Reducing Preventable Inpatient Deaths in … Reducing Preventable Inpatient Deaths in Community...
Transcript of Reducing Preventable Inpatient Deaths in … Reducing Preventable Inpatient Deaths in Community...
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Reducing Preventable Inpatient Deaths in Community Hospitals
Quality Symposium • February 19, 2007
Dr. Jeremy Theal MD FRCPC, CMIO
Ms. Linna Yang RN MHI, Clinical Informatics
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Introduction of Speakers
Jeremy Theal MD FRCPC
Chief Medical Information Officer
Linna Yang RN MHI
Manager, Clinical Informatics
Add Speaker
Photo Here
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Conflict of Interest
Jeremy Theal MD FRCPC
Linna Yang RN MHI
We have no real or apparent conflicts of interest to report.
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Agenda
• Overview of NYGH’s multi-year eCare project
• Methodology for engaging clinicians and integrating evidence into daily care
• Results from our study of CPOE outcomes
• Iterative quality improvement with eCare
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Learning Objectives• Explain how engagement of clinicians is crucial for system adoption and culture change
• Illustrate why integration of standardized evidence into daily clinician workflow
catalyzes improvement in quality and safety of patient care
• Enumerate the patient care benefits that can result when the goals of clinician adoption,
evidence integration, culture change, and system stewardship are achieved together
• Outline success factors required for meaningful improvements in quality and safety of
patient care when designing, implementing and maintaining CPOE systems
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Realizing Value of Health IT (STEPS)
T – Treatment/Clinical
• Integrated up-to-date evidence
into daily decision-making workflow of physicians
• Reduced mortality among inpatients in the Medical program,
specifically those with a diagnosis of pneumonia or COPD
exacerbation
E – Electronic Secure Data
• Business intelligence for tracking/reporting use of evidence-based care and patient outcomes
• Iterative quality improvement though corporate quality framework
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About North York General Hospital
• Community teaching hospital
affiliated with University of Toronto,
serving > 400,000 citizens
• Three Facilities
• Beds: 426 acute care
192 long-term care
• Volumes per year:
– 124,000 ED visits
– 31,000 inpatient cases
– 214,000 outpatient cases
– 5,800 births
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What is eCare?
Advanced Electronic Medical Record
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Standardization on Evidence-Based Care
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Safe Prescribing andMedication Administration
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Clinical Decision Support (Order Sets, Rules, Alerts)
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Multi-year hospital-wide clinical
transformation project utilizing health
information technology
Kickoff: 2007
Phased Implementation:
2008-2015
Hospital-wide: 2015
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Goals of the eCare Project
• Implement advanced EMR to improve patient outcomes:
Quality and safety of patient care
Enable Clinical & Business intelligence for better decisions
• Embrace culture of evidence-based care, best practices
Make it “easy to do the right thing”
Build evidence and best practice into optimized workflows
• SHARED VISION = “by clinicians, for clinicians”
100% clinician adoption via comprehensive engagement
Team-based interprofessional approach/workflows
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Phases of eCare
Phase Date Scope
1 Oct 2008 Med/Surg: Clinical Doc (Nsg, Allied)
2 Oct 2010 Med/Surg/CrCU: CPOE, eMAR, CDS, MedsRec
3 June 2012 Paediatrics: CPOE, eMAR, CDS, MedsRec
CrCU: Device Integration, Documentation
4 Oct 2013 L&D/PP: CPOE, eMAR, CDS, MedsRec, integrated
Fetal Monitoring
OR System – device integration
Anesthesia integration – Anesthesia doc
5 Oct 2014 Mental Health – CPOE, eMAR, CDS, MedsRec
6 Oct 2015 NICU – CPOE, eMAR, CDS, MedsRec
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PROGRESSEmergency Department – Tracking, triage, CPOE,
eMAR, CDS, MedsRec, Documentation
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How Physicians use Evidence in Daily Practice
• “Pull model”: almost 0% success rate
• “Push model”: 75% success rate
• Order sets: a key mechanism for building evidence into workflow
Predictor of Success Adjusted OR
Computer-based generation of decision support 6.3
Provision of recommendation rather than just an assessment 7.1
Provision of decision support
at the time and location of decision-making
15.4
Automatic provision of decision support as part of workflow 112.1
Kawamoto K et al. Systematic review of clinical decision support system success factors. BMJ 2005
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Change Management
Focus on Physicians for CPOE
and Order Set adoption:
• Gap analysis: 350 order sets to build
• 3 years of effort leading up to go-live
(2007-2010), direct MD involvement
• CMIO and physician champion network
• Goal: Communicate at least 7 times, 7 ways
• Change Management seminars for
project team, Physician Champions
• Standardization on evidence (no personal order sets!)
• Hired external firm: final go-live campaign
13Case #4: Reducing Inpatient Mortality
Involving Clinicians in CPOE Content Development
1• Order Set Prototyping (central build team)
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• Order Set Interprofessional Review (ViewSpace):Nursing, Allied Health, Lab, Radiology, Medical Imaging
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• Order Set MD Review (ViewSpace):online, one-on-one, group sessions
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• Comment review and consolidation, evidence updates, consensus meetings as needed
5• Order Set Final Approval (MAC - monthly)
Evidence for care
discussed at each
step
Evidence was the
foundation for
consensus
NO personalized
order sets permitted
15Case #4: Reducing Inpatient Mortality
Pneumonia Admission Order Set:Integrated Evidence
Risk Stratification (home / ward / Critical Care):
Prophylaxis and Proactive Care:
16Case #4: Reducing Inpatient Mortality
Pneumonia Admission Order Set: Evidence-Based Empiric Antibiotic Selection
18Case #4: Reducing Inpatient Mortality
Pneumonia Admission Order Set: “Choosing Wisely”
Workflow-integrated
clinical decision
support to reduce
un-necessary
testing and
healthcare costs
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\Metro Edition Thursday Dec 13, 2012
In-Hospital Death Rates Down
Across Greater Toronto Area• Annual CIHI Report demonstrated that
preventable in-hospital deaths were
reduced
• NYGH – top performer in Greater Toronto
and second best in all of Canada
• CEO Tim Rutledge: “health information
technology has hard-wired quality and
safety into the hospital”
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HSMR Explained
• Reported from
hospitals to
CIHI annually
• Reported to
public by CIHI
annually
• GOAL:
Reduce
preventable
inpatient
deaths
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NYGH’s HSMR Performance – 2010
In 2010, the HSMR score at NYGH was worse than the
national average in several large clinical areas.
Inpatient
Population
Probability
of Death
Actual
Death
HSMR
Medicine Program
Overall
429.38 481 112.0
Pneumonia 46.82 56 119.6
COPD
Exacerbation
30.62 43 140.4
22Case #4: Reducing Inpatient Mortality
NYGH Medicine:Mortality (HSMR) Pre/Post CPOE
112
81
140.4
89.5
119.6
79.7
0
20
40
60
80
100
120
140
Pre-CPOE 2010 Post-CPOE 2011
Medicine Program
COPD
Pneumonia
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Study Methods
Retrospective chart review• All patients discharged with a most responsible diagnosis of
Pneumonia or COPD
• Population #1 (2010): Pre-CPOE (520 patients)
• Population #2 (2011): Post-CPOE (511 patients)
Why were Pneumonia and COPD selected?• High-volume diagnoses for inpatient care
• Plenty of evidence to guide treatment
• Clear clinical decision support available
• Diagnosis often made on admission
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Statistical Analysis
Baseline Population Characteristics:
• Wilcoxon rank-sum test for continuous variables
(e.g. probability of death, age, length of stay)
• Chi-squared test for other variables
Odds of death and readmission:
• Logistic regression
All statistical analyses performed using Stata 12
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Characteristics of Patient Groups were Similar
Paper Orders CPOE (eCare) p-value
Number of Patients 520 511 NS
Gender F=262, M=258 F=269, M=242 0.468
AgeMean: 78.13 yrs
Median: 81 yrs
Mean: 76.54 yrs
Median: 80 yrs0.152
CrCU Admission
Total: 61
Pneumonia: 16
COPD: 45
Total: 62
Pneumonia: 32
COPD: 30
0.351
Length of Stay
(days)
Mean: 9.85
Median: 6
Mean: 10.00
Median: 60.936
30 day Readmission 68 57 0.344
DiagnosisPneumonia = 248
COPD = 272
Pneumonia = 285
COPD = 2260.009
Probability of Death
- Pneumonia
- COPD
Mean / Median
0.128 / 0.103
0.155 / 0.130
0.104 / 0.087
Mean / Median
0.123 / 0.098
0.142 / 0.122
0.099 / 0.080
0.199
0.114
0.294
Death (unadjusted) 78 47 0.004
Statistical correction
applied for difference
in diagnosis-related
groups
Raw death rate
significantly lower
with eCare vs paper
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Outcome Odds RatioConfidence
Intervalp-value
Death 0.574 0.39 – 0.84 0.005
Death adj for
Probability of
Death
0.571 0.38 – 0.85 0.006
Death adj for
Probability of
Death and CrCU
Admission
0.547 0.36 – 0.83 0.005
30-Day
Readmission0.835 0.57 – 1.21 0.345
30-Day
Readmission adj
for Probability of
Death and CrCU
Admission
0.837 0.56 – 1.25 0.380
Results: CPOE vs Paper
Odds of dying in
hospital from
pneumonia or COPD
exacerbation
decreased by 45%
using CPOE vs.
paper processes
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Results: Evidence-Based Order Set Selection
Order Set OutcomeOdds
Ratio
Confidence
Interval
p-
value
Diagnosis-
appropriateDeath
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0.48 0.26 – 0.90 0.022
Diagnosis-
appropriate
Death adj for
Probability of Death
and CrCU Admission
0.44 0.21 – 0.90 0.024
Diagnosis-
appropriate30-Day Readmission
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1.35 0.75 – 2.38 0.30
Close to diagnosis Death.
1.47 0.71 – 3.01 0.30
Close to diagnosis
Death adj for
Probability of Death
and CrCU Admission
1.82 0.78 – 4.23 0.16
Any order set Death.
0.55 0.12 – 2.54 0.44
Any order set 30-Day Readmission .
1.53 0.19 – 11.92 0.69
Odds of dying in
hospital from
pneumonia or COPD
exacerbation
decreased by 56%
when the admitting
physician used the
correct evidence-
based order set
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Adoption and Culture Change
Overall proportion of
patients admitted to
hospital with a
standardized,
evidence-based
order set increased
from 36% to over
97% upon transition
to eCare / CPOE
Paper Orders CPOE (eCare)
Percentage of patients for
whom a diagnosis-
appropriate order set was used
Pneumonia 26.05% Pneumonia 60.43%
COPD 0.0% COPD 45.1%
Percentage of patients for
whom any admission
order set was used .
Pneumonia 37.90% Pneumonia 97.54%
COPD 35.11% COPD 97.35%
CULTURE CHANGE + TRUST = SYSTEM STEWARDSHIP
29Case #4: Reducing Inpatient Mortality
Inpatient Preventable Mortality: Medicine Program
E – C A R EP A P E R
1 – eCare Phase 2 Implementation (CPOE, order sets, electronic med management)
2 – Quality Based Procedure (QBP) implementation – phased, over 1 year
1 2
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Inpatient Preventable Mortality: Pneumonia
E – C A R EP A P E R
1 – eCare Phase 2 Implementation (CPOE, order sets, electronic med management)
2 – Pneumonia QBP implementation, admission order sets in CPOE (April 1, 2015)
1 2
31Case #4: Reducing Inpatient Mortality
Inpatient Preventable Mortality: COPD
E – C A R EP A P E R
1 – eCare Phase 2 Implementation (CPOE, order sets, electronic med management)
2 – COPD MRP care taken over by generalists (rather than specialist respirologists)
3 – COPD QBP integration with admission order sets in CPOE (May 26, 2014)
1 2 3
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Using our Hospital Information System to integrate the latest evidence into the
decision-making workflow,
we saved an estimated 120 lives from
pneumonia and COPD exacerbation between 2010 and 2015
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Iterative Quality Improvement
• Over 850 evidence-based order sets
in NYGH library
• Regular order set updates – many inputs
– Front-line clinician requests: system stewardship!
– Updated evidence, utilization reporting, policy
– Formulary, government, user requests
– “Choosing Wisely Canada” campaign
• Past 12 months:
– 379 new/updated electronic order sets – completed 5-step
interprofessional design and review process
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Data Warehouse: Business/Clinical Intelligence
Finance System (SAP)
Coded Health Record (Med2020)
HR Database (Infinium_HR)
EHR System (Cerner)
Patient/Employee Survey (NRC Picker)
IPAC Database (Quality & Safety)
Transcription Services
Hand Hygiene Audit System
Critical Care Information System
ED System (Wellsoft)
Bed Tracking System (TeleTracking)
Wait Time Information System
Incident Reporting System (Parklane)
Other Sources (MRI, CIRT, etc)
Outcomes
Analysis
Patient
Safety
Research
PhysicianPerformance
Quality
Improvement
Compliance
Monitoring
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IPAC Committee
eCare
Falls Committee
Never Event Action Team Committee
Medication Use Safety Committee
(MUSC)
Research and Ethics
Board
Program Quality
Committees
Emergency Preparedness
Committee
Access to Care (ATC) Committee
Hospital Quality of Care Committee
Senior Leadership Team
Quality Committee of the Board
Medical Advisory Committee
Board of Governors
Quality Governance at NYGH
Other Committees
Accreditation Standards
Other Committees
Other Committees
All Cases: Continuous Quality Improvement, BI, Education
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Team
Communication
Recognition
and Profiling
Rigorous
Delivery
Improvement
Methodology
Capacity
Building
Transparent
Reporting
• Lean
• Six Sigma
• Simulation modelling
and operations
research
• Define
• Measure
• Analyze
• Improve
• Control• Summary Poster
• Celebrating Success
• Award Applications
• Conference
Presentation
• Quality Improvement Plan
• QIO Dashboard
• Annual QIO Magazine
• QI Innovation Lab
• Knowledge Translation
• Program Quality
Committee Support
• Huddles
• Team Meetings
• Quality Circles
QIO
Core
Functions
QI Office: Core Functions
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QIO Dashboard identifies:
• Number of open projects
• High level progress and status of
each project
• Risks before they become an issue
• Impact of QIO project work on
outcomes
All Cases: Continuous Quality Improvement, BI, Education
QI Dashboard:Reporting to Our Leaders
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Education channel
running in a loop,
live data feed from
BI system
Folders with
trending
indicators
Calendar to
track daily
trends e.g.
falls
Kamishibai
cards to
sustain
process
changesWhiteboard for
documenting quick
action plans and
improvement ideas
Unit-Based Quality Boards
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If you remember 3 things from this presentation…
1. The key to meaningful outcomes from use of CPOE is
transformation of clinical practice and culture … this takes time, and
lots of hands-on clinician engagement … don’t rush!
2. Focus on redesigning and standardizing care, based on evidence.
Be strong, personalized order sets are not necessary for system adoption!
3. Quality improvement is an ongoing, iterative process. Success requires:
– Automated outcome measurement
– System stewardship with ongoing monitoring
– Effective corporate quality improvement governance structure and team
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Realizing Value of Health IT (STEPS)
T – Treatment/Clinical
• Integrated up-to-date evidence
into daily decision-making workflow of physicians
• Reduced mortality among inpatients in the Medical program,
specifically those with a diagnosis of pneumonia or COPD
exacerbation
E – Electronic Secure Data
• Business intelligence for tracking/reporting use of evidence-based care and patient outcomes
• Iterative quality improvement though corporate quality framework
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Thank you for your attention! Questions?
Dr. Jeremy Theal MD FRCPC
Twitter: @drjeremytheal
Ms. Linna Yang RN MHI
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