February 16, 2011

Quality & Patient Safety at Vanderbilt

Department of Biostatistics

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Crossing the Quality Chasm6 AIMS

S safeT timelyE effectiveE efficientP patient-centeredE equitable

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National Priorities PartnershipConvened by National Quality Forum

National Priorities and Goals:1. Engage patients and families in managing their

health and making decisions about their care2. Improve the health of the population

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3. Improve the safety and reliability of America’s health care system

- infection- adverse events- hospital level mortality rates- 30-day mortality rates post hospitalization

4. Ensure patients receive well-coordinated care within and across ALL healthcare organizations, settings, and levels of care

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5. Guarantee appropriate and compassionate care for patients with life-limiting illnesses

6. Eliminate overuse while ensuring the delivery of appropriate care

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Triple AIM1. Health of the

Population2. Reduced Costs in

Health Care3. Improve Safety,

Reliability, and Experience

- D. Berwick

Dr. Donald Berwick

Quality Pillar We relentlesslypursue and

measureourselves against

the highest qualityperformance in allareas, from patientcare to scholarship

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Quality Pillar: Q2 FY2011 ResultsGoal Q1 FY2011

ResultsQ2 FY2011

ResultsQ3 FY2011

ResultsQ4 FY2011

ResultsFY2010 Results Threshold Target Reach

Reduce O/E Mortality*

0.71* 0.78*Data through

Nov 2010

.73(FY11-0.75)*

0.76* 0.73* 0.71*

Reduce Healthcare Associated Infections

0.82 0.85Data through

Nov 2010

1.21 1.17 1.11 0.98

Reduce Adverse Events

9.24 9.42 9.50 8.08 7.67 7.27

Achieve Top Performance in Clinical Programs

86% 89% 89% 85% 90% 95%

Improve System Reliability

4 10 Not Applicable

6 - 7 8 - 9 10 - 12

Establish Quality Improvement Learning System

Progressing Developing Curriculum

Not Applicable

Develop curriculum

Develop standard tools and methods

Deliver to identified

target group

*Statistics for O/E reflect recalibration in October 2010, resulting in change to FY2011 goal to reflect Top 10, Top 5 and Top 3 of the US World & News Report peer group

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Reduce Healthcare Acquired Infections

GoalQ1 FY2011

ResultsQ2 FY2011

ResultsQ3 FY2011

ResultsQ4 FY2011

ResultsFY2010 Results Threshold Target Reach

Ventilator Associated Pneumonia

1.19 1.11 1.69 1.43 1.26 1.09

Central Line Associated Blood Stream Infections (ICU)

1.01 0.69 1.69 1.45 1.28 0.85

Surgical Site Infection

0.85 0.91Data through

Nov 2010

1.12 1.15 1.09 0.96

Catheter Associated Urinary Tract Infection

0.42 0.53 0.74 0.67 0.63 0.56

Hand Hygiene 79% 80% 77% 85% 90% 95%

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Hand Hygiene

Area

Numerator YTD FY2011

(Jul-Dec)

Denominator YTD FY2011

(Jul-Dec)

Compliance Rate YTD FY2011

(Jul-Dec) Threshold Target Reach

Adult Outpatient 4407 4733 93% 85% 90% 95%

Pediatric Outpatient 1005 1223 82% 85% 90% 95%

VPH 118 118 100% 85% 90% 95%

VCH 4355 6000 73% 85% 90% 95%

VUH 3019 4232 71% 85% 90% 95%

TOTAL 12904 16306 79% 85% 90% 95%14

Overall Historic Trend

y = 1.13x + 65.4R² = 0.58

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55

60

65

70

75

80

85

90

95

100

Jun. 2009 Jan. 2010 Sept. 2010

Com

plia

nce

Rate

Vanderbilt Handwashing Compliance Rate by Month

Rate

Linear (Rate)

Goal: 90% Hospitalwide Hand Hygiene Compliance

March 2011 Improvement Gap per trend

Reduce Adverse Events

GoalQ1 FY2011

ResultsQ2 FY2011

ResultsQ3 FY2011

ResultsQ4 FY2011

ResultsFY2010 Results Threshold Target Reach

Pressure Ulcers (per 1,000 pt days) 0.87 1.08 1.11 0.91 0.86 0.82

Falls (per 1,000 pt days) 3.57 3.75 3.62 3.16 3.00 2.84

Medication Errors (per 1,000 pt days) 4.80 4.59 4.61 4.01 3.81 3.61

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Achieve Top Performance in Clinical Programs

GoalQ1 FY2011

ResultsQ2 FY2011

ResultsQ3 FY2011

ResultsQ4 FY2011

ResultsFY2010 Results Threshold Target Reach

Stroke 85%(Data through

Aug 2010)

89%(Data through

Nov 2010)

91% 86% 91% 95%

Pneumonia 79% 72%(Data through

Nov 2010)

82% 83% 90% 95%

Heart Failure 93% 97%(Data through

Nov 2010)

90% 90% 95% 100%

SCIP 95% Not Available

91% 90% 94% 99%

OPPS 86% Not Available

92% 91% 94% 99%

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Vanderbilt Performs in Top Decile of Leapfrog Hospitals

(1,184 hospitals in 45 States)

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Reliable Process DesignGoal Q1 FY2011

ResultsQ2 FY2011

ResultsQ3 FY2011

ResultsQ4 FY2011

Results Threshold Target Reach

Medication Reconciliation

0 (Progressing)

1Develop

prototype based on admission

Expand prototype to

include discharge

Establish baseline and compliance measures

Blood Management

0 (Progressing)

0 (Progressing)

Build data set for process

Establish internal baseline

Implement monitoring

system

Universal Protocols

2 2Disseminate and spread electronic

process

Implement quantitative

and qualitative analysis of

process

Zero defect in surgical site

Handovers 2 2Finalize

standardized infrastructure

and tools

Disseminate and spread process to 3

areas

Target plus 2 additional

areas

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Building Collaborations to Improve Safety and Quality in Health Care

Challenge: Awards for the best graphical displays of data related to patient safety or quality improvement

Submission: Hang poster in the hall between offices of Frank and Lynda

Deadline: April 15, 2011