LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER SHREVEPORT

Transcription

1 LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER SHREVEPORT (HOSPITAL WIDE) PERFORMANCE IMPROVEMENT AND PATIENT SAFETY PLAN 2013 Leisa Oglesby, BSRN, MBA, CPHQ Executive Director of Medical Services Date Kevin Sittig, MD Senior Associate Dean for Clinical Affairs/ Chief Medical Officer Date Joseph Miciotto Hospital Administrator Date (Board Approval) The information, data and reports used in the Medical Staff and Resident Peer Review Process may only be provided to the following for review: The attribution physician, the Department Chairperson of the attribution physician, the Medical Director and, in cases involving litigation, Legal Affairs 1

2 Table of Contents Performance Improvement and Patient Safety Performance Improvement Plan I. Introduction 3 II. Performance Improvement & Patient Safety Goals 5 III. Design 6 IV. Measure 6 V. Assess 7 VI. Improve 18 VII. ATTACHMENTS: A PI Communication Process Attachment A B. LSUHSC-S PI Reporting Process Attachment B C. LSUHSC-S Performance Improvement Cycle Attachment C D Hospital Wide Generic Indicators Attachment D E. Medical Staff, Resident & APP Peer Review Process Attachment E F. Medical Staff, Resident & APP Appeal Process Attachment F G. MD/ APP Profile Form Attachment G H. FPPE Process Attachment H I. OPPE Process Attachment I J. Physicians Profile Report Attachment J K. Adjunctive Staff OPPE Process Attachment K L. Adjunctive Staff FPPE Process Attachment L M. Electronic Health Record (EHR) Meaningful Use Measures (Stage One Measures) Attachment M N. 2013Variance Process Attachment N 2

3 PERFORMANCE IMPROVEMENT & PATIENT SAFETY PLAN INTRODUCTION The Performance Improvement and Patient Safety Plan is a description of the organizational, multidisciplinary, and systematic performance improvement function designed to support the Mission, Values, and Philosophy of the University Health Sciences Center. The Performance Improvement Communication Process may be found in (Attachment A). The intent of the Performance Improvement and Patient Safety Plan is to identify the facility s systematic approach to improving and sustaining its performance through the prioritization, design, implementation, monitoring, and analysis of performance improvement initiatives. Moreover, the Performance Improvement and Safety Plan is an ongoing program that demonstrates measurable improvement in indicators for which there is evidence that they will improve patient outcomes, and identify and reduce medical errors. All Performance Improvement and Patient Safety activities / processes are depicted in (Attachment B). In accordance with the 2012 Joint Commission (TJC) Standards, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (COPs) and the vision of the facility established expectations include but are not limited to: 1. Providing a safe environment for patients, visitors, and staff. 2. Performing patient care services in a timely and efficient manner. 3. Participation of all staff in Performance Improvement activities. The Performance Improvement and Patient Safety Plan, with total support of Leadership, will utilize internal and external reference databases in an ongoing effort to design, measure, assess, and improve the organization (Attachment C). The needs, opinions, and perceptions of safety risks to patients, visitors, and staff as well as suggestions for improvements are also incorporated into the plan. The organization s approach to Performance Improvement and Patient Safety is guided by, but not limited to, the following Joint Commission standards: PI PI PI PI The hospital collects data to monitor its performance. The hospital compiles and analyzes data. The hospital improves its performance on ORYX accountability measures. The hospital improves performance on an ongoing basis. LD The governing body is ultimately accountable for the safety and quality of care, treatment and services. LD The mission, vision, and goals of the hospital support the safety and quality of care, treatment, and services. LD The governing body, senior managers and leaders of the organized medical staff address any conflict of interest involving leaders that affect or could affect the safety or quality of care, treatment and services. 3

4 LD The governing body, senior managers and leaders of the organized medical staff regularly communicate with each other on issues of safety and quality. LD The hospital manages conflict between leadership groups to protect the quality and safety of care. LD Leaders create and maintain a culture of safety and quality throughout the hospital. LD The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality. LD Leaders use hospital-wide planning to establish structures and processes that focus on safety and quality. LD The hospital communicates information related to safety and quality to those who need it, including staff, licensed independent practitioners, patients, families, and external interested parties. LD Leaders implement changes in existing processes to improve the performance of the hospital. LD Those who work in the hospital are focused on improving safety and quality. LD The hospital has policies and procedures that guide and support patient care, treatment, and services. LD The hospital makes space and equipment available as needed for the provision of care, treatment, and services. LD The leaders address any conflict of interest involving licensed independent practitioners and/or staff that affects or has the potential to affect the safety or quality of care, treatment, and services. LD The hospital provides services that meet patient needs. LD Patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital. LD Care, treatment, and services provided through contractual agreement are provided safely and effectively. LD The hospital manages the flow of patients throughout the hospital. LD Leaders establish priorities for performance improvement. 4

5 LD New or modified services or processes are well designed. LD The hospital has an organization-wide, integrated patient safety program within its performance improvement activities. LD The hospital considers clinical practice guidelines when designing or improving processes. Performance Improvement & Patient Safety Goals The hospital s approach to performance improvement is continuously assessed and revised to meet the goal of ensuring that patient outcomes are continually improved and safe patient care is provided. Examples of information utilized to achieve this goal include: variance related data such as medication errors and falls; infection control surveillance; sentinel event alerts; and TJC/CMS Quality Measure data, as well as, patient satisfaction reports. Staffing effectiveness data focusing on patient complaints, patient falls, staff turnover and employee injuries is also addressed. The hospital recognizes that to be effective in improving patient safety there must be an integrated and coordinated approach to reducing errors. To such an end, Louisiana State University Health Sciences Center has a Performance Improvement/Patient Safety list of goals that include, but are not limited to the following high risk, high volume, high cost, and potentially increased patient safety risk priorities: 1. Achievement of a Patient Safety conscious environment integrated throughout the facility. 2. Improve the reporting of medical errors by establishing a policy focusing on corrective actions through staff education for those reporting their errors, rather than punitive or disciplinary actions. 3. Implementation of a confidential online Variance/Sentinel Event reporting process that identifies a safety risk index to analyze harm score distribution for reported incidences. 4. Monitoring of hospital-wide indicators in comparison to their thresholds. 5. Reducing the number of medication errors. 6. Monitoring completion of informed consent. 7. Reducing the number of falls. 8. Decreasing staff turnover rates and retention of qualified staff by monitoring staffing effectiveness. 9. Develop a process to address right site surgery. 10. Monitoring of patient safety indicators related to an area s specific Scope of Service. 11. Identifying an area for improvement and completing a Failure Mode, Effects Analysis. 12. Monitoring and improving areas identified through Patient Satisfaction. 5

6 DESIGN In order to design or redesign effective processes, functions or services, the following key elements are considered when relevant and available: 1. The process design is based on the organization s mission, vision and strategic imperatives. 2. Consideration is given to the needs and expectations of patients, staff, and others, as well as, the direct effect or criticality of the design on patients. 3. Research of current literature and practice guidelines are reviewed for successful or best practice(s). 4. Design is consistent with sound business practices. 5. Baseline performance expectations are utilized to guide measurement and assessment activities. Performance monitoring and evaluation standards are department, division, service line and/or population focused. Certain processes are measured on an ongoing basis both in response to occurrences and proactively. Selected processes which are high volume, problem prone, high risk, and high cost are measured on an ongoing basis using the four step TJC Cycle for Improving Organizational Performance, Design, Measure, Assess, and Improve. Performance Improvement projects that are designed or redesigned to monitor expected performance within the hospital are developed to measure, assess, improve and maintain process improvements. Performance levels may be established through comparison performance with other like facilities to identify variations or failure modes. Comparative data is used from the UHC, NACHRI, LHCR, or current/past department performance. Each activity monitored has an established performance level or threshold to measure expected performance. A strategy for maintaining the effectiveness of the redesigned process over time is also implemented. MEASURE Data collection is the basis of all Performance Improvement activities and provides a means of measuring performance through which informed decisions can be made. 1. Program data is collected for a comprehensive set of performance measures based on the priorities established by the leaders of the organization in order to: a. Establish a baseline when a process is implemented or redesigned. b. Describe process performance or stability. c. Describe the dimensions of performance or stability. d. Describe the dimensions of performance relevant to functions, processes, and outcomes. e. Identify areas for improvement including the effect on patients. f. Determine whether changes in a process have met objectives g. Implement a strategy for maintaining the effectiveness of the redesigned process over time. 2. Data is collected as a part of continuing measurement, in addition to data collected for priority issues. 3. Data collected considers measures of processes and outcomes. 4. Data collection includes at least the following processes or outcomes: 6

7 a. Operative and other invasive and noninvasive procedures that place patients at risk b.processes related to medication usage/errors c. Processes related to the use of blood and blood components d. Needs, expectations, safety, and satisfaction of patients e. Quality Control Activities 1. Clinical and Support Departments 2. Medical Staff Departments 3. Medical Staff Committees 4. Variance Reporting 5. Patient Satisfaction 6. Patient Complaints ASSESS Program activities involve the assessment process, which includes the necessary discipline of departments to draw conclusions about the need for more intensive measurement. A systematic process is used to assess collected data in order to determine whether specifications for newly designed processes were met and the level of performance and stability of important existing processes. Priorities for possible improvements or redesign of existing processes, actions taken to improve the performance improvement processes and whether changes in the processes resulted in improvement are also assessed. Collected data is reported monthly and analyzed quarterly. Findings are documented and are forwarded through the performance improvement communication structure. Quarterly reports are compiled through the Quality Management Department and reviewed by the Quality Leadership Team. Quarterly reports would include the following: Variance Report LSUHSC will utilize online variance reporting (Attachment N) to identify events or occurrences requiring rapid problem solving. Variances are forwarded to the Quality Management Department for investigation. Variances, including patient safety issues, are forwarded to the Safety Department for prompt investigation, reporting to external agencies in accordance with law and regulation, resolution, tracking and trending. Any employee or physician who witnesses an unusual or unexpected event, which has the potential to result in an undesirable outcome for the patient, may initiate variance reports. Risk reduction and appropriate problem solving will be documented, tracked and trended. A Harm Score Distribution is used to assess the degree of risk. Certain serious outcomes will be reported to the State of Louisiana and other regulatory agencies as required. Monthly and Quarterly results are reported to the Quality Leadership Team and action taken as appropriate. Patient Satisfaction Patient Satisfaction surveys are utilized to evaluate the needs and expectations of patients including safety needs. AVATAR coordinates and submits the Satisfaction Survey results to CMS to ensure compliance with the HCAHPS requirements and these survey results are reported quarterly to the Quality Leadership Team for follow up internally. The Quality Management Department works in concert with the Ambulatory Care Division to compile and 7

8 submit Outpatient Satisfaction Survey results. The Quality Leadership Team and Clinical Board review a summary of the findings quarterly. When opportunities for improvement are identified, pertinent information is forwarded to the appropriate department or individual for review, evaluation, and action as necessary. Patient Complaints The Patient Relations Department is a resource to patients and families in helping address unmet needs or complaints that have not been resolved through front-line efforts. Patient Issues Committee facilitates the patient grievance process. The activities provide resolution to enhance the patient s experience. Sentinel Event - Sentinel events are one source of identification of opportunities for improvement. LSUHSC has adopted The Joint Commission s (TJC) definition of a sentinel event, which states, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, or the risk thereof, includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response. The terms sentinel events and medical error are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events. Events may include unanticipated death or major permanent loss of function, an infant abduction, an infant discharged to the wrong family, rape by another patient or staff, hemolytic transfusion reaction, surgery on the wrong patient or wrong body part, equipment malfunction resulting in paralysis or loss of life, medication error resulting in death or near death, nosocomial infection resulting in unanticipated death or major permanent loss of function, or suicide of an inpatient. Root Cause Analysis (RCA) is a process for identifying the basic or causal factors that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individual performance. A standardized format developed by the TJC called a RCA, Root Cause Analysis, has been adopted to investigate all sentinel events. An adverse outcome that is directly related to the natural course of the patient s illness or underlying condition, except for suicide in the hospital, or any Near Miss in which a recipient of care was not actually or permanently affected is not considered a reportable sentinel event. Near Miss A near miss represents an opportunity to proactively identify and implement a risk- reduction strategy and action plan that includes measurement of the effectiveness of process and system improvements to reduce risk. LSUHSC has adopted the Joint Commission s definition of a near miss, which states, any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome. Such a near miss falls within the scope of a definition of a sentinel event, but outside the scope of those sentinel events that are subject to review by The Joint Commission under its Sentinel Event Policy. 8

9 TJC / CMS Quality Measures - LSUHSC participates in the UHC Clinical Database for monitoring and reporting of TJC/CMS Quality Measures. TJC / CMS Quality Measures were designed to permit more rigorous comparisons using standardized, evidenced based measures to identify performance outcomes. The Core Measures have been added to the list of hospital-wide indicators for the Medical Staff and Resident Peer Review Process The following is a list of the inpatient and outpatient core measures and their related indicators for 2013: INPATIENT and OUTPATIENT CORE MEASURES: INPATIENT Core Measure GROUP AMI PN CHF AMI-01 AMI-02 AMI-03 AMI-05 AMI-07 AMI-08 AMI-10 PN-03a PN-03b PN-06a PN-06b CHF-01 CHF-02 CHF-03 INDICATORS ACUTE MYOCARDIAL INFARCTION ASA at arrival or contraindication documented ASA prescribed at discharge or contraindication documented ACEI or ARB for LVSD prescribed at discharge or contraindication documented Beta Blocker prescribed at discharge or contraindication documented Fibrinolytic therapy received within 30 minutes of hospital arrival PCI received within 90 minutes of hospital arrival Statin prescribed at discharge PNEUMONIA Blood cultures performed within 24 hrs prior to / or 24 hrs after hospital arrival Blood cultures performed in ED prior to initial antibiotic received Initial antibiotic selection for CAP in Immunocompetent patient (ICU) Initial antibiotic selection for CAP in Immunocompetent patient (Non-ICU) CONGESTIVE HEART FAILURE Written discharge instructions for CHF include: Level of activity, diet, medications, followup appointment, weight monitoring, and worsening of symptoms documented that educational material given to pt. Documentation of LVS function evaluated before arrival, during hospitalization or planned after discharge Documentation of ACEI and/or ARB prescribed at discharge for patient with LVSC (LVEF,40%) or contraindication documented for BOTH ACEI and ARB 9

10 INPATIENT and OUTPATIENT CORE MEASURES (continued): INPATIENT Core Measure GROUP ED INDICATORS ED -THROUGHPUT ED-01 Median Time from ED arrival to ED Departure for Admitted ED Patients IMM SCIP HBIPS ED-02 IMM 1b IMM 1c IMM 2 SCIP INF-1 SCIP INF-2 SCIP INF-3 SCIP INF-4 SCIP INF-6 SCIP INF-9 SCIP INF-10 SCIP Card-2 SCIP VTE-1 SCIP VTE-2 HBIPS-1 HBIPS-2 HBIPS-3 HBIPS-4 HBIPS-5 HBIPS-6 HBIPS-7 Admit Decision Time to ED Departure Time for Admitted Patients GLOBAL IMMUNIZATION MEASURE SET Pneumococcal Immunization- Age 65 and older Pneumococcal Immunization- High Risk Populations (Age 6 through 64 years) Influenza Immunization SURGICAL CARE IMPROVEMENT PROJECT Prophylactic antibiotic received within 1 hour prior to surgical incision Prophylactic antibiotic selection for surgical patients Prophylaxis antibiotics discontinued within 24 hours after anesthesia end time Cardiac surgery patients with controlled 6 a.m. post-operative serum glucose Surgery patients with appropriate hair removal Urinary catheter removed on post-op Day 1 or post-op Day 2 with day of surgery being day zero Surgery patients with peri-operative temperature management Surgery patients on Beta Blocker Therapy prior to arrival who received a beta blocker during the peri-operative period Surgery patients with recommended venous thromboembolism prophylaxis ordered Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery HOSPITAL-BASED INPATIENT PSYCHIATRIC SERVICES Admission screening for violence risk, substance abuse, psychological trauma history and patient strengths completed Hours of physical restraint use Hours of seclusion use Patients discharged on multiple antipsychotic medications Patients discharged on multiple antipsychotic medications with appropriate justification Post discharge continuing care plan created Post discharge continuing care plan transmitted to next level of care provider upon discharge 10

11 INPATIENT and OUTPATIENT CORE MEASURES (continued): INPATIENT Core Measure GROUP STK INDICATORS STROKE STK-1 Venous Thromboembolism (VTE) Prophylaxis STK-2 Discharged on Antithrombotic Therapy STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter STK-4 Thrombolytic Therapy STK-5 Antithrombotic Therapy by End of Hospital Day 2 STK-6 Discharged on Statin Medication STK-8 Stroke Education VTE STK-10 VTE-1 VTE-2 VTE-3 VTE-4 VTE-5 VTE-6 Assessed for Rehabilitation VENOUS THROMBOEMBOLISM Venous Thromboembolism Prophylaxis Intensive Care Unit Venous Thromboembolism Prophylaxis Venous Thromboembolism Patients with Anticoagulation Overlap Therapy Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol Venous Thromboembolism Discharge Instructions Incidence of Potentially-Preventable Venous Thromboembolism OUTPATIENT Core Measure GROUP SCIP INDICATORS OP-6 SURGICAL CARE IMPROVEMENT PROJECT Timing of Antibiotic Prophylaxis (Prophylactic ABX initiated within 1 Hr. prior to Surgical Incision) ED OP-7 OP-18 OP-19 Antibiotic Selection ED -THROUGHPUT Median time from ED arrival to ED departure for discharged ED patients Transition record with specified elements received by discharged patients OP-20 Door to Diagnostic Evaluation by a Qualified Medical Personnel PM PAIN MANAGEMENT OP-21 Median Time to Pain Management for Long Bone Fracture STROKE OP-23 STROKE Head CT/MRI scan results for Acute Ischemic Stroke or Hemorrhagic Stroke patients who received head CT/MRI scan interpretation within 45 minutes of ED arrival 11

12 Hospital-Acquired Conditions - Foreign object retained after surgery - Air Embolism - Blood incompatibility - Stage III and IV pressure ulcers - Falls and Trauma Fractures Dislocations Intracranial Injuries Crushing Injuries Burns Other Injuries - Manifestations of poor glycemic control Diabetic Ketoacidosis Nonketotic Hyperosmolar Coma Hypoglycemic Coma Secondary Diabetes with Ketoacidosis Secondary Diabetes with Hyperosmolarity - Catheter-associated urinary tract infection (UTI) - Vascular catheter-associated infection - Surgical site infection following: o Coronary Artery Bypass Graft (CABG) Mediastinitis o Bariatric Surgery for Obesity Laparoscopic Gastric Bypass Gastroenterostomy Laparoscopic Gastric Restrictive Surgery o Certain Orthopedic Procedures Spine Neck Shoulder Elbow o Following Cardiac Implantable Electronic Device (CIED) - Deep vein thrombosis (DVT)/Pulmonary embolism (PE) following: o Certain Orthopedic Procedures Total Knee Replacement Hip Replacement - Iatrogenic Pneumothorax with Venous Catheterization Any performance measure outlier is investigated to determine reasons expected performance was not achieved. The Quality Management Department identifies outlier cases and determines which departments need to improve performance. o Central Line Associated Bloodstream Infections (CLABSI), as defined by the Centers for Disease Control and Prevention (CDC) - The tracking and reporting of Central Line Associated Bloodstream Infections (CLABSI) as defined by the CDC and to meet the requirements of the Centers for Medicare and Medicaid Services Hospital Quality Reporting Program will be managed by the Infection Control Department. The annual Infection Control Plan will specify the frequency of reporting in detail. 12

13 Pelican / EPIC reports - The transition over to the Electronic Health Record (EHR) that began in November 2011 continues to evolve. The previously utilized Patient Safety Report (Quality Performance Report) will now be replaced by reports accessed by the departments via the Reporting module from within the EPIC systems. An example of one of the Reporting modules is the WILLOW module; which is utilized by the Pharmacy Department to capture and report various Medication Administration functions for the hospital. Reports are being developed to track various patient safety areas of concern within the hospital based on EHR attestation requirements, as well as Meaningful Use requirements (see also attachment M). The new EPIC reports shall be accessed by individual departments and scheduled for reporting (daily, weekly, monthly, quarterly, etc.) to hospital administration as deemed appropriate based on data content. Areas of concern include: Eligible Professional (EP) Measures: EP Core Objectives CPOE Drug-Drug and Drug-allergy checks Up-to-Date Problem list Maintain Medication List Maintain Medication Allergy List Record Demographics (language, gender, race, ethnicity, date of birth) Record and chart vital signs (height, weight, blood pressure, BMI, growth charts (2-20 y/o) including BMI Record smoking status for patients >/= 13 y/o Clinical Decision Support After Visit Summary E-Prescribing Report ambulatory quality measures to CMS Electronic Copy of Health Information Exchange Key Clinical Information Electronically Protect Electronic Health Information EP Menu Objectives Drug formulary check Patient education Medication Reconciliation Summary of Care Incorporate clinical lab-test results Generate list of patients by specific conditions Electronic access for patients Submit data to immunization registries EP Quality Measures Core Set Tobacco Use Assessed and Cessation Intervention documented BMI Documented and Follow (>/= 18 y/o) Patients >/= 18 y/o have Blood pressure documented Alternate Core set Patients >/= 50 y/o receive Influenza Immunization Childhood Immunization Status BMI Documented (2-18 y/o) Additional Set Controlling High Blood Pressure 13

14 Preventative Care and Screening: Advising Smokers to Quit Breast Cancer Screening Chlamydia Screening for Women Pneumonia Vaccination Status for Older Adults Prenatal Screening for HIV LSUHSC-S Eligible Professionals will be following 12 Quality Measures (3 Core set, 3 Alternate Core set, & 6 Additional Measures) Eligible Hospital (EH) Measures: EH Core Objectives Comprehensive Physician Order Entry (CPOE) Drug to Drug and Drug Allergy Checks Maintain up-to-date problem list Maintain an active medication list Maintain medication allergy list Record demographics (language, gender, race, ethnicity, date of birth, date/preliminary cause of death) Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth charts for children </= 2 years of age with BMI) Record Smoking status for patients >/= 13 years of age Clinical decision support Provide patients with an electronic copy of their discharge instructions at the time of discharge Report hospital quality measures to CMS Provide patients an electronic copy of their health information Capability to exchange key clinical information among providers of care electronically Protect electronic health information created or maintained by the certified EHR EH Menu Objectives Implement Drug-Formulary Checks Record Advance Directives for patients >/= 65 years of age Summary of Care provided to accepting provider Generate list of patients by specific conditions to use for quality improvement Use certified EHR technology to identify patient-specific education resources Medication Reconciliation on patients transferred from another facility Incorporate clinical lab-test results Capability to submit electronic date to Immunization Registries EH Quality Measures Emergency Department median time of arrival to departure, Emergency Department median time of admit decision to departure, Ischemic stroke patients prescribed antithrombotic at discharge Ischemic stroke patients with atrial fibrillation/flutter prescribed anticoagulation therapy at discharge Acute Ischemic Stroke patients receive tpa within 2 hours Ischemic Stroke patient administered antithrombotic therapy by the end of hospital day 2 Ischemic Stroke patients with LDL > 100 on lipid lowering medication prior to arrival are prescribed statin at discharge Ischemic or hemorrhagic stroke patients or caregivers given educational materials during hospital stay Ischemic or hemorrhagic stroke patients assessed for rehabilitation services VTE prophylaxis within 24 hours of arrival ICU VTE prophylaxis Anticoagulation overlap therapy Platelet monitoring on unfractionated heparin VTE discharge instructions Incidence of potentially preventable VTE 14

15 Cooperative Forums LSUHSC-S participates in the Louisiana Health Care Review (LHCR) Cooperative forums to benchmark our results with other Louisiana facilities. Departmental Performance Improvement Report The following departments participate in ongoing Performance Improvement activities using The Joint Commission Cycle for Improving Performance, Design, Measure, Assess, and Improve. The departments/clinics/units include: Admitting, Biomedical Engineering, Bone Marrow Unit, Cancer Registry, Cardiopulmonary Dept., Central Medical Supply, Clinical / Anatomic Pathology Lab, Clinical Neurophysiology, Echo Lab, Environmental Services, Heart Cath Lab, Hospital Telecommunications, Infection Control, Laundry & Linen, Medical Education, Medical Records, Medical Staff, Nursing: ACD / OTPT Care Clinics, Ophthalmology (Eye) clinic, Nursing: ECC / Emergency services, Nursing: FWCC, Nursing: PCS/ INPT Care depts., Nutritional Services, Patient Relations, Perfusion Services, Pharmacy, Physical Plant, Public Safety (UPD), Quality Management, Radiology, Rehabilitation Services, Social Services, Special Hematology Lab, Trauma Registry, All departments participate in ongoing monitoring and evaluation using the TJC, Cycle for Improving Performance. Quarterly the Quality Leadership Team reviews results and work with Department Directors regarding their performances. Performance Improvement activities are reported to the Clinical Board through the Quality Leadership Team. University HealthSystem Consortium (UHC) Cooperative Studies LSUHSC participates in cooperative studies coordinated by UHC. The clinical benchmarking/process improvement projects collect and use data to develop best practices and reduce cost, increase efficiency, and improve the quality and safety of patient care. Cooperative Studies for 2012 include, but are not limited to: Rapid Rescue Response Catheter Associated Urinary Tract Infections (CAUTI) Project through cooperation with UHC s Health Engagement Network (HEN) Quality Improvement Committee Establishes hospital-wide indicators (Attachment D) and oversees the Medical Staff and Resident Peer Review process to ensure consistency and optimal patient care including patient safety. Peer Review results are monitored and tracked and level 3 s and 4 s are reported to the Credentials Committee monthly. In addition, physician profiles are used at the time of reappointment to support physician performance for reappointment to the medical staff. Recommendations are made to the Clinical Board for approval to improve patient outcomes. Clinical Board Monitors and approves the clinical operations of the hospital including Medical Staff appointment and re-appointment, approval of adjunctive staff and Medical Staff Credentialing, Hospital Policies and other issues impacting greater than one department. 15

16 Medical Staff Each Medical Staff Department participates in the hospital s peer review process (Attachment E), as well as, the Clinical Appeals Process (Attachment F). The Medical Staff Department Chairperson approves aspects of care to be monitored, based on high volume, high risk, high cost, or problem prone procedures/diagnoses. Each month the designated Department Peer Reviewer receives cases and renders a preliminary disposition. The cases are reviewed and returned to Quality Management for tracking and trending. Cases that are rendered a preliminary disposition of Level One, Clinical Practice/Treatment within National Standard of Care, require no further review. Cases that have a preliminary disposition of two, Questionable Clinical Practice/Treatment not Clearly within National Standard of Care, are referred to the Medical Staff Department Quality Council for review and a final level of disposition is rendered. Final dispositions may include: Level 1 - Clinical Practice/Treatment within National Standard of Care. (No further review necessary). Level 2a- Questionable Clinical Practice/Treatment Not Clearly Within National Standard of Care reflecting a Documentation Issue. Level 2b - Questionable Clinical Practice/Treatment Not Clearly Within National Standard of Care reflecting a Clinical Concern/Issue. Level 3 - Clinical Practice/Treatment does not meet National Standards of Care and has a low probability of causing patient harm. Level 4 - Clinical Practice/Treatment does not meet National Standards of Care and has a high probability of causing patient harm. Monthly and Quarterly Department Chairpersons receive departmental performance summaries. Resident Program Chairpersons receive quarterly resident performance summaries. All mortality reviews are discussed and documented in the department s monthly meeting. Monthly meeting minutes are kept in each department and a copy forwarded to the Quality Management Department. Each Medical Staff Department participates in: Focused Professional Practice Evaluation (FPPE): A process (Attachment H) in which the organization evaluates the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization. FPPE is a time limited period during which the organization evaluates and determines the practitioner s professional performance. Focused Professional Practice Evaluations (FPPEs) will be completed on all new physicians. For each physician, a minimum of 3 cases will be reviewed for each privileged category (privilege group) requested within the first year of practice. For all adjunctive staff members, (CRNA, PA, FNP, CNM, CNS, NP, NNP, PNP, PhD, and LPC) a focused evaluation will be completed on the ACGME six competencies, which include the following: Patient Care, Medical Knowledge, Practice Based, Interpersonal and Communication Skills, Professionalism, and Systems Based Practice. For an overview of this process for adjunctive staff, see Attachment L. 16

17 The organized medical staff does the following: Evaluates practitioners without current performance documentation at the organization. Evaluates practitioners in response to concerns regarding the provision of safe, high quality patient care. Develops criteria for extending the evaluation period. Communicates to the appropriate parties the evaluation results and recommendations based on results. Implements changes to improve performance. At time of initial appointment, the department Chairperson will identify the specific cases to be reviewed for evaluation of permanent status; also individual privileges will be decided by the department Chairperson for each applicant based upon the privileges requested at time of initial application. The Joint Commission standards MS : The organized Medical Staff defines the circumstances requiring monitoring and evaluation of a practitioner s professional performance. In addition, each Medical Staff Department also participates in: Ongoing Professional Practice Evaluation (OPPE): The OPPE process (Attachment I) allows the organization to identify/monitor the individual professional practice trends that impact on quality of care and patient safety. For new procedures and new equipment, 100% chart review is completed. Additionally, physicians are monitored by two separate OPPE processes: 1. For each physician that comes up for reappointment monthly, 40 charts are reviewed, based on the previous 24 month time period. This information is then presented to the Department Chairperson and Credentials Committee to be used in the decision for reappointment. 2. On a quarterly basis, a physician profile report (See Attachment J) is generated that identifies a detailed listing of cases by physician. In addition, each Department Chairperson and each Program Director receives the results of cases entering peer review for specific indicators. (See complete list of indicators in attachment D) 3. Items #1 & #2 above will also apply to all adjunctive staff. Please see Attachment K for an overview of this process for the adjunctive staff members. The Joint Commission standard MS : Ongoing Professional Practice Evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privilege(s) or to revoke an existing privilege prior to or at the time of renewal. Attachment G is an example of the OPPE form (UHC MD/ APP Profile Form) which is used to report the results of a physician s performance for a 24 month period. The results are used by the Department Chairperson and the Credentials 17

18 Committee to evaluate the performance of the individual practitioner based on privileges granted. Medical Staff Committees The Medical Staff Committee chairpersons are responsible for assessing the Performance Improvement activities related to their assigned committees and recommending policy and operational changes based on analysis of committee related data. Each of the Medical Staff committees submits a monthly report to the Clinical Board. The Medical Staff committees include: Operative, and Other Invasive Procedure Review Committee Antibiotic Review Committee Cancer Committee Blood Utilization Review Committee Pharmacy and Therapeutics Committee Infection Control Committee Utilization Review Committee Medical Records Committee Credentials Committee Graduate Medical Education Committee Trauma Committee Special Care Committee Quality Improvement Committee When data analysis identifies a problem or trend, proactive risk reduction activities or a corrective action plan will be developed and implemented by the Department Head. These actions may include: 1. System Changes Changes in communication channels, changes in organizational structure, adjustments in staffing and changes in equipment or chart forms. 2. Knowledge Enhancement In-service education, continuing education and circulating informational material. 3. Intensive Reviews/Focus Studies When a medical/health care system error-related occurrence is identified; proactive risk assessment activities are implemented including intensive review and/or a focused study. A data collection tool is developed to address processes, functions, and services that can be designed or redesigned to prevent trends that may have contributed to the problem. Once all charts are reviewed, a summary report is compiled to report conclusions. 4. Root Cause Analysis When a medical/health care error is classified by Administration as a Near Miss or Sentinel Event, the recommended Root Cause Analysis format by TJC is used to detect the underlying causes of the variation. Upon approval by administration, the outlined action plan is implemented. 5. Failure Mode Effects Analysis In accordance with TJC published information regarding the most frequently occurring types of sentinel events and patient safety risk factors, at least one high-risk process is selected annually for proactive risk assessment. 18

19 6. Behavior Changes Informal or formal counseling, consulting, changes in assignments, and disciplinary action. 7. Policy Revisions Policies are developed or revised for significant organizational issues that are interdepartmental or mandated to be hospital-wide by accreditation agencies or state/federal legislation. Any potential policy revisions are presented to the Policy Committee to identify the appropriate entity for development, and ensure that input is obtained and incorporated into a final policy statement. Once completed, the committee will submit the policy to the Hospital Administrator for approval, who will then forward it to the Clinical Board for final approval. 8. Multidisciplinary Process Teams Teams are formed as needed and over site is provided by the Quality Leadership Team to investigate and make recommendations when organization-wide performance becomes unacceptable or when a process has been identified to be proactively redesigned. The process team presents the recommendations to the Quality Leadership Team for approval. 9. Operational Changes Any activity that may need to be performed differently in order to expedite a process or improve overall patient care will be examined and changed if appropriate. The assessment process includes the use of statistical process control techniques/tools as appropriate. When assessment of data indicates a variation in performance or potential risk to patient safety, more intensive measurements and analysis will be conducted, and in addition, the department/service or team will reassess its performance measure. When a performance measurement does not reach the predetermined optimal threshold, or if it is attained but further evaluation indicates that performance is not acceptable, the Performance Improvement process should continue. If the level of performance shows no improvement for the time frame established by the identified department/service or team plan, an intensive evaluation should be conducted with input from the Quality Leadership Team, or Director regarding the need for continued measurement and additional corrective action. When any process remains stable or minimal variation is demonstrated in overall performance after two quarters of data collection, the performance measure should be re-evaluated to determine the need to continue measurement, and re-prioritization of performance measurements should occur. IMPROVE When opportunities for improving performance are identified, a proactive systematic approach is used to redesign the involved process, or to design a new process. The leadership, through the Quality Leadership Team will establish hospital-wide priorities and provide adequate resources to be effective. 19

20 1. When a department or service identifies an opportunity for improvement, the department/service will determine if other disciplines or departments will have an impact on the design/redesign of the process. If other disciplines or departments are involved, the opportunity for improvement will be referred to an appointed team. 2. The assigned team/department will establish priorities for improvement based on the guidelines established in this plan. When necessary, the Quality Leadership Team will assist the team or department/service in establishing priorities. The Performance Improvement and Patient Safety Plan will be reviewed, evaluated, and revised as necessary to incorporate the most current TJC/CMS standards. A summary of evaluation results will be presented to the Clinical Board. The annual review will assess, at least, the objectives, scope, organization effectiveness and appropriateness of the program. The plan will be modified as needed based on the results of the annual evaluation. Individual committees and departments will review, evaluate and revise their performance improvement activities and plans annually as part of the organization-wide review. 20

21 Attachment A Credentials Committee Clinical Board PERFORMANCE IMPROVEMENT COMMUNICATION PROCESS (2013) Graduate Medical Education Committee Medical Staff Department Chairperson Quality Improvement Committee Quality Leadership Team Medical Directors Medical Staff Department PEER Review Hospital (Generic Indicators) Department Indicators Department Focus Study PI Communication Process 2013 Functional Medical Staff/Hospital Committees Antibiotic Blood Utilization Review Cancer Infection Control Medical Records Operative, Other Invasive and Non- Invasive Procedure Review (Surgical Case) Pharmacy Therapeutics Special Care Trauma Utilization Review Other Related Performance Activities TJC Core Measures Benchmarking Studies FMEA 21 Clinical/Risk Management Variance Reporting Requested Reviews Mortality Reviews Patient Complaints Patient Safety report Hospital Clinical and Support Department Reports Clinical Departments Nursing PI ( and Outpatient) Support Departments

22 Attachment B LSUHSC-S UNIVERSITY HOSPITAL Performance Improvement Reporting Process Graduate Medical Education Committee Credentials Committee Clinical Board Quality Improvement Committee Quality Leadership Team Hospital Clinical and Support Departments Functional Medical Staff Committees Committees: Antibiotic Blood Utilization Review Cancer Infection Control Medical Records Operative and Other Invasive Procedure Review Pharmacy & Therapeutics Special Care Committee Trauma Committee Utilization Review Other Hospital Committees: Endoscopy Environment of Care Forms Laser Material Evaluation Radiation Safety Respiratory Therapy Safety Medical Staff Department Peer Review Medical Staff Departments: Anesthesiology Emergency Medicine Family Medicine Medicine Neurology Neurosurgery OB/GYN Ophthalmology Oral Surgery Orthopedics Otolaryngology Pathology Pediatrics Psychiatry Radiology Surgery Urology PLANNING PHASE: What are Objectives? What is Function or Process for improvement? ACTING PHASE: Implementing Improvements/ Innovations to correct Identified Process Issues STEP 1: Design (PLANNING) STEP 4: Improve (ACTING) Core Measures PROCESS USED FOR IMPROVEMENT TJC" Cycle for Improving Performance STEP 2: Measure (DOING) STEP 3: Assess (STUDYING) 1. Design 2. Measure 3. Assess 4. Improve DOING PHASE: Utilize sources for Performance Measurement: Internal Database: Variance Database /Reports Comparative Information: External databases (UHC, AVATAR) STUDYING PHASE: What are the Improvement Priorities? Clinical & Support Departments Biomedical Engineering Echo Dept. Cardiopulmonary Services Dept. Anatom / Clinical Path. Lab Clinical Neurophysiology Lab CMS - Central Med. Supply Environmental Services Cardiac Cath Lab Hospital Telecommunications Infection Control Laundry and Linen Service HIM - Medical Records Nutritional Services PCS -Patient Care Services (Nursing) ER- Emergency services Dept. ACD- Ambulatory Care Clinics FWCC- Feist-Weiler Cancer Center EYE CLINIC Hospital Med. Education Hospital Med. Staff Patient Admitting Patient Relations / Volunteer Services Pharmacy Physical Plant Physical Rehabilitation Services Public Safety / UPD Quality Management Radiology Bone Marrow Unit Trauma Registry Cancer Registry Perfusion Services Social Services Hem/Onc- Spec. Hem. Lab Developed 1/97 Reviewed/Revised 1/98, 1/99, 7/99, 11/00, 12/00, 12/01, 12/02, 9/03, 12/03, 1/04, 10/05, 10/06, 10/07, 10/08,10/09, 12/10, 11/12 22

23 Attachment C LSU Health Sciences Center at Shreveport Improve Start Design Continue to Monitor Performance, Re- Evaluate Scope of Service/Plan for Provision of Review/Revise Care High Volume Problem Prone High Risk Cost Variance Report Patient Satisfaction Patient Complaints System Changes Knowledge Enhancement Intensive Review Behavior Changes Policy Revisions Actions Taken to Improve Performance as Appropriate Identified Problems Analyzed, Plan of Action Developed Assess Reports & Actions Taken to Improve Performance are sent to Clinical Board, Medical Staff Departments, & Medical Staff Committees Variance Report Patient Satisfaction Patient Complaints ORYX Data Performance Report Card LHCR Cooperative Studies Departmental PI Report Performance Improvement Cycle Quarterly Reports Compiled and Reviewed by Quality Leadership Team 23 Quality Management Receives and Tracks Reports Compiled Monthly of Performance Variations Analyzed Ongoing Monitoring Implemented Indicators Selected Level of Performance Identified (Threshold) Action Taken Measure National Association

24 Attachment D Louisiana State University Health Sciences Center Shreveport 2013 Hospital-wide Generic Indicators Medical Staff and Resident Peer Review Thresholds as determined by TJC 1st Q 2012 National Average (Pg 1 of 3) Indicator Threshold Indicator Threshold /Outpatient Generic Indicators Hospital-Acquired Conditions Indicators * Per CMS 10/12 Appropriate care rendered. 100% Foreign Object retained after surgery. 100% Mortality review completed and documentation of autopsy offered Air Embolism. 100% 100% on cases that meet criteria. No admit for adverse reaction to OP management. 100% Blood Incompatibility. 100% No re-admit within 31 days. 100% Stage III and IV pressure ulcers 100% Falls and Trauma (Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, No unplanned transfer from general to special care unit. 100% Burns, other injuries). 100% Manifestations of poor glycemic control (Diabetic Ketoacidosis, Nonketotic 100% No coded complications occurring during or following procedure 100% Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with performed. Ketoacidosis, and Secondary Diabetes with Hyperosmolarity). All abnormal lab/x-rays/tests addressed by physician. 100% Catheter-associated urinary tract infection (UTI). 100% Legal Review completed. 100% Vascular catheter-associated infection. 100% Manifestations of Poor Glycemic Control (Diabetic Ketoacidosis, 100% Code management measures appropriate. 100% Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity) All operative /invasive procedures are performed with no returns to Surgical site infection, Mediastinitis, following Coronary Artery Bypass 100% 100% the OR. Graft (CABG) No unscheduled return to clinic within 48 hours with the same Surgical site infection following Certain Orthopedic Procedures (Spine, 100% 100% complaint. Neck, Shoulder, Elbow). Surgical site infection following Bariatric Surgery for Obesity (Laparoscopic 100% All documentation/forms completed. 100% Gastric Bypass, Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery). Appropriate restraint/seclusion documentation. 100% Surgical site infection following cardiac Implantable Electronic Device 100% (CIED) AVATAR Requested Review. 100% Deep vein thrombosis (DVT), Pulmonary embolism (PE) following Certain 100% Orthopedic Procedures (Total Knee Replacement, Hip Replacement). All medication orders are appropriate/accurate. 100% Iatrogenic Pneumothorax with Venous Catheterization 100% History and Physicals updated within 24 hours of admission. 100% INTENTIONALLY LEFT BLANK **** 24