2012 quality and patient safety performance results annual report the quality committee of the board...
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2012 Quality and Patient SafetyPerformance Results
Annual Report The Quality Committee of the Board
Confidential & Privileged Peer Review Materials; Pages 1-31 of this material has been prepared under the direction of the director of Quality/Patient Safety Officer as part of the delegated responsibilities of the role to ensure the state and federal protections:Pursuant to GPR Statutes Georgia Code Sections 31.7.130-133.3, and Federal Immunity under the HCQI Act 1986.
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Table of Contents
Downstream Impact: Affordable Care Act #Understanding the Clinical Climate #Patients with Underlying Conditions #Advancement of Safe and Reliable Care #Focus on Harm Reduction: Healthcare Acquired Conditions #Executive Summary #Healthcare Acquired Condition Reports - 2012 #-#Organizational Responsiveness to Quality and Patient Safety Issues #-#
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One is Too Many
Harm from the Patient’s Point of View
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Down Stream Impact: Affordable Care Act
CMS & Innovation Center (CMMI)
$1B to Partnership for Patient Safety (PfP) to Achieve 2 Goals 2013:
1. Reduce HAC’s by 40%
2. Reduce Re-admissions by 20%
State level - Healthcare Engagement Networks (HEN’s):
• 26 HEN’s Across Country
GA HEN / Georgia Hospital Association:
• Drive improvement of 10 HAC’s
Local Accountability for [Organization]:
• Reduce Harm for ___ HAC’s
• Demonstrate Best Practice
• Influence policy
• Report Data to CMS
Pa
y for P
erfo
rma
nce
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• Patient Volume [amount of change] from 2011 to 2012.
• Total Number of Patient Days [amount of change] from 2011 to 2012.
• Administered doses of medication [amount of change] (__ for Inpatient and __ for
Outpatient) from 2011 to 2012.
Understanding the Clinical Climate of 2012
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Patients with Underlying Conditions
Most complex secondary med mgmt Least complex secondary med mgmtSingle Focused Injury
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[Graph of Comorbiditites by Tier]
Tier 0 Tier 1 Tier 2Tier 3
Approach
Advancement of Safe and Reliable Care THROUGH:
Safe andReliable Care
Standardize:High Risk Practice
Mindful:Delivery of Care
Engage:Patients and Families
Adoption:Scientific Evidence
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Focus on Reduction of Harm
CLABSI(Central Line Associated Blood Stream Infection)
Adverse Drug Events(INR/Glycemic)
CAUTI(Catheter Associated Urinary Tract Infection)
Pressure Ulcers
VAP(Ventilator Associated Pneumonia)
VTE(Deep Vein Thrombosis)
Falls with HarmPreventable Readmissions (within 30 days of discharge and readmit to a Georgia hospital)
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Healthcare Acquired Conditions 2012 Rate
2012 # Patients
2013CMS Target*
Advancement of Safe & Reliable CarePg.#Evidence Engage Mindful Standardize
CLABSI*(Central Line Associated Blood Stream Infection)
• Blood stream infection related to a central venous catheter
• Per 1,000 device days0.48 10
CAUTI*(Catheter Associated Urinary Tract Infection)
• Urinary tract infection related to indwelling catheter
• Per 1,000 catheter days0.48 13
VAP(Ventilator Associated Pneumonia)
• Confirmed Pneumonia related to a mechanical ventilator
• Per 1,000 ventilator days0.66 16
Falls with Harm • Fall resulting in injury (category E-I)• Per 1,000 patient days 0.5 18
Inpatient Fall Rate• Assisted and Unassisted Falls –
Inpatient only• Per 1,000 patient days
2.15 21
Adverse Drug Events • Adverse Drug Events with harm (category E-I)
• Per 1,000 Doses
5% pts. INR>57% pts. BG<50 22
Pressure Ulcers*• New Stage III, Stage IV, and
Unstageable PU’s• Per 1,000 Discharges
3.21 25
VTE(Pulmonary Embolism/Deep Vein Thrombosis)
• Any Patient with pulmonary embolism or deep vein thrombosis
• Per 1,000 Discharges5.56
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Preventable Readmissions
• Unplanned all cause readmission within 30 days Medicare
• # Readmissions / Discharges
20%Reduction
from Baseline
Organizational Responsiveness to Quality and Patient Safety Issues
• Reportable Sentinel Events
31• Serious Adverse Events thatTriggered Drill Down
* Worst, acceptable rates established by CMS: Effective 2013 **Mandated by CMS LTCH Quality Reporting Program: Effective October 2012
Central Line Associated Blood Stream Infections CLABSI
# Patient Harms
10
[note: Include 1 icon for each harm]
The Person
• [Patient Profile]
The Story of CLABSI Harm• [Story of patient Harm]
Central Line Associated Blood Stream Infections CLABSI
Harm from the Patients Perspective
The Impact/Temporary• [Impact of patient Harm]
The Discharge• [Patient’s discharge status]
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Central Line Associated Blood Stream Infections CLABSI
Definition: Rate based on the total number of inpatients with confirmed blood stream infection per 1,000 central line days, based on CDC definition
2012 Rate:
2013 CMS Target: 0.48 / 1,000 device days
2012 Performance: • [Summary]
Potential Cost of Harm: $45,000 / hospital stay2
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[Control Chart of CLABSI Rate]
Catheter Associated Urinary Tract Infections CAUTI
# Patient Harms
13
[note: Include 1 icon for each harm]
Catheter Associated Urinary Tract Infections CAUTI
Harm from the Patients Perspective
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The Person
• [Patient Profile]
The Story of CAUTI Harm• [Story of patient Harm]
The Impact/Temporary• [Impact of patient Harm]
The Discharge• [Patient’s discharge status]
Catheter Associated Urinary Tract Infections CAUTI
Definition: Rate based on the number of patients with indwelling catheters who are symptomatic with confirmed infection per 1000 catheter days, based on CDC definition.
2012 Rate:
2013 CMS Target: 0.48 / 1,000 catheter days
2012 Performance:• [Summary]
Potential Cost of Harm: $44,043 / hospital stay8
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[Control Chart of CAUTI Rate]
Ventilator Associated Pneumonia VAP
ZERO Patient Harm
____ Days : free from Harm
____ Years: based on the CDC definition
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____ Patients: were kept free from Ventilator Harm
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Ventilator Associated Pneumonia VAP
Definition: Rate based on total number of inpatients with confirmed infection per 1,000 ventilator days. National Healthcare Safety Network's definition of VAP: patient on ventilator, physician diagnosis of pneumonia post admission based on diagnostic, imaging, and/or laboratory results.
2012 Rate:
2013 CMS Target: 0.66 / 1,000 vent days
2012 Performance:• [Summary]
Potential Cost of Harm: $40,000 / hospital stay1
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[Control Chart of VAP Rate and Device Utilization]
Falls with Harm
# Patient Harm
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[note: Include 1 icon for each harm]
Falls with Harm
Harm from the Patients Perspective
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The Person
• [Patient Profile]
The Story of Fall with Harm• [Story of patient Harm]
The Impact/Temporary• [Impact of patient Harm]
The Discharge• [Patient’s discharge status]
Falls with Harm
Definition: Figures are based on number of individual falls with harm reported through incident reports. The hybrid scale developed by Georgia Hospital Association (GHA) defines categories E - I as "with harm." The range is between temporary harm, prolonged hospitalization, permanent harm, near death and death.
2012 Rate:
2013 CMS Target: 0.5 injury falls / 1,000 pt. days
2012 Performance:• [Summary]
Potential Cost of Harm: Variable
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[Control Chart of Falls with Harm Rate]
Inpatient Fall Rate
Definition: Individual inpatient falls are reported through incident reports capturing assisted and unassisted falls. Rate is number of falls per 1,000 pt days
2012 Rate:
2013 CMS Target: 2.15 / 1,000 patient days
2012 Performance:• [Summary]
Potential Cost of Harm: Variable
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[Control Chart of Assisted Falls Rate]
[Control Chart of Unassisted Falls Rate]
Adverse Drug Events ADE
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# Patient Harms
[note: Include 1 icon for each harm]
Adverse Drug Events ADE
Harm from the Patients Perspective
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The Person
• [Patient Profile]
The Story of ADE Harm• [Story of patient Harm]
The Impact/Temporary• [Impact of patient Harm]
The Discharge• [Patient’s discharge status]
Adverse Drug Events ADE
Definition: Harm is defined on a scale developed by Georgia Hospital Association, categories E - I (temporary Harm to Death). Figures based on number of individual medication incidents with harm as reported through incident reports.
2012 Rate:
2013 CMS Target: 5% INR>5 & 7% BG<50
2012 Performance:• [Summary]
Potential Cost of Harm: Variable
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[Control Chart of ADE Rate]
Pressure Ulcers
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# Patient Harms
[note: Include 1 icon for each harm]
Pressure Ulcers
Harm from Patients Perspective
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The Person
• [Patient Profile]
The Story of PU Harm• [Story of patient Harm]
The Impact/Temporary• [Impact of patient Harm]
The Discharge• [Patient’s discharge status]
Pressure Ulcers
Definition: Hospital Acquired Pressure Ulcers with Harm are Stage III and Stage IV pressure ulcers that developed while in the hospital.
2012 Rate:
2013 CMS Target: 3.21 / 1,000 discharges
2012 Performance:• [Summary]
Potential Cost of Harm: $1,600 / day4
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[Control Chart of HA PU Rate]
Venous Thromboembolism VTE
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# Patient Harms
[note: Include 1 icon for each harm]
Venous Thromboembolism VTEHarm from Patients Perspective
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The Person
• [Patient Profile]
The Story of VTE Harm• [Story of patient Harm]
The Impact/Temporary• [Impact of patient Harm]
The Discharge• [Patient’s discharge status]
Definition: Any Patient with pulmonary embolism or deep vein thrombosis per 1,000 discharges
Venous Thromboembolism VTE
2012 Rate:
2013 CMS Target: 5.6 cases/1,000 discharges
2012 Performance:• [Summary]
Potential Cost of Harm: $19,000 (DVT)
$37,000 (PE)
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[Control Chart of VTE Rate]
Preventable Readmissions
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# Patient Harms
[note: Include 1 icon for each harm]
Preventable ReadmissionsHarm from Patients Perspective
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The Person
• [Patient Profile]
The Story of Readmission Harm• [Story of patient Harm]
The Impact/Temporary• [Impact of patient Harm]
The Discharge• [Patient’s discharge status]
Definition: Definition: Unplanned all cause readmissions within 30 days - Medicare patients only
Preventable Readmissions
2012 Rate:
2013 CMS Target: Reduce hospital baseline by 20%
2012 Performance:• [Summary]
Potential Cost of Harm: TBD
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[Control Chart of Readmission Rate]
Organizational Responsiveness to Quality and Patient Safety Issues
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Significance: A significant adverse event, also known as a sentinel event, is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof and signals the need for immediate drill down and organizational response.
The terms "sentinel" and "error" are not synonymous. Not all serious adverse (sentinel) events occur because of an error, and not all errors result in a serious adverse (sentinel) event.
Analysis:
Organizational Responsiveness to Quality and Patient Safety Issues
+
+
Q1 Q2 Q3 Q4 2012 Total All Types Medication Error
Procedural Error
Infection
Allergy
Delay in Care
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