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Page 1: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Presented to

IHA Quality Encounter“Delivering Measurable Results Through Process

Improvement”

June 16, 2009

Robin Oakley, Manager CCUSusan Eller, Manager ED

Kevin O’Leary, MD Hospital Medicine

Pneumonia Core Measures

Northwestern MemorialHospital

®

Page 2: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia Core Measures ProjectOverview

Linkage to BPE/BP/Finance: BPE – Deliver the most effective care based on clinical evidence

Problem Statement: Adherence to core measures guidelines helps improve patient outcomes. In FY2007, NMH compliance with the aggregate pneumonia core measure set was 65%; 8% below the internal compliance goal of 73%. The ‘Initial Antibiotics within 4 Hours’ and ‘Pneumococcal Vaccination Assessment’ individual measures, 78% and 72% compliance respectively, were the most detrimental to achieving the overall goal. These two metrics are especially important as administering antibiotics in a timely manner has been shown to reduce 30 day mortality rates and the pneumococcal vaccine has proven up to 75% effective against pneumococcal bacteremia. These and the other pneumonia metrics must improve if we are to attain our goal of top decile performance in the pneumonia core measure set in FY2008.

Goal/Benefit: By 6/2008, work with the ED, the inpatient units and other relevant groups to improve compliance with the all pneumonia core measures to above 95% compliance.

Scope: The pneumonia metrics for all patients meeting core measure inclusion criteria.

Deliverables: New processes, protocols and/or tools needed to achieve the stated goals.

Resources Required: Leadership and staff from Nursing, the Emergency Department, the Department of Medicine, Clinical Quality, a Pulmonologist and Clinical Informatics. Fast-track changes to relevant Powerchart rules / forms.

Key Metric(s) • Compliance with Pneumonia Overall Guidelines (%)• Initial Antibiotics Delivered within 4 / 6 Hours (%)• Pneumococcal Vaccination (%)• Blood cultures performed in ED prior to initial antibiotic received in hospital (%)• Antibiotic selection for immunocompetent patients (non ICU) (%)• Influenza Vaccination (%)

Executive Sponsor: Sponsors: Clinical Sponsors: Process Owner: Improvement Leader: Dan Derman Corrine Haviley / Deb Livingston Kevin O’Leary / Mike Schmidt Robin Oakley / Susan Eller Mark Schumacher

Project Charter

Page 3: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Why Were We Focused on Pneumonia?

• Influenza kills 36,000 people in the US per year• Community-Acquired Pneumonia (CAP) kills 10,000 people in

the US per year• Over 1400 pneumonia patients admit to NMH each year; over

100 patients with a diagnosis code indicating pneumonia die

• The Centers for Medicare & Medicaid Services (CMS) measures our ability to meet evidence-based care guidelines

• In FY2007, NMH compliance with the aggregate pneumonia core measure set was 65%

D M A I C

Page 4: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

What are the CAP Core Measures Again?

• CMS measures to ensure that for all CAP patients we… Assess oxygenation within 24 hours of arrival

Perform blood cultures prior to initial antibiotic administration

Administer the initial antibiotic within 6 hours of arrival

Administer the right antibiotic per best practices

Administer the pneumococcal vaccine prior to discharge

Administer the flu vaccine prior to discharge

Counsel patients with a history of smoking on smoking cessation prior to discharge

We need focused improvement in administering the vaccines

D M A I C

Page 5: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Measuring the ProblemTo meet the NMH goal of top decile performance (>95% compliance) in all publicly

reported metrics we needed to improve in 5 / 7 pneumonia core measures

D M A I C

29 28

7 6 5 42

35.8%

70.4%79.0%

86.4%92.6%

97.5% 100.0%

0

5

10

15

20

25

30

35

PN

-2

Pneum

ococcal

Vaccin

ation

PN

-5b

Antibio

tic

within

4 H

ours

PN

-3b

BC

in

ED

Prior

to

Antibio

tic

PN

-4

Adult

Sm

okin

g

Cessation

PN

-6a

Antibio

tic in

Imm

uno -

IC

U

PN

-6b

Antibio

tic in

Imm

uno -

Non

ICU

PN

-3a

BC

within

24H

rs f

or

ICU

Fa

ilu

re V

olu

me

s

0%

20%

40%

60%

80%

100%

120%

Cu

mu

lative

Pe

rce

nta

ge

Pneumonia Measure Failure Cumulative Percentage

Notes: *Pneumonia patients 4.1.2007 – 9.30.2007

• The pneumococcal vaccination and antibiotic timing metrics accounted for 70% of the failures

• Five total metrics required either improvement or stabilization: pneumococcal vaccine, antibiotic timing, blood cultures in ED, appropriate antibiotic selection and influenza vaccine

Pneumonia Core Measure Failures Stratified*

Page 6: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Setting a Goal

Top decile performance requires a nearly error free process

D M A I CNotes: Pneumonia patients 4.1.2007 – 9.30.2007

Performance Required for 95% Compliance

  Pneumococcal Vaccination Initial Antibiotic within 4 hours

Compliance Rate 81.2% 81.2%

Goal Success Rate 95.0% 95.0%

Average Metric Failures / Month 4.8 4.7

Permitted Metric Failures / Month 1.3 1.2

• Achieving 95% compliance allows approximately 1 metric failure per metric per month

• We needed to reduce failures by more than 75%

Page 7: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Building The Team

Success requires a carefully built, inclusive team with engaged sponsors.

ED Nurses

Inpatient Nurses

ED Nurse Manager

Inpatient Nurse Managers

ED Director

Nursing Director

ED Physicians

Medicine Physicians

Pharmacists

Quality Staff

IS Staff

Registration Staff

Registration Manager

Page 8: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: ED Wait TimesThe teams analyzed potential failure drivers for the ED metrics and identified ED

wait times as the primary driver

D M A I C

0

1

2

3

4

5

6

7

8

9

0 15 30 60 90 120 150 180 240 > 240Minutes

Pa

tien

t V

olu

me

0%

20%

40%

60%

80%

100%

120%

Cu

mu

lativ

e %

Failures Successes Failure Cum% Success Cum %

ED Wait Time (Arrive to ED Bed) and Antibiotic Timing Compliance

• Patients waiting for a bed for more than 90 minutes did not receive antibiotics within 4 hours

Page 9: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Turn Wait Time into Care Time

The ED team members implemented a new triage / registration process to facilitate early x-ray orders

D M A I C

• Implemented new parallel triage / registration process to reduce processing time by 40% (4 minutes) for ALL patients

• Trained RNs on protocol x-ray orders from triage and revised the Powerchart x-ray order process to turn ED wait time into productive time

New Triage / Registration Process

Page 10: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Antibiotic Ordering DelaysThe team analyzed additional failure drivers for the ED metrics and

identified the antibiotic order process as another key driver

D M A I C

0123456789

10

Ordered Released Ordered Released

ABX Admin > 4 hours ABX Admin < 4 hours

Pat

ient

Vol

ume

Antibiotic (ABX) Order Method and Antibiotic Timing Compliance

• Ordering an antibiotic via the tube, versus the Omnicell, increased turnaround time by 20min (median 57 versus 37min)

• In addition, there were no warnings / triggers to ensure a blood culture was drawn prior to antibiotic administration

Page 11: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Antibiotic Ordering Flow

The ED team members implemented a new antibiotic ordering process to reduce turnaround times

D M A I C

MD writesantibiotic

order

RN callsPharmacy on thenew ED antibiotic

line

Antibioticin the

Omnicell?

Pharmacy tubesthe antibiotic to

ED # 805 orEDOU # 125

Pharmacyreleases antibioticfrom the Omnicell

RN accessesand

administersantibiotic

NO

YES

RN gives patientname, allergies,indication, medname and dose

Pharmacy readsback the order

information

RN confirms theread-back or

providescorrections

Pharmacyverbalizes deliverymethod: Omnicell

or tube

MD checksfor bloodcultures

RN checksfor bloodcultures

• Implemented new antibiotic order process to reduce turnaround times:

•Removed MD from the Pharmacy contact role, introduced a new antibiotic phone line and leveraged the Omnicell to improve process flow

•Reduced turnaround time by an average of 18 minutes for ALL patients

• Introduced a reminder on the Omnicell to ask about cultures prior to release

• Also implemented a new ED MD protocol to improve blood culture and appropriate antibiotic selection compliance

New Antibiotic Order Process

Note: CMS also changed the antibiotic timing requirement from 4 hours to 6 hours

Page 12: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: ED Results

D M A I C

Antibiotic administration within 6 hours improved, but a CMS documentation requirement dampened results until a new documentation system was

implemented in FY09 Q1.

ED Metric Q1 to Q4 Comparison

Metric FY08 Q1 FY09 Q1 GAIN

Timelines ABX 76.7% 93.3% 16.6%

Blood Cultures in ED 90.7% 95.0% 5.0%

ABX Selection 89.7% 92.0% 2.3%

*Note: Threshold changed from 4hrs to 6hrs in April

• Implemented ED interventions in May and June• Compliance with the time to antibiotic requirement increased by 16.6% and the median

time to 1st antibiotic decreased by 39 minutes• Compliance with the blood culture and antibiotic selection measures increased by 5%

and 2.3% respectively

Compliance with Timeliness of Antibiotics

60%

70%

80%

90%

100%

Sep-0

7

Nov-0

7

Jan-

08

Mar

-08

May

-08

Jul-0

8

Sep-0

8

Nov-0

8

Jan-

09

Mar

-09

% Compliant with Guidelines NMH Goal

Page 13: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Myths, triggers and orders

The teams analyzed potential failure drivers for the vaccine metrics

D M A I C

Pneumococcal / Influenza Vaccination Failures

Failure Driver Volume %

Vaccine order never charted against 8 47%

Vaccine order charted against incorrectly 4 24%

Patient profile never completed 3 18%

Other 2 12%

The team analyzed 3 months of vaccine failures to determine the key drivers:

• Commonly held myths about vaccine safety / efficacy

• Problems with Powerchart trigger architecture

• Problems with Powerchart order behavior

Page 14: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Education

• Discussions with nurses identified five commonly held myths

• The team educated ALL inpatient nursing staff using an online course and quiz:1. Can the Influenza Vaccine Cause the Flu?

2. Is the Influenza Vaccine is Safe for Sick Patients?

3. Is the Influenza Vaccine Only for the Elderly?

4. Do Flu Shots Work?

5. Does the Pneumococcal vaccine work?

D M A I C

The team implemented an annual education program to overcome common vaccine myths.

Page 15: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Order Triggers

• Error-proofed, required questions on the nursing patient profile trigger the vaccine orders

• Question design ensures that ALL appropriate patients receive a vaccine order

D M A I C

Use electronic documentation as a tool

Page 16: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Daily Snapshot Report

The team members also implemented a suite of PowerChart changes and the new Daily Snapshot Report.

D M A I C

• Daily Snapshot Report

– The report provides daily actionable information to the bedside nurse

– It provides information on vaccine compliance, patient profile status, medication reconciliation status, fall risk and pressure ulcer risk / treatment

– The report provides information using exception criteria to minimize waste and re-work

Page 17: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia: Inpatient Results

D M A I C

Improvements resulted in an almost 15% improvement in the Pneumococcal Vaccine Assessment measure.

Pneumovax Q1 to Q4 Comparison

FY08 Q1 FY08 Q4 GAIN

Pneumovax 78.7% 93.3% 14.6%

• Implemented all pneumococcal vaccine interventions by July

• Almost 15% improvement realized in FY08 Q4 (June – August) and sustained in FY09

Compliance with Pneumococcal Vaccination Assessment

60%

70%

80%

90%

100%

Sep-0

7

Oct-0

7

Nov-0

7

Dec-0

7

Jan-

08

Feb-

08

Mar

-08

Apr-0

8

May

-08

Jun-

08

Jul-0

8

Aug-0

8

Sep-0

8

Oct-0

8

Nov-0

8

Dec-0

8

Jan-

09

Feb-

09

Mar

-09

% Compliant with Guideline NMH Goal

Page 18: Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager.

Pneumonia Core Measures: Results

D M A I C

Overall Compliance demonstrated greater than 30% improvement

Overall Q1 to Q4 Comparison

FY08 Q1 FY08 Q4 GAIN

Overall 58.3% 90.3% 32.0%

• Implemented new processes in May, June and July

• 32% improvement realized in FY08 Q4 (June – August) and sustained in FY09

• Pre and post implementation variability reduced by over 80%

Compliance with Pneumonia Guidelines

30%

40%

50%

60%

70%

80%

90%

100%

Sep-0

7

Oct-

07

Nov-0

7

Dec-0

7

Jan-

08

Feb-0

8

Mar

-08

Apr-0

8

May

-08

Jun-

08

Jul-0

8

Aug-0

8

Sep-0

8

Oct-

08

Nov-0

9

Dec-0

8

Jan-

09

Feb-0

9

Mar

-09

% Compliant with PN Guidelines