Patient Care Services Quality Report Evaluation of 2013 Outcomes August 2014

Patient Care Services Quality Report Evaluation of 2013 Outcomes August 2014 Submitted by, Carol A Dwyer, MSN, MM, RN, CENP Vice President, Patient Care Services Chief Nursing Officer 1

Index INTRODUCTION...3 SERVICE Patient Satisfaction.4 CLINICAL QUALITY Hand Hygiene 5 Hospital Acquire Pressure Ulcers...6 Patient Falls 7 Catheter Associated Urinary Tract Infection (CAUTI) 8 Ventilator Associated Pneumonia..9 Central Line Associated Blood Stream Infection (CLABSI)..10 Bar Code Medication Administration.11 Core Measure Perfect Care....13 Clinical Quality Summary.14 2

Patient Care Services Quality and Performance Improvement Program Evaluation of 2013 INTRODUCTION Our Saint Joseph Hospital vision is to be recognized as a national leader in quality and patient experience. Performance improvement within the Patient Care Services (PCS) division provides one mechanism to accomplish this goal by continuously evaluating our nursing practice and taking actions that improve the quality of services and care. The PCS Quality and Performance Improvement program demonstrates outcomes achieved through collaboration with many disciplines and with national and statewide collaborations to develop an integrated plan. An evaluation of the PCS Quality and Performance Improvement Program is generated annually and submitted to the Nursing and Clinical Leadership at Saint Joseph Hospital and to the Quality, Risk and Safety Steering Committee, and ultimately to the Saint Joseph Hospital Board of Trustees. The subsequent plan for improvement and sustainability is implemented through our Strategic Plan for Nursing. The cycle continues and repeats until such time that the desired outcomes are achieved and maintained. The PCS Quality and Performance Improvement Program is communicated to the leadership of PCS and to Nursing and support staff through such means as: Staff representation on the Quality, Risk and Safety Steering Committee Use of Huddle Boards * Proclamation of data at the Nursing Leadership Council Meeting with Managers and Directors Communication at unit level staff meetings/huddles Quarterly Operating Performance Reviews* Data Sharing at the Medical Surgical and Critical Care Service meetings Unit Based Scorecards* Educational Inservices* Annual Nursing Leadership Retreat* 3

*To Be Initiated 2013 NURSING OUTCOMES Measurement of nurse sensitive indicators generates data that is monitored and assessed for trends and opportunities for improvement. Most, if not all, of the improvement and projects described in this report involve PCS as a part of an interdisciplinary team working toward improvement. This list of measures and improvement goals is not meant to be inclusive of all projects within Saint Joseph Hospital, but rather it represents those indicators that have a strong correlation to nursing care outcomes. Primarily, we benchmark against the National Database for Nursing Quality Indicators (NDNQI) on a quarterly basis. Based on our results, improvement plans are developed to elevate our bedside practice to achieve the highest quality outcomes. SERVICE Patient Satisfaction This indicator measures progress of the Saint Joseph Hospital initiative to improve patient satisfaction. The Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) is a national, standardized, publicly reported survey of patient perspectives of hospital care. HCAHPS was developed from a partnership between Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). The phone survey asks patients 27 questions about their hospital experience. Surveys are administered from 2 weeks to 6 weeks after discharge to a stratified random sample of adult patients 18 years or older that stay overnight for all medical conditions, except psychiatric conditions. Results are published quarterly on the Hospital Compare website using a rolling year format. The most current results represent completed inpatient surveys between July 1, 2013 and June 30, 2014 and can be found at www.hospitalcompare.hhs.gov. Data Source: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. HCAHPS Results for Inpatients Domain FY2011 FY2012 FY2013 FY2014 Change from 2013 to 2014 Plus/minus% Overall Hospital Rating 74.2% 73.4% 74.6% 69.0% 5.6% Likelihood to Recommend 79.3% 76.6% 78.3% 75.5% 2.8% Nurse Communication 80.8% 78.7% 81.7% 78.0% 3.7% 4

Doctor Communication 81.4% 80.5% 79.5% 79.6% + 0.1% Responsiveness of Staff 64.7% 63.4% 65.3% 62.5% 2.8% Pain Management 74.9% 73.5% 74.6% 70.6% 4.0% Communication of Medications 65.2% 63.4% 65.2% 64.0% 1.2% Cleanliness of Room/Bathroom 70.2% 71.6% 74.9% 68.9% 6.0% Quiet at Night 62.9% 66.3% 64.9% 64.8% 0.1% Discharge Instructions 86.8% 86.1% 87.4% 87.4% No change Analysis: In 2013, Saint Joseph Hospital demonstrated a decrease in HCHAPs scores overall, with the exception of doctor communication and discharge instructions. Performance Improvement Interventions: 1. In July the Nurse Managers and Directors began an HCAHPS Book Club whereby they read chapters and discuss tactics to implement. 2. Nurse Leader Rounding began August 18, 2014. Validation of practice was conducted. Rounding tools are evaluated bi weekly at Director and VP level. Trends are beginning to become evident for further attention. 3. Hourly Rounding was re instituted on paper, effective September 8, 2014. This re activation is meant to validate practice. Since Cerner implementation, the actual practice of hourly rounding has waned considerably. 4. The use of whiteboards and AIDET plans are underway to optimize their effectiveness. 5. All Nurse Leaders will be enrolled in a Patient Experience Program through KentuckyOne, beginning October 13, 2014 which will further develop skills and expectations. CLINICAL QUALITY Hand Hygiene We adhere to the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines, including hand hygiene before providing patient care and hand hygiene after glove removal. To measure compliance, stealth monitoring is performed on all nursing units. The Infection Control Committee and key stakeholders reviews hand hygiene data, identifies opportunities for improvement, determines the annual hand hygiene 5

improvement plan and monitors performance. Stealth hand hygiene monitoring training, data cleaning and data distribution are conducted by the Infection Prevention and Epidemiology department. Hand hygiene data is entered electronically by unit champions. Interventions to maintain high compliance consists of unit based monitoring with in time feedback for non adherence. Data Source: Unit based monitoring results of hand hygiene compliance Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 All Units 98% 95% 98% 97% 98% 97% 98% 97% Analysis: Our overall compliance for 2013 was 97.5%. We have maintained compliance at 97 98% in 7 out of 8 quarters. Maintaining hand hygiene compliance at 98% is a result of focused, standardized practices and individual accountability. Hospital Acquired Pressure Ulcers Pressure ulcers are defined as any lesion caused by unrelieved pressure over a bony prominence resulting in damage to the underlying tissues. Since muscle and subcutaneous tissue are more susceptible than skin to pressure damage, pressure ulcers are often worse than their initial appearance. Pressure ulcers are associated with extended length of stay and mortality and cause considerable pain and suffering to patients. Data Source: Data is obtained quarterly during point prevalence studies. These intensive, one day surveys involve a skin assessment of every adult inpatient. This information is then submitted to the National Database for Nursing Quality Indicators (NDNQI). The NDNQI was established by the American Nurses Association in 1998 to assist hospital in monitoring quality of patient care and to show relationships between nurse staffing and patient outcomes. Using NDNQI, Saint Joseph Hospital s pressure ulcer prevalence rate is benchmarked against the mean of national hospitals of similar demographics. Hospital Acquired Pressure Ulcers 2009 2010 2011 2012 2013 NDNQI Units 9.8% 6.6% 8.7% 10.4% 6.7% National Acute Care Trends for Hospital Acquired Pressure Ulcers 5.3% 4.8% 4.5% 4.0% 3.7% Analysis: Saint Joseph Hospital s pressure ulcer rate for 2013 is 6.7% which is a 36% improvement from 2012. While Saint Joseph Hospital s facility acquired pressure ulcer rate is above the national trend, we strive to hardwire best practices that will help us achieve our goal of < 3%. 6

Performance Improvement Interventions: In 2013, all nurses and support staff were assigned an educational module via the online LEARN system. The interactive educational program, developed by NDNQI and national experts, incorporated 4 modules that trained the nursing staff on causes of pressure ulcers, pressure ulcer recognition, accurate staging and documentation of pressure ulcers. Each staff member had to pass an interactive test to receive credit. In addition, the Pressure Ulcer Pressure Prevention Program PUPP was reinforced in the monthly Skin and Falls Team. PUPP includes 8 evidence based interventions to reduce the likelihood of developing a pressure ulcer during hospitalization. In the Cerner electronic medical record, nursing staff members assess the patient for risk of developing a pressure ulcer using a nationally recognized screening tool (Braden Score) and the PUPP interventions are available as a reminder for implementation. Skin Care products are grouped together in the supply room on each unit. Patients that develop a Stage 1 and/or Stage 2 hospital acquired pressure ulcers present our greatest opportunity for improvement. In August, 2014 we have separated the two functions of the falls and skin care committee so that focus of the champions is only on one nurse sensitive indicator. New membership and leadership assignments are underway. Additionally, monthly skin prevalence studies (instead of quarterly) will be conducted with detailed actions plans established. Patient Falls The CDC reported in 2009 that falls are the leading cause of injury related deaths for individuals over 65 years of age. Falls remain a challenging issue for the hospitalized patient. In the hospital setting, as many as 20% of acute care patients fall at least once during their hospital stay which translates to 4 12 falls per 1000 occupied bed days. 1 The National Quality Forum s Safe Practices Report from 2010 indicates that patients admitted to inpatient oncology, critical care and infectious disease units are at greatest risk. Data Source: Data is obtained from event reports submitted to the Risk Management department and then submitted to NDNQI for tabulation. Table: Total Number of Inpatient Falls and Total Number of Inpatient Falls with Moderate & Major Injuries Calendar Year 2010 2011 2012 2013 Total Number of Falls 333 338 345 270 Total Number of Falls with Combined Moderate & Major Injury 18 20 11 16 Analysis: 7

In 2013, Saint Joseph Hospital witnessed a decrease in the total number of inpatient falls, with the most significant decrease in July September 2013. January March 2013 = 89 Falls April June 2013 = 73 Falls July September 2013 = 39 Falls October December 2013 = 62 Falls Anecdotally, we believe the significant drop is the increased staffing and presence of the nursing staff at the patient bedside during the Cerner Go Live. Performance Improvement Interventions: There has been considerable focus on patient falls and particularly falls with moderate or severe harm. Nurses assess the patients for fall risk using the Morse Falls Scale. If a patient score indicates that the patient is at risk or per nursing judgment, falls prevention interventions are implemented. The greatest opportunities for improvement are critical thinking and individual accountability to follow evidence based protocols to prevent falls or reduce the level of harm if a patient does fall. We have developed a comprehensive action plan and submitted it to CHI for approval. Quarterly reports will be created to track our progress and implement course corrections when necessary. Additionally we have designated the Falls Focus Group to be a singular function, selected new membership and appointed a physician champion. Catheter Associated Urinary Tract Infection (CAUTI) In accordance with new regulatory standards to reduce catheter associated urinary tract infections (CAUTI) Saint Joseph Hospital monitors CAUTI s on all inpatient units. SJH has been identified by the Kentucky Hospital Engagement Network (KHEN) for our superior outcomes related to CAUTI. Data Source: The Infection Control and Prevention Department evaluates potential CAUTI cases from concurrent and retrospective chart reviews and then submitted to National Healthcare Safety Network (NHSN) and National Database for Nursing Quality Improvement (NDNQI). Calculated CAUTI Rate = #CAUTI/Total Catheter Days X1000. CAUTI CAUTI Rate per 1000 catheter days Number of CAUTI Total Catheter Days 8

2Q 2012 0.6 3 4762 3Q 2012 0.4 1 5261 4Q 2012 1.5 7 4728 1Q 2013 0.9 5 5463 2Q 2013 0.8 4 4788 3Q 2013 0.8 4 4916 4Q 2013 1.5 7 4586 Analysis: Lately, much attention has been paid to the indwelling catheter due to evidence showing their risk of associated infection. As new, evidence based practice is identified, clinicians are challenged to adopt new practices in order to continually improve outcomes. This once readily used cathertization is now being used less frequently and removed as soon as possible. At Saint Joseph Hospital, to meet our goals of eliminating CAUTIs, changing the behavior is relatively simple, but to hard wire the habit, caregivers need to understand the rationale of the interventions and see the benefit of improved patient outcomes. After implementation of Cerner, the number of CAUTIs increased slightly. We attribute this trend to the elimination of the nurse driven protocol to remove indwelling catheters. The paper process did not translate to a task assigned to the nurse in the electronic platform. A team of key stakeholders has worked diligently to edit Cerner content to alert the nurse to assess to remove the indwelling catheter as soon as the patient meets clinical criteria. Ventilator Associated Pneumonia Ventilator Associated Pneumonia (VAP) is defined as an airway infection that develops after a patient has been intubated with an artificial airway. VAP increase mortality, increases critical care length of stay up to 6 days, and hospital length of stay up to 9 days. Each infection increases cost of care an average of $40,000. The Institute for Healthcare Improvement identifies VAP as the leading cause of death among hospital acquired infections. Nationally, hospital mortality of ventilated patients who develop VAP is 46% compared to 32% for patients who do not develop VAP. The Critical Care Units at Saint Joseph Hospital, in collaboration with our multidisciplinary team, have implemented the VAP Prevention bundle at Saint Joseph Hospital. Data Source: The VAP rate is obtained from current and retrospective chart reviews and then submitted to National Healthcare Safety Network (NHSN) and NDNQI. Calculated VAP Rate = #VAP/Total Ventilator Days X1000 9

VAP VAP Rate per 1000 Ventilator Days Number of VAP Total Ventilator Days 2Q 2012 0 0 1010 3Q 2012 0 0 868 4Q 2012 1 1 964 1Q 2013 0 0 688 2Q 2013 0 0 721 3Q 2013 0 0 712 4Q 2013 0 0 688 Analysis: The Saint Joseph Hospital VAP rate is exceeds national benchmarks. In 2014, the CHI Evidence Based Practice Toolkit added 2 new best practices to prevent VAP and improve patient outcomes: Implementation of an Early Mobility Protocol and early identification and management of delirium. Physical Therapy currently ambulates or begins weight bearing ambulation with patients who meet assessment criteria to safely begin mobility. In addition to reducing the incidence of VAP, early mobility decreases the incidence of delirium in critically ill patients. Central Line Associated Blood Steam Infections (CLABSI) One of the most common healthcare infections, central line associated blood stream infections (CLABSI), is highly associated with increased length of stay and associated costs. CLABSI can increase mortality 35% and each infection increases cost of care an average of $45,000. As of January 2013, the definition from NHSN was expanded to include all units that had central line catheters all inpatient units, not just critical care units. Data Source: The Infection Prevention and Control Department evaluates potential CLABSI cases from concurrent and retrospective chart reviews and then submitted to National Healthcare Safety Network (NHSN) and NDNQI. Calculated CLABSI Rate = #CLABSI/Total Central Line Days X1000 10

Analysis: CLABSI CLABSI Rate per 1000 Central Line Days Number of CLABSI Total Central Line Days 2Q 2012 2.3 5 2200 3Q 2012 0.5 1 2198 4Q 2012 0.9 2 2222 1Q 2013 0 0 2438 2Q 2013 0.6 1 1804 3Q 2013 0 0 2028 4Q 2013 0.6 1 1804 In 2013, Saint Joseph Hospital expanded its focus to all central line catheters placed in all inpatient units, consistent with the revised NHSN definition. Saint Joseph Hospital has successfully implemented the CLABSI Prevention Bundle, which includes evidence based interventions. Bar Code Medication Administration Scanning (BCMA) On July 27, 2013, Saint Joseph Hospital implemented the Cerner electronic medical record. One of the functions of the new electronic medical record is barcode medication administration (BCMA). Each dose of medication is packaged with a barcode that identifies the medication, dosage, and route (tablet, IV, etc). The medication administration record is also now electronic. At the bedside, the nurse uses a hand held scanner to first scan the patient identification bracelet and then the medication package. If the medication is not found on that patient s medication record profile, it will alert the nurse to verify the 5 rights of medication administration (Right patient, Right medication, Right route, Right dosage, and Right time). Bar Code Medication Administration is a proven method to promote safe medication administration. Data Source: The Cerner system tracks the number of medication administration events (MAE) where the medication package and patient identification bracelet are scanned. Our goal for medication and patient 11

scanning is 90%. Nursing leadership receives the report from our Clinical Informatics Department on a weekly basis. Analysis: SJH Medication Scanning % Patient Scanning % Total # of MAE Aug 13 73.18 74.98 129817 Sep 13 69.63 69.32 144597 Oct 13 76.15 75.15 143623 Nov 13 77.84 76.68 134002 Dec 13 79.28 77.68 136113 Jan 14 79 76.62 162845 Feb 14 81.47 80.38 138136 Mar 14 82.71 82.36 157432 Apr 14 83.65 82.96 166492 May 14 82.7 82.4 140849 Jun 14 80.91 81.09 142633 Jul 14 80.27 80.1 140015 Aug 14 83.65 83.40 129382 Sep 14 86.43 86.16 Since implementation of Cerner at Saint Joseph Hospital, we have seen a steady increase in Medication and Patient scanning percentages. While this is a new process, staff nurses receive weekly reports comparing unit scanning rates. Individual nurses are encouraged to report barriers to scanning medications and patient identification bracelets to the clinical informatics team. Nursing Leadership is working closely with the Clinical Informatics team and IT departments to eliminating barriers to scanning, which may include the following: Connectivity issues with mobile computer workstations Barcode is not recognized in the system Dose administration from multi dose package 12

Patient armband is not recognized using scanner System downtimes (planned and unplanned) Core Measure Perfect Care The Joint Commission announced four initial core measurement areas for hospitals in May, 2001. Simultaneously, The Joint Commission worked with the Center for Medicare and Medicaid Services (CMS) on the Acute Myocardial Infarction (AMI) and Heart Failure (HF) sets common to both organizations. Alignment occurred and hospitals began collecting AMI measures beginning July 2002. By November 2003 the measures were identical, resulting in one common set of measurements. All hospitals must comply in tracking and reporting Core Measure Perfect Care. 13

Core Measure Perfect Care Composite Saint Joseph Hospital FacilityName Saint Joseph Hospital Report Date: 08/06/2014 Preliminary results for FY2014 Q4 Date Range Den CoreMeasName Values AMI PC HF PC PN PC SCIP PC VTE PC STK PC* IP PC Composite (6) Core Measure Rate Den Core Measure Rate Den Core Measure Rate Den Core Measure Rate Den Core Measure Rate Den Core Measure Rate Den Core Measure Rate FY2011 Q3 111 98.2% 94 80.9% 101 93.1% 296 82.8% 602 87.0% FY2011 Q4 114 100.0% 76 88.2% 105 94.3% 314 87.9% 609 91.3% FY2012 Q1 105 100.0% 73 91.8% 78 91.0% 277 87.4% 533 91.0% FY2012 Q2 111 100.0% 87 86.2% 102 88.2% 268 88.4% 568 90.3% FY2012 Q3 96 100.0% 69 98.6% 65 90.8% 282 86.5% 512 91.2% FY2012 Q4 103 100.0% 70 95.7% 50 96.0% 265 85.3% 488 91.0% FY2013 Q1 91 100.0% 72 95.8% 64 100.0% 267 89.9% 494 93.9% FY2013 Q2 88 100.0% 70 92.9% 70 95.7% 280 87.1% 508 91.3% FY2013 Q3 112 100.0% 103 82.5% 44 95.5% 179 87.7% 255 62.0% 50 32.0% 743 76.7% FY2013 Q4 97 100.0% 89 73.0% 39 97.4% 187 85.0% 223 65.9% 35 51.4% 670 78.2% FY2014 Q1 87 100.0% 76 52.6% 26 100.0% 182 91.2% 179 59.2% 43 39.5% 593 74.5% FY2014 Q2 85 98.8% 81 56.8% 28 92.9% 172 86.6% 194 70.6% 35 54.3% 595 77.5% FY2014 Q3 85 91.8% 80 97.5% 20 90.0% 190 88.4% 186 73.1% 32 65.6% 593 84.1% FY2014 Q4 79 93.7% 82 96.3% 21 95.2% 187 86.6% 191 75.9% 32 53.1% 592 84.0% Perfect Care Composite includes: AMI, HF, PN, SCIP, STK and VTE 100.0% 90.0% 80.0% 70.0% Core Measure Perfect Care Composite Saint Joseph Hospital 93.9% 91.0% 91.2% 91.3% 91.3% 90.3% 91.0% 87.0% 84.1% 84.0% 76.7% 77.5% 78.2% 74.5% 60.0% 50.0% 40.0% FY2011 Q3 FY2012 Q1 FY2012 Q3 FY2013 Q1 FY2013 Q3 FY2014 Q1 FY2014 Q3 14

Analysis: There has been considerable variation in achieving Perfect Care, with a decline of significance beginning in 3 rd quarter of FY2013 and lasing four (4 quarters). The past two (2) quarters have improved or sustained gains in nearly all measures. Greatest opportunity lies in the core measures of stroke, VTE and SCIP with none of these attaining 90% in the past three (3) quarters, if at all. Performance Improvement Interventions: Recent organizational and structural changes in nursing has prompted new assignments in this area of Clinical Quality. Core Measure Teams are forming to address operational issues related to compliance. Another tactic recently introduced is to include key core measures on unit based scorecards. Opportunity exists for a Quality Department Scorecard that would provide transparency to all stakeholders on our interdisciplinary approach to Perfect Care. CLINICAL QUALITY SUMMARY In 2013, we demonstrated improvement and sustained scores in all of the nurse sensitive indicators, although our rates for falls and hospital acquired pressure ulcers are below national benchmarks. Our goal is to meet and exceed national benchmarks in the NDNQI database at the All Hospital Mean Level. To accomplish this, we must focus on empirical outcomes that are nurse sensitive. It is critical for us to exceed mean level performance in 5 of 8 quarters. Thus our 2014 Quality goals are the following: 1. Achieve or exceed patient experience target of 8 out 10 HCAHPS domains as measured by CMS national average. 2. Measure Nurse Satisfaction using the NDNQI Annual Nurse Satisfaction Survey. 3. Achieve or exceed the All Hospital Mean in all Nurse Sensitive Indicators for 5 of 8 quarters for reporting units. 4. Achieve or exceed Core Measure Perfect Care at 90% by December 31, 2014. 15