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
®
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
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
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
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*
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%
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
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
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
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
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
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
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
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.
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
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
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
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
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