Bon Secours Baltimore Health System Baltimore, Maryland

1
Bon Secours Baltimore Health System Baltimore,
Maryland
Raising The Bar On Excellence June 21, 2006
Presented at Premier Breakthroughs
Conference Orlando, Florida

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Hospital Demographics

• Acute Care
• Not-for-Profit
• Religious Sponsored
• Licensed 143 inpatient beds
• Median age 54
• Medicare, Medicaid, Other Commercial Insurances
• 86 of patients admitted thru the ED
• CMI 1.06 (APR DRG)

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Highlights of Programs and Services

• 24-Hour Emergency Department Physician Triage
• Critical Care Services Intensivist Managed
• Medical/Surgical Services
• Perioperative Services
• Inpatient/Outpatient Psychiatric Services
• Inpatient/Outpatient Renal Services

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Other Services

• Cardiac Catheterization Lab
• Cardiopulmonary Rehabilitation
• Vascular Center
• Podiatry Services
• Ophthalmology/Optometry
• Orthopaedics
• Pastoral Care
• Imaging/MRI/Nuclear Medicine

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Outreach Services

• Adapt Cares
• Drug Abuse Treatment Program provides methadone
  therapy and counseling services
• New Hope
• One of the First JCAHO accredited Methadone
  Program in the Maryland and in the Country
• New Phases
• Psychiatric Rehabilitative Program assists
  individuals who suffer from chronic mental
  illness.
• Next Passage
• Outpatient Drug-free substance abuse

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Outreach Services

• Community Institute for Behavioral Services
• Outpatient Mental Health and Substance Abuse
  Services for the entire family, including
  screenings and diagnostic services, individual
  and group therapy and specialized case management
• Community Support Center
• Literacy Assistance Program- GED, literacy
  education, family therapy, parenting and child
  development skills
• Bon Secours Womens Resource Center
• Domestic Violence Program- counseling, support
  groups, job skills bank and variety of other
  resources for women
• Bon Secours of Maryland Foundation
• Community and Senior Housing Program- local
  economic development, enrichment program for
  families and youths

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Outreach Services

• Bon Secours Rehabilitation Wellness Center
• Physiatry, social work, physical and
  occupational therapy services
• The Connection
• State of the Art Fitness Center for
  rehabilitation and wellness
• Bon Secours Tele-Heart Program
• Comprehensive Monitoring System- home visits,
  heart-health, nutrition and education classes
• Bon Secours Imani Center
• Outpatient HIV Care and Treatment Program-
  including counseling, testing and medical
  evaluations.

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Background (2003)

• Started in 2003- Compliance rates were below
  target
• Limited Buy-In (non compliance with the
  guidelines)
• Limited Engagement (Autonomy)
• Gap between accountability and training
• Lack of use of Clinical Guidelines/Protocols/Path
  ways
• Lack of multidisciplinary approach
• Unfamiliarity with Core Measure Indicators
• Limited Resources
• Sporadic Concurrent Monitoring

9
Corrective Action (Beginning of Project)

• CEO requirement to improve
• Specific Improvement time line established and
  communicated
• Organizational Commitment / Engagement
• Defined expectations / created vision
• Distribution of guidelines to the Care Staff
• Consumer Expectations / Transparency for Quality
  and Patient Safety

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Results by 2nd Quarter 2004

• Results showed that there was still room for
  improvement
• Leaders drilled down to identify further
  roadblocks and methods to overcome lack of
  compliance
• CHF score improved from 40 to 60
• Pneumonia score improved from 60 to 73
• AMI score improved from 60 to 75

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Premier Consultant Recommendations

• Implement CAP Protocols in the ED
• Timing of Antibiotics- CAP protocols in ED for
  timely treatment of patients upon arrival to the
  ED
• Blood Cultures - Lab Redesign process to enter
  into the system the time blood culture was drawn
  vs. time blood culture processed in the lab
• Implement AMI Protocols ED and Inpatient
• ASA Beta Blockers at Arrival
• Developed Standing Orders to include ASA on
  arrival for chest pain patients.
• AMI Order Sheet - Physician approved protocols
• Revised Cardiac Care discharge instruction
• Monitor impact of the Revised Cardiac Care
  Discharge Instruction Sheet and upgrade as
  necessary
• Development of CHF Protocol
• Developed Physician approved protocols
• Revised General Discharge Instruction Sheet to
  include CHF discharge instructions and a pamphlet
  in the discharge package

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Premier Consultant Recommendations

• Emergency Room Flow Redesign
• ED ThroughPut
• ? Triage
• ? Admission to the Floor
• ? Bed Huddles
• ? Patient Satisfaction
• ? Equipment
• Nurses were re-educated regarding the new
  process and the completion of the Congestive
  Heart Failure Teaching/Learning Flow Sheet

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Six Sigma Vaccination Project

• Six Sigma Vaccination Project Physician approved
  protocol
• re-enforced
• ? Pilot Unit
• ? Nurse driven process (Standing order Protocol)
• ? Universal Vaccination of all eligible patients
  (criteria
• based)
• ? SMS computer capture of prior vaccination
  status (updated monthly registry shared with the
  units)
• Collaboration with Surrounding Nursing Homes in
  obtaining vaccination status of nursing home
  patients

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QUALITY MANAGEMENT
Run Admission/Transfer/Discharge report
Patients Admitted prior day with diagnosis
Perform 100 Chart review for Indicator
compliance.

• Identify non-compliance by placing Neon Colored
  communication on the Chart.
• Perform onsite counseling/education
• Direct ED interaction

Core Measure color coded system Hospital Wide
Daily E-mails identifying responsible
Individual/area of non-compliance Response/Correc
tive Action due w/in 24hrs
Distribute daily/weekly compliance scores
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Overall Corrective Action

• Rounds conducted daily, concurrent chart review
  (Saturday Sunday reviews done on Monday)
  corrective actions taken immediately
• Rounds Components Core Measures, National
  Patient Safety Goals, Surgical Case Review
• Deficiencies are sent via daily e-mail to unit
  Managers and Directors of Service/Department
• Daily excel spread sheet template of overall
  scores is attached to alert the unit staff on
  their daily score

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Overall Core Measures Corrective Action

• Development and implementation of administrative
  Non-Compliance policy for Medical Staff
• Physician Champion was identified - Tracking and
  Trending of physicians performance
• Unit Nurse Huddles
• Part of Nursing Competency
• Review daily emails to improve nursing compliance
• Positive feedback and re-enforcement to Medical
  and Nursing staff during rounds given verbally or
  via letters from Senior Vice President of
  Operations
• Education Material included in the Medical Staff
  Orientation
• Education Material included in the General
  Hospital Orientation
• Part of JCAHO employee handbook and Staff Guide
• Recognition for Quality Core Measure Performance

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Overall Core Measures Corrective Action

• Developed color coded charting system in
  ED/Hospital Wide to easily recognize patients
  with Core Measure Diagnosis
• Core Measure checklist initiated in the ED and
  forwarded to the floor for verifying compliance
  with the guidelines
• Universal Smoking Cessation initiated by
  Registration (Recommendation from Performance
  Engineer).
• Part of Continuum of Care PI Plan (Smoking
  Cessation/counseling and Vaccination status)
• Discharge status reviewed and corrections
  communicated to Premier regularly

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Overall Core Measures Corrective Action

• Data discussed in Medicine Departmental Meetings,
  Performance Improvement Council, Medical
  Executive Committee Meetings, Management Council
  Board of Directors
• Peer Review and Validation of non compliant
  records - Referrals to the Chairpersons
• Education about Evidence Based Medicine
  Guidelines (physician profiling)
• Monthly Preliminary Reporting of HQI Report
• Communication to the Board/ Local System
  priorities

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Overall Corrective Action

• Universal engagement at all levels
• Executive Core Measure rounds include CEO,
  Senior VP Operations, VP Care Management,
  Physician Advisor, Medical Director, Director
  Nursing Professional Development, Quality
  Management Coordinator, VP of Mission, Compliance
  Officer, Chair of Surgery, Director of
  Peri-operative Services

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Results (2nd Quarter 2005)

• CHF 94.53 composite
• AMI 91.33 composite
• Pneumonia 86.05 composite

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HEART FAILURE IMPROVEMENT
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AMI IMPROVEMENT
25
PNEUMONIA IMPROVEMENT
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Barriers (End 2005)

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Corrective action
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1- AMI Aspirin at Arrival
29
2- AMI Beta Blockers at Arrival
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3- AMI Adult Smoking Cessation
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4- AMI Beta Blockers at Discharge
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5- AMI Aspirin at Discharge
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1- CHF LVEF Assessment
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2- CHF ACEI/ARB for LVEF 35
3- CHF Adult Smoking
36
4- CHF Discharge Instructions
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1- Pneumonia Non-ICU
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2- Pneumonia ICU
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3- Pneumonia Oxygenation
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4- Pneumonia Adult Smoking
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5- Pneumonia Influenza
42
6- Pneumonia Vaccination
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7- Pneumonia Blood Cultures
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8- Pneumonia Initial Abx 45
FUTURE INITIATIVES

• LVEF will be included in the ER Cardiac Profile
  Order Set
• CHF/ AMI/ PN preprinted discharge instructions
  (Medication Reconciliation/Discharge
  Instructions)
• Planning an E-link to the Cardiac Lab - interface
  ER Order with last LVEF on file
• Reviewing ER standing order protocol to have the
  triage nurse draw the blood of patients with
  sepsis/ elevated temperature, severe cough
• Reviewing the Medical Evaluation in the ED to
  include patients with symptoms as urgent to be
  seen within 2 hours of arrival

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END

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