of anticoagulation therapy 23

Medication Management Initiatives System-wide policies and procedures

Management of high-risk medications Look alike, sound alike medications Hypoglycemic protocol Insulin therapy protocol Heparin protocol Vasoactive titration guide Standardized concentration for drips

Reporting of medication errors through RiskQual Technologies Health Advisory Series (H.A.S) program Broward Health Complete Trials and research studies

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Infection Control Key Initiatives

Hand Hygiene Campaign Personal Protective Equipment Elimination of Hospital Acquired Infections (HAI)

Central Line Associated Bloodstream Infections (CLABSI)Catheter Associated Urinary Tract Infections (CAUTI)Ventilator Associated Events (VAE)Surgical Wound InfectionsMultidrug Resistant Organisms (MDRO)

• C-difficile, VRE, CRE, MRSA

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Infection Control Program

CDC, APIC, AORN Guidelines Risk Assessment, Prioritization, Planning, Implementation, and Evaluation

Ongoing and annually Root Cause Analysis as needed

Targeted surveillance NHSN definitions for reporting

System-wide epidemiology meetings Standardization of plans, policies Standardization of products and best practices

MedMined computer system for surveillance and antimicrobial stewardship

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Patient SafetyDelivery of Care Overview

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UPDATEValue Based Purchasing

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Delivery of Care Initiatives Interdisciplinary Provision of Care Policies and Procedures The Journey to Interdisciplinary Rounds:

DSC Programs Pain Behavioral Health Hospitalists (Pediatric and Adult) Neonatologists Intensivists Journey to Top of Licensure Practice

Interdisciplinary Communication Support Electronic Plan of Care Electronic Patient Education Record (Teachback) Decision Support and Alerts Various Screen Views to aggregate the process of care Each hospital has prioritized a sequence of hourly rounding, bedside report and shift

huddles

Focus on Standardizing Resource Systems Lexicomp®, Cerner Content, Lippincott, Ovid

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Environment of Care

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Abbe Bendell, RN, BSN, MBAVice President

Abendell@BrowardHealth.org