Measurement Systems to Support Quality and Safety. Chuck Derus, MD Vice President - Medical Management

Transcription

1 Measurement Systems to Support Quality and Safety Chuck Derus, MD Vice President - Medical Management

2 Why? Mrs. Stevens Bill Saunders Mr. Jones

3 World class Criteria 4.1 How do you select, collect, align, and integrate data and information for tracking daily operations and overall organizational performance including progress relative to strategic objectives? How do you use data and information to improve performance at all levels of the organization?

4 Leadership System Set Direction Establish Goals Learn, Improve & Innovate Motivate & Acknowledge Inspire & Raise the Bar Understand Stakeholder Requirements Physicians Volunteers Associates Families Mission Values Philosophy 1 Patient Community Suppliers Partners Integrity Passion Caring Role Model & Build Commitment Organize, Plan & Align Communicate, Engage & Empower Develop, Reward & Recognize Accountability for Results Perform to Plan

5 Performance Measurement System

6 Managers Tracked Many Goals and Measures.

7 Key Strategic Objectives Health Outcomes Associate Engagement Patient Satisfaction Physician Engagement Growth Funding Our Future Sustain Excellence of Health Outcomes Reduce Preventable Harm to Patients Sustain Loyal Associate Relationships Sustain Loyal Patient Relationships Sustain Loyal Physician Relationships Grow Service Area Overall Net Revenue Generate Financial Resources to Fund Our Future

8 Organizational Alignment Health Outcomes Associate Engagement Patient Satisfaction Physician Engagement Growth Funding Our Future 30% 5% 20% 10% 5% 30% 7.5 Core Measures 4.5 Falls with Injury 4.5 CPOE 4.5 Post OP DVT/PE 3.0 ICU Central Line Infection 3.0 ICU Mortality 1.5 Acute Care Readmits 1.5 ED Sepsis Mortality 0.0 LOS Building Loyal Relationships 35% 5.0 Assoc Sat 5.0 Inpatient 5.0 Outpatient 5.0 ED 5.0 HCAHPS 10.0 Physician Sat 5.0 Net Revenue 15.0 Oper Margin 12.0 Expenses 3.0 Philanthropy 4.5% 5.0% 7.5% Falls Inpatient 15.0% Oper Core with Measures Margin Injury 5.0% Outpatient 5.0% ED

9 Mission Critical: Goal Alignment Advocate Goals / Strategy GSam Strategy Regulatory GSAM ET Determines Preliminary Goals & Targets Goal Deployment Worksheet Completed Directors Provide Input into Goals/Targets Goals/Targets Finalized Individual Goals Populated Organizational and Department Action Plans Created Goals, Targets, Action Plans Shared with Teams

10 Sample Deployment with Weights Executive Team Core Measure Bundles (AMI/PN/CHF/SCIP) Weight 7.5% Med/Surg Nursing Director PN Bundle (8 CMS Measures) Weight 10.0% Nurse Manager Pneumoccocal Vaccination (1 Measure) Weight 15.0%

11 Integration Using Automation Advocate Management System (AMS) Transparency Goals are Objective & Measureable Intranet based for all 85 Leaders Evaluation and Management System Profiles Annual Goals, Weights & Results Quarterly Action Plans Annual performance evaluation

12 Deployment Organization wide Department Pillar Boards Hospital Goals & Results Dept Goals & Results Information Sharing

13 Performance Measurement System

14 KRA Baseline Goal/Stretch Jan-11 Feb-11 Mar-11 1st Qtr Apr-11 May-11 Jun-11 2nd Qtr 2011 Target Health Outcomes Acute Care Readmission within 30 Days % 11.8% (10.9 / 10.0) 10.8% 10.9% 11.2% 11.2% 11.4% 11.4% 11.4% 11.4% 10.9% CHF Readmissions within 30 Days Percent 14.6% (16/13) Tracking 14.0% 11.4% by 20.0% Month/Quarter 15.0% 20.0% 16.0% Overall LOS Index 0.90 (0.91 / 0.87) STS Composite ** (**/***) Compared ** to Baseline, ** Goals, Targets ** *** *** ** ACC Outcome Measures Risk adjusted mortality index 90th (75th/90th) 90th % 75th Emergency CABG 25th (75th/90th) 25th 0.5% 0.5% 75th Post Procedure Stroke 99th (75th/90th) 99th 0.0% 0.0% 75th AHRQ Post-operative PE/DVT* Worse* As expected/ Better Worse Worse Worse Worse Worse Worse Worse Worse As Expected ICU Mortality* As expected As expected/ Better As Expected As Expected As Expected As Expected Sepsis Mortality* As expected As expected/ Better As Expected As Expected As Expected As Expected NICU Mortality* As expected As expected/ Better As Expected As Expected Meaningful Use** Not Compliant Compliant NC NC NC NC NC NC NC NC Compliant All Pillars / Key Result Areas Core Measure Bundles HQA All or None Overall Bundle 94% (94 / 97) 96% 97% 95% 96% 95% 98% 94% Electronic AMI Core Measure Bundle 99% (100/100) 100% 100% 100% 100% 100% 100% 100% CHF Core Measure Bundle 99% (100/100) 100% 100% 100% 100% 100% 100% 100% Pneumonia Core Measure Bundle 94% Used (95/97) by Leaders 97% to 95% Populate 91% 94% AMS 88% 100% 95% Pneumococcal Vaccine U51/52 97% (98/100) 100% 100% 100% 100% 100% 100% 98% Influenza Vaccine U51/52 97% (98/100) 100% 100% 100% 100% N/A N/A 98% SCIP Core Measure Bundle 93% (95/97) 90% 96% 93% 92% 96% 95% 95% Antibx DC within 24 hours 97% Stoplight (97/100) Allows 100% for 100% Visual 97% 99% 100% 98% 97% Beta Blocker 96% (98/100) 95% 100% 100% 98% 100% 100% 98% VTE Prophylaxis Ordered 99% (96/100) Management 100% 100% 100% 100% 100% 100% 96% Post op Urinary Cath Removed POD 91% (91/95) 86% 89% 86% 87% 88% 95% 91% Patient Safety /Infection Prevention AHRQ Bundle Index Better As expected/ Better Better Better Better Better Better Better Better Better Same As NDNQI Falls with Injury Rate/1000 Pt Days 0.37 (0.25/0.00) Unit 41 (0.25/0.00) Unit 42 (0.25/0.00) Unit 43 (0.25/0.00) Unit 51/52 (0.25/0.00) Unit 53 (0.25/0.00) CCU (0.25/0.00) Infection Prevention By Individual Unit/Area SSI Knee/Hip/Spines/CABG (1.0/0.70) Influenza Vaccine Associate Compliance % 59% (65%/75%) 62% 66% 68% 68% 68% 65% Hand Hygiene Compliance 85% (85%/95%) 98% 99% 100% 99% 99% 98% 99% 99% 85% Emergency Department (85%/95%) 93% 100% 100% 96% 100% 100% 96% 99% 85% CCU (85%/95%) 100% 100% 100% 100% 100% 100% 100% 100% 85% U41 (85%/95%) 100% 100% 100% 100% 96% 100% 100% 98% 85% U42 (85%/95%) 98% 100% 100% 98% 100% 100% 100% 100% 85% U43 (85%/95%) 97% 100% 100% 99% 100% 100% 100% 100% 85%

15 How do we track organizational performance aligned with strategic objectives

16 Performance Measurement System

17 Key Data Review Schedule Data By Pillar Daily Weekly Monthly Quarterly Health Outcomes Patient Satisfaction Associate Engagement Physician Engagement Growth Safety events - PRN Safety events Hand hygiene metrics Patient Safety Dashboard Complaints Patient satisfaction scores Discharge call results Open position report Turnover CPOE volumes Volumes Volumes Growth report Apache data STS data Funding our Future Revenues Cash collections Revenues Cash collections Productivity report Revenue cycle dashboard Solucient reports Other PM/Night shift administrative report

18 Data Savvy Assessment 1. We don t know what data to look at or how to use them. 2. We have lots of data; we look at them, but we are not sure how to use them. 3. We translate data into information and use them to make improvements and drive decisions. 4. As an organization, we analyze data rigorously to drive breakthrough change.

19 DATA

20 Data Rigor Scale Decisions based on gut, mood, or intuition Key decisions and improvements are driven by data Rigorous data analysis leads to breakthrough improvement Variability Steady Improvement World Class Performance

21 Rigorous Use of Data Competent Select and collect relevant data Participate in national databases to provide risk-adjusted comparisons Analyze and translate data into information for action and improvement Allow data to drive decisions Track your performance against goals Share results with your one-up and staff

22 Key Data Review Schedule Data By Pillar Daily Weekly Monthly Quarterly Health Outcomes Patient Satisfaction Associate Engagement Physician Engagement Growth Safety events - PRN Safety events Hand hygiene metrics Patient Safety Dashboard Complaints Patient satisfaction scores Discharge call results Open position report Turnover CPOE volumes Volumes Volumes Growth report Apache data STS data Funding our Future Revenues Cash collections Revenues Cash collections Productivity report Revenue cycle dashboard Solucient reports Other PM/Night shift administrative report Analysis Variances to goal Trending Gap analysis Trending Variances to goal Budget to actual Statistical Quarterly variances Decisions Decisions Made Made from from Data Data Service recovery Safety Regulatory compliance Staffing Reinforce action plans Staffing Recognition Modify action plans Charter new teams How I I Make Results Visible Daily Huddle Pillar board filler Manager Pillar boards Administrative Council meeting

23 World class Criteria 4.1 How do you select, collect, align, and integrate data and information for tracking daily operations and overall organizational performance including progress relative to strategic objectives? How do you use data and information to improve performance at all levels of the organization?

24 Rigorous Use of Data: Senior Leaders Data Analysis Decision Healthcare reform Action OI data Cost per adjusted discharge 100 Top Hospital metrics Variance analysis Does performance support our vision? Are we positioned for healthcare reform? Will current performance sustain us? Add value to GSAM vision Implement LEAN Enterprise strategy to reduce waste and increase value

25 100 Top Hospital Metrics Top Decile

26 Rigorous Use of Data: Senior Leaders Data Analysis Decision Healthcare reform Action OI data Cost per adjusted discharge 100 Top Hospital metrics Variance analysis Does performance support our vision? Are we positioned for healthcare reform? Will current performance sustain us? Add value to GSAM vision Implement LEAN Enterprise strategy to reduce waste and increase value

27 Rigorous Use of Data: Departments & Frontline Associates

28

29 PI Showcase Process Training Workshops Department Indicators Selected Senior Leaders Review / Selection Department: Collect, Review, Analyze Process Data PI Action Plans Developed Presentation of Results / Plans Senior Leader Debrief Feedback to Presenters Annual PI Superbowl Annual Review and Evaluation of Process

30 Executive Team Selection Criteria Alignment with Health Outcome key result area Alignment with pillar(s) Meets customer requirements Benchmark available Scores added up top 36 departments/units selected for presentation

31 2010 PI Showcase Environmental Services and Infection Control Improving High-Touch Surface Cleaning

32 Marking a Telephone

33 Improve Cleaning Via Fluorescent Tagging Indicator: Percentage of tagged high-touch surfaces that are cleaned Goal: 100% of high-touch surfaces will be cleaned completely

34

35 2010 PI Showcase Unit 43 Oncology Improve Documentation of Chemotherapy Medication

36 PDSA Study Indicator Percentage of documentation of verifications of correct chemotherapy drug, dose, patient, and rate by 2 RN s. Goal 100% of all chemotherapy drugs administered will have documentation of specific verifications by 2 RN s.

37

38 Rigorous Use of Data: In the OR

39 ANTICIPATION 2007 First NSQIP Semi Annual Results

40 * Includes General and Vascular Surgery Cases 30-Day Mortality Observed rate: 1.23% Expected Rate: 1.70% O/E Ratio: 0.72 Status: As Expected Participating Hospitals: Baylor, Stanford, Mayo Clinic, Duke, Cleveland Clinic GSAM

41 * Includes General and Vascular Surgery Cases Cardiac Complications Observed rate: 0.00% Expected Rate: 0.64% O/E Ratio: 0.0 Status: Exemplary GSAM

42 A PROBLEM WAS IDENTIFIED! High Outlier Higher than expected number of postoperative occurrences of renal failure Improvement Needed!

43 Overall Renal Failure Observed rate: 2.16 % Expected Rate: 0.75 % O/E Ratio: 2.89 Status: Needs Improvement GSAM

44 Rigorous Use of Data: In the OR Data Analysis Decisions NSQIP results Chart reviews Interviews with MDs/OR staff Benchmarking w/other organizations Failure Mode And Effect Analysis [FMEA] Process changes Patient education prep for surgery Hydration protocols

45 Overall Renal Failure GSAM

46 In Conclusion The rigorous use of data has been used to improve performance at all levels of our organization: Executives Housekeepers Nurses Surgeons and Anesthesiologists So that

47 Mrs. Stevens Bill Saunders Mr. Jones

48 Questions