Reporting Pneumonia

1
Reporting Pneumonia Heart Failure..What
color can do

• Katrina Strowbridge, RN
• Quality Improvement Coordinator
• St. Luke Community Healthcare Network

2
The way it was.. the data doldrums

• Standardized order protocols
• Pneumonia HF order sets
• Pneumonia Influenza vaccine screen
• Standard discharge form
• Data was collected retrospectively
• Posted in nurses station
• Also shared at Nursing staff, Medical Staff BOD
  quarterly

3
Reporting format

• Reported using histogram
• Canned report from CART/Q-Net Exchange for
  Medical Staff
• Same report format each quarter and then we began
  to beat the drum
• And we beat the drum some more

4
Pneumonia
5
And the response was

• Ho Hum
• Issues-
• Disinterest
• Lack of engagement
• Time delay of reports /- 6 months did not
  support buy in, motivation or interest
• Belief that numbers are small (ie, miss one, its
  okay)

6
Trying to raise the bar

• ER Physician packets
• Letters to all providers
• Laminated pocket cards
• Daily reminder sheets
• Software changes
• enhanced reporting capabilities

7
What finally changed things?
.Whoda thunk it???
8
Pneumonia - 2007
9
Heart Failure - 2007
10
Strutting stepping along

• Using concurrent abstraction
• Reported quarterly with live data
• Report format changed
• Trended dashboard
• Color copies shared at quarterly Department
  Managers meetings, Nursing staff meetings _at_
  Medical Staff
• 2 reports provided
• St. Luke Quarterly Report trended dashboard
• HQA Comparable Data trended dashboard report
• Shared with the Board of Directors annually (or
  more often)

11
And the response was

• Interest at all levels
• Engagement
• Initiative
• Motivation

12
Our Day-to-day Champions
13
Pneumonia 1 Oxygen Assessment
14
Pneumonia 2 Pneumococcal vaccination
15
Pneumonia 3 Blood Cultures in the ED
16
PN 4 Smoking Cessation
17
Pneumonia 5a/c Antibiotic Timing
Change of hours Q207
18
Pneumonia 5b Antibiotic Timing
19
Pneumonia 6b Antibiotic Selection
20
Pneumonia 7Influenza vaccination
21
HF 1 Discharge Education
22
HF 2-LVF Assessment
23
HF 3-ACE or ARB or LVSD
24
HF 4-Smoking Cessation
25
Changes for the future

• Physician drilldown..
• Stimulates their competitive nature
• Allows focus of educational needs at the
  individual level versus group level
• Accountability
• Medical Staff, Department Managers, Nursing