quality, safety & patient experience committee meeting ...€¦ · committee minutes –aug 29,...

Quality, Safety & Patient Experience Committee Meeting

Thursday, October 31, 2019 9:00 a.m.

Chair Welcome

Therese Everly, BS, RRT QSPE Committee Chair

Lee Health Board of Directors

2

All public input will take place at the Board of Directors meetings (not Committee meetings).

At that time input is limited to three minutes and a “Request to Address the Board of Directors” card

should be completed and submitted to the Board Staff prior to meeting.

Non-Committee members are present to observe only and not to participate.

Please contact the Board Office with any questions (239) 343-1500.

Public Input Statement

3

Agenda

1. Committee Minutes – August 29, 2019 Approval of Minutes

2. Performance Oversight – Scott Nygaard, MD

3. System Strategic Scorecard – Scott Nygaard, MD

4. FY20 Proposed System Strategic Scorecard – Scott Nygaard, MD

5. Medical Staff Reports – Keri Mason, DO

6. Hospital Acquired Infection Performance – Marilyn Kole, MD & Marcelo Zottolo

7. Readmission Steering Committee and Engagement – John Chomeau

8. ExceptionalLee Patient Experience – Lisa Sgarlata

9. Safety Event Update and Trends – Alex Daneshmand, DO

10. IBM Watson Top 100 Hospital – Marcelo Zottolo

11. Ambulatory Quality and Safety Scorecard Build – Marcelo Zottolo

12. Celebrations – Scott Nygaard, MD

13. Committee Member Report/Meeting Evaluation – Members

4

Current Agenda Schedule

5

Committee Minutes – Aug 29, 2019 Approval

QUALITY, SAFETY & PATIENT EXPERIENCE (QSPE) COMMITTEE MEETING MINUTES Thursday, August 29, 2019

LOCATION: Gulf Coast Medical Center, Medical Office Building, Board of Directors Boardroom, 13685 Doctors Way, Fort Myers, FL 33912 MEMBERS PRESENT: Therese Everly, Board Secretary and QSPE Chairman, Stephen Brown, MD, Board Chairman, Sanford N. Cohen, MD, Board Member (left at 10:30 am), Stephanie Meyer, Board

Member, Asif Azam, MD, Mitko Badov, MD, Daniel Eason, DO, Larry Hobbs, MD, Keri Mason, MD (arrived at 9:34 AM), Scott Nygaard, MD, QSPE Administrative Sponsor ALSO PRESENT: Larry Antonucci, MD, LH President & CEO, Donna Clarke, Board Vice Chair, Mary Briggs, Alex Daneshmand, DO, Regina Eberwein, Kris Fay, David Klein, Marilyn Kole, MD,

Joby Kolsun, DO, Mary McGillicuddy, Tracy Pyles, Brian Saso, Lisa Sgarlata, Barbara Shearer, Marcelo Zottolo

NOTE: Documents referred to in these minutes are on file by reference to this meeting date in the Office of the Board of Directors and on the Board of Directors website at www.leehealth.org/boardofdirectors, for public inspection.

SUBJECT DISCUSSION ACTION OR SPECIFIC REQUEST FOLLOW-UP

MEETING CALLED TO ORDER

Therese Everly, QSPE Chairman welcomed everyone to the 2nd committee meeting. She officially welcomed the physician members from the medical staff; Dr. Asif Azam, Dr. Mitko Badov, Dr. Eric Eason, Dr. Larry Hobbs, Dr. Keri Mason, who were formally appointed by the BOD on April 25, 2019. She explained that at the beginning of each administrative report there will be framing question(s) to consider during the presentation.

QUALITY, SAFETY & PATIENT EXPERIENCE COMMITTEE MEETING was CALLED TO ORDER at

9:00 a.m. by Therese Everly, Quality, Safety & Patient Experience Chairman.

PUBLIC INPUT STATEMENT Therese Everly read the Public Input statement.

QSPE COMMITTEE MINUTES Theresa Everly asked for approval of the April 25, 2019 Quality, Safety, & Patient Experience Committee (QSPE) meeting minutes.

A motion was made by Dr. Sanford Cohen to approve the April 25, 2019 QSPE meeting minutes. The motion was seconded by Dr. Stephen Brown and carried with no opposition.

QUALITY, SAFETY & PATIENT EXPERIENCE PRESENTATIONS

Performance Oversite and System Strategic Scorecard – Dr. Scott Nygaard provided an overview of the system strategic scorecard, CMS 5-star dashboard, and Leapfrog Safety scores. CMS star data release has been suspended and expected next release in February 2020. CMS is considering revising the CMS star program. Medical Staff Reports - Two medical staff members presented their first report: Dr. Larry Hobbs, GCMC, provided an overview on the work to improve CLABSI

(Central Line Associated Blood Stream Infections) performance that focused on less use of central lines, increase use of midline catheters, early removal of lines, reducing central line blood draws and changing as soon as able to oral medications.

Dr. Asif Azam, LMH, provided an overview on the work to improve the patient experience. The hospitalist and specialists are conducting nurse/ physician rounding, HCAHPS data is being presented to individual medical staff physicians, considering early rounding for test results and better planning for discharge, asking hospitalist and specialist to own physician to physician communication.

Hospital Acquired Infections – Dr. Marilyn Kole and Marcello Zottolo presented the work currently underway with our HAC performance and reviewed CMS Star rating on CLABSI, MRSA (Methicillin Resistant Staph Aureus), C diff, SSI colon, and CAUTI. Readmissions - Dr. Jody Kolsun presented information on the performance improvement initiatives to reduce readmissions. They are looking at expanding the outpatient follow up clinic, meds to beds and QLK application to identify readmissions, including the need to assist the CHF and COPD patients with follow-up appointments.

QSPE to provide input for the FY2021 scorecard.

Dr. Nygaard - April 2020 agenda.

6

Performance Oversight

Presented by:Scott Nygaard, MD, MBAChief Operating Officer

Update Frequency: Monthly

Percentile Stars

0-19

20-39

40-59

60-79

80-100

9

CMS 5 Star Campus Summary Score Trend

Performance periods: Mortality:3Q14-2Q17, Readmission: 3Q14-2Q17; 3Q16-2Q17 (Hosp-Wide), HAIs (2Q17-1Q18) , PSI90 (4Q15-2Q17), COMP-HIP-KNEE (2Q14-1Q17), HCAHPS (2Q17-1Q18), Efficient Use of Medical Imaging (3Q16-2Q17), Timeliness (2Q17-1Q18), Effectiveness of Care (2Q17-1Q18)

Updated Frequency: Pending official review of program methodology,CMS has not announced schedule for next Star Rating update. Data Source: CMS Star Rating 10

Update Frequency: April & OctoberData Source: LeapFrog

Current Leapfrog GradesSpring 2019

11

#3

400

.159

Re

v. 1

1/1

6

FYTD 19 System Strategic Scorecard UpdatePresented by:Scott Nygaard, MD, MBAChief Operating Officer

Exceptional Patient Experience

HCAHPS overall rate: National 73%; State 69%-- as of June 2018

Strategic Priority Key Performance Indicator

Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT CULTURE

84.2% 73.7% 75.9% 68.2%

Does not

MeetFY 2019

Does not

MeetFY 2019

Exceptional

Patient

Experience

Patient Experience (Adult Acute IP HCAHPS)

Patient Access(Adult LPG Access Perception)

Higher is

Better

Higher is

Better81.3% 69.6% 73.0% 67.9%

14

Right Care


Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT CARE

118 188 118 127

Patient Impact(National Healthcare Safety Network nursing units,

NHSN)

Lower is

Better

Meets

Goal

12-mos

ending Aug

2019

Excellent Health

Outcomes

Mortality(Lee Health facilities only)

1.57%Lower is

Better1.52% <1.52% 1.46%

Better

than GoalFY 2019

Higher is

Better7,000 8,400 7,342

Meets

GoalFY 2019

Increase the LPG Primary

Care Patient Base--

15

Patient Impact by Condition

16

Coordinated Care Model

17


Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT TIME & PLACE

14.6% 15.5% 14.6% 15.6%16.3% 4th QTD Aug

Does not

Meet

15.1% 15.5%Meets

GoalFYTD Aug

FYTD Aug

Coordinated

Care

ModelAdult IP Ambulatory Care

Sensitive Condition Rate14.4%

Lower is

Better15.8%

Medicare Payor 30-day

Readmission Rate (Lee Health facilities only)

Lower is

Better

Right Cost


Nat'l Leader

Target

Desired

Direction

Meets

Goal

Exceeds

Goal

Current

Status Tracking

Reporting

Period

RIGHT COST

Better

than GoalFY 2019

Year over year freestanding

outpatient revenue growth (2018 vs 2019)

Higher is

Better

Better

than GoalFY 201930.0% 36.1%

3.5% 4.0%

Strong Financial

Results Operating Margin % 4.6%

-- 25.0%

Higher is

Better3.0%

18

#3

400

.159

Re

v. 1

1/1

6

FY20 Proposed System Strategic Scorecard UpdatePresented by:Scott Nygaard, MD, MBAChief Operating Officer

Medical Staff Report

Presented by:Keri Mason, DOCape Coral Hospital

24

CCH Medicare PE/DVT: Performing at 3-Star LevelPulmonary Embolus-Deep Vein thrombosis

90 Day Action Plan – Current:

• Post go –live EPIC hard stops and edits to the tools created upon request of Medical Staff

• Evaluating data and compliance for next 60 days

• Required VTE education approved by all Medical Executive committees-October

Benchmark: CMS Value-Based Purchasing National Percentiles

90 Day Action Plan – System-Previously:

• June 25th Go live completed • Weekly calls for update and concerns• Help to identify provider barriers and share

with us• Encourage physicians and AP’s to use EPIC

floor support and Doctor Lounge Epic support to wrench in the side bar report

The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations.

25

CCH Development of Observation Unit


• Opening of Observation Unit November 11th

• Decrease ALOS from 45 hours to 30 hours• Improve throughput• Improve financial sustainability• In line with the Triple Aim


26

Hospital Acquired InfectionsPresented by:Marilyn Kole, MD, MBA, VP Clinical TransformationMarcelo Zottolo, MS, VP Data & Analytics

QUESTION:

Based on current efforts around HAC, are we confident that we are deploying the right tactics to improve HACs further towards zero harm goal?

CLABSI Performing at 4-Star LevelCentral line-associated bloodstream infections


90 Day Action Plan – Previously:

• Increase CHG cleansing compliance • Re-education for maintenance and collection of specimens

completed• Campus safety huddle standard reporting for elements for

devices and infections• Increasing surveillance specific to CHG cleansing• VAN-Vascular access nursing redesign of Intravenous

access alternatives


• Reached out to FHA IP Consultant

• New emphasis on increasing Mid line insertions

• Increased focus on 5 Why and post event evaluation

• Review daily need of the central line

• Request to include mid lines into Unit Patient daily line

list


28

MRSA: Performing at 3-Star LevelMethicillin Resistant Staph Aureus


90 Day Action Plan - Previously: 90 Day Action Plan - Current:

• Peripheral IV policy change for every 4 hour IV assessment as result of case review and findings

• CNA feedback and survey to optimize educational opportunities

• Distribution and marketing of MRSA toolkit• CHG cleansing • Increased CNA-Certified Nurse Assistant

education• CHG and MRSA educational cards• CHG compliance through ongoing

compliance and education• Family education developed

• Increased post event analysis• Review of usage of MRSA toolkit by staff • Monitor Chlorhexidine (CHG) cleansing for MRSA positive nasal

screens• Monitor gown/linen changes with each CHG cleansing• Monitoring of daily CHG cleansing for midlines

The disclosure of this document and the contents herein does not constitute a waiver of any and all protections afforded Patient Safety Work Product under the Patient Safety Quality Improvement Act of 2005 and implementing regulations. 29

C Diff: Performing at 4-Star LevelClostridioides Difficile



• New C. diff order review by IP’s on weekends• EPIC alert for care team to order Isolation• Re-design of Infectious diarrhea algorithm• Redesign EVS standard work for daily cleaning (Sept 2019)• Ongoing Epic review of Predictive analytic tool• Antimicrobial Stewardship Workgroup conducting

rounding and prospective audits for antibiotics• Family education developed


• Develop patient specific educational tool for early identification of diarrhea

• Weekly monitoring of C. diff bundle• Monitor daily cleaning of environmental surfaces

with bleach ( eg: commode, bath tub, bedside table, bed rail, door knobs etc.)


30

SSI-COLO: Performing at 4-Star LevelColorectal: Surgical Site Infections



• Continue 1:1 surgeon to surgeon communication and documentation

• Education on wound class 1:1 surgeon to surgeon• Discussing Epic documentation enhancements as an option


• Wound classification document approved• Intraoperative Glucose protocol approved• Continued weekly discussions on Wound class with

surgeons and OR nursing• Increasing engagement in Enhanced Recovery after

Surgery program (ERAS)


31

CAUTI Performing at 5-Star LevelCatheter Associated Urinary Tract Infections


• Re-education on proper collection• Daily Nursing rounds to include unit leadership

engagement• Weekly monitoring of CHG cleansing, bundle, and

education• Weekly monitoring of bundle• Ongoing monitoring for “Do not remove “ label process



• Addition of 48 repeat voiding trial- addition to algorithm

• Review evidence for CHG and perineal cleansing• Re-education on Foley alternatives• Ongoing surveillance with Infection Prevention


32

PE/DVTWent Live June 25th

33

Medicare PE/DVT: Performing at 5-Star LevelPulmonary Embolus-Deep Vein thrombosis


• Post go –live EPIC hard stops and edits to the tools created upon request of Medical Staff

• Evaluating data and compliance for next 60 days• Required VTE education approved by all Medical

Executive committees-November• Addition of Orthopedic Quality physicians to

CCC-CCG structure


90 Day Action Plan – Previously:• June 25th Go live completed • Weekly calls for update and concerns• Help to identify provider barriers and share with us• Encourage physicians and AP’s to use EPIC floor

support and Doctor Lounge Epic support to wrench in the side bar report


34

PSI-4 Follow up

35

PSI Action Plans

90 Day Action Plan – Current:• Improved understanding of PSI’s with consultant

group and Optum Physicians• Increasing Physician awareness of these metrics• Continue work with (QDP) Quality Documentation

Department and coding to optimize documentation

90 Day Action Plan – Previously:• PSI 12 Go live completed June 25th

• Reviewing care gaps and results from PSI-12 EPIC reports• Continue weekly PSI review with coding/CDI• Engaged Pulmonary/ICU physician to on documentation for

PSI-4 (Bronchoscopy with mortality)• Engaging Pulmonary/ICU physician to work on

documentation for PSI - (Pneumonia with mortality)• Working with Lead CCG Surgeon to provide awareness and

visibility of PSI’s to surgeons• Evaluating how to add PSI’s to EPIC surgeon scorecard

36


Readmission Steering Committee

Presented by:John ChomeauChief Population Health Officer

QUESTION:

What is our strategy to optimize our 30-day All Cause Readmissions?

Readmissions

Readmission rates rising 2016-2018

Case Mix Index increasingImplemented new best practiceprograms for FY19:

Meds to beds

Pharmacy medication reconciliation

Scheduling follow up appointments

38

Readmissions Committee

Met monthly for past several years.

In April 2019 we moved to every other month meeting.

Membership: June meeting data review Joby Kolsun Marilyn Kole Cora Murphy John Armitstead Anson Phetteplace Mike Montgomery Cindy Drapal Lisa Looney Robert Millette Cathy Murtagh Schaffer Deb Koishal Jason Yost Kevin Ahmadi Holly Adler Cindy Kinney

39

Readmission Risk Variables

As low risk patient volume decreased coupled with a more consistent volume of high risk patients, the overall readmission rate has risen.

The Epic 30 day Readmission Risk score and the Case Mix Index calculation have also risen during the year.

40

Seasonal Variation

41

Yearly Comparisons

*

* Data through August 2019

*

1.05% decrease

42

Action Plans

90 Day Action Plan – last 90 days:

Adding moderate risk Heart Failure and COPD to process for follow up appointments

Continue expanding meds to beds program

Deployed new Qlik Readmissions application

90 Day Action Plan - Current:

Analyzing 1-3 day readmissions by campus with 60 day reporting of findings

Monitor Moderate COPD and HF patients for process change improvement for August and September

Improve follow appointment scheduling process deployment within 60 days

43

ExceptionalLee Patient Experience and EngagementPresented by:Lisa Sgarlata, DNP, MSNChief Patient Care Officer

QUESTIONS:

What help can the Board of Directors offer to improve our patient experience?

Is there nursing leadership support with Nurse-Leader Rounding?

System Strategic ScorecardFY2019

45

Moving from Transactional to TransformationalLee Health IP Dimensions

We have seen how Nurse Leader Patient Rounding is moving from a transactional to transformational leadership practice. This mindset shift will translate to consistent quality practices and outcomes.

Nursing Directors have begun to model the way in ownership and development by being more aware of “yellow flags” and addressing them before they turn into “red flags”.

Dimension3 month rolling

June3 month rolling

Sept % Change

Overall Score 66.4 69.7 + 5%

Care Transitions 50.1 51.8 + 3%

Communications w nurses 76.1 78.4 + 3%

Responsiveness of staff 59.0 60.1 + 2%

Would Recommend Hospital 68.8 72.7 + 5%

46

Success by the Numbers…

To date the following % of nursing units at each campus have seen improvement in their Overall Score:

Cape Coral Hospital 87.5%

Gulf Coast Medical Center 80%

Health Park Medical Center 75%

Lee Memorial Hospital 45%

47

What our Nursing Leaders are Saying…

Nurse Leader Rounding on Patients is the best part of my day.

This practice fills my cup.

This practice has made my job easier. I recognize issues and can address them in real time. In the past it might be months before they came to my attention.

Great leadership stories along this journey which impacts the overall score either directly or indirectly.

48

CipherHealth Digital Rounding

CIPHER ROUNDS DIGITAL ROUNDING SOFTWARE

• 650 mobile devices to be deployed (LPG + Inpatient + ED)• 2 Data Interfaces• 10 unique surveys to be developed• Staff education • Estimated roll out plan 6 months

49

LPG Adult Patient Access

50

LPG Adult Patient Access Strategy

FY2019 Strategic Priority: Meets Goal: 69.6% Exceeds Goal: 73%

• How often did you get an urgent care appointment as soon as you need?

• How often did you get a routine appointment when you needed?

• How often did you get an answer to your medical questions that same day?

Adult Patient Access3 Questions

• Workgroup of CSR & Call Center Staff developed Key Words at Key Times (May 2019)

• Roll out Key Words across all LPG Divisions

• Communicated 3 & 2 step formula to identify the n to move from Good to Exceptional (August 2019)

• Dedicated direct support to 6 key adult practices

Access StrategySummary

51

Progress Overview

52

Safety Event Update and Trends

QUESTIONS:

How do we reduce the number of serious safety events in the system as compared to last year?

How do good catches contribute to this improvement?

Presented by:K. Alex Daneshmand, DO, MBAVP of Quality and Patient Safety Officer

Good Catches vs Precursor Events

40% Increase in Good Catches

Better reporting from ambulatory and post acute

Improve safety coach program

Personalizing safety with Staff

Monthly leadership rounding

54

Overall Safety Trends


SSE System Bench Mark: 0.06 SSER / 10,000 Adjusted Patient Days

Year to Date: 0.0996 SSER / 10,000 Adjusted Patient Days

6 SSEs / 602,273 Adjusted Patient Days

SSE System Bench Mark: 0.06 SSER / 10,000 Adjusted Patient Days

Year to Date: 0.0479 SSER / 10,000 Adjusted Patient Days

3 SSEs / 626,714 Adjusted Patient Days

Sept 18-Aug 19Oct 17-Sep 18

55

IBM Watson Top 100 HospitalPresented by:Marcelo Zottolo, MSVP Data & Analytics

QUESTION:

Does the roadmap to Top 15 Health Systems and Top 100 hospitals make sense?

Job 1: Improving Care for our Patients

We are not working BECAUSE of the scorekeepers (Leapfrog, CMS Star, IBM Watson Top 100 Hospitals, HCAHPS, CG-CAHPS, etc.):

– JOB 1 to improve the quality of care, patient experience and value we provide to our patients and community (Professional Promise)

– The recognition is a result of OPERATIONAL EXCELLENCE

– External validation is important (True North)

– Celebrate our accomplishments

Many different measurement systems, far in excess of what human being is capable of digesting

Choosing what matters most - “Fewer things done exceptionally well will make a bigger difference to those we serve.”

Slide from BOD Quality workshop on May 2018 57

Strategic Pillars Measures Overall Hospital Quality Star Ratings Watson Health 100 Top Hospitals

Exceptional Patient

ExperienceSystem-wide Patient Experience HCAHPS (22%) HCAHPS

Excellent Health

Outcomes

Patient Impact (HACs)

Mortality

Increase the LPG primary care

patient base

Safety of Care (HACs-22%)

30-Day Mortality (22%)

Timeliness of Care (4%)

---------------------

Efficient use of Imaging (4%)

Effectiveness of Care (4%)

HACs (to be added)

Inpatient and 30-Day Mortality

ED Measures

---------------------

Complications

Avg. LOS

Coordinated Care

Model

Medicare 3-day Readmission Rate

Ambulatory Sensitive Conditions 30-Day Readmissions (22%) 30-day Readmissions

Strong Financial

Results

Operating Margin %

OP Net Revenue Growth

IP Expense/Discharge

Medicare Spend Per Beneficiary

Oper Profit Margin

Focus: System-based Hospital-Based Hospital-Based

Strategic Plan, Star Ratings and Watson Health Crosswalk

Watson Health evaluates large, medium and small health systems

Results correlate with the Baldrige Award winners¹.

1. Comparison of Baldrige Award Applicants and Recipients with Peer Hospitals on a National Balanced ScorecardNational Institute of Standards and Technology. October 25, 2011.

58

https://www.nist.gov/document-8485

All 100 Top Domains are Equally Weighted

Domain Performance Measure2017

Weight

Trend

Weight

Clinical

Outcomes

Risk-adjusted inpatient mortality 1 1

Risk-adjusted complications 1 1

Mean Healthcare-Associated Infections index* 1 na

Extended

Outcomes

Mean 30-day mortality rate (AMI, HF, PN,

COPD, STK)1 1

Mean 30-day readmission rate (AMI, HF, PN,

THA/TKA, COPD, STK)1 1

Efficiency

Severity-adjusted average length of stay 1 1

Mean emergency department throughput 1 1

Inpatient expense per discharge, AWI and case

mix adjusted1 1

Financial Adjusted operating profit margin 1 1

Patient

ExperienceHCAHPS Overall Patient Rating Score 1 1

Qu

alit

yO

pe

ratio

ns

59

Hospital Comparison Groups

100 Top Hospitals® Comparison Groups Winners Total

Major Teaching Hospitals – 3 ways to qualify: 15 217

─ 400+ acute beds (operating bed size), 0.25 GME student to acute

beds ratio, 10 GME sponsored programs or 20 GME affiliated

programs

─ 30 GME affiliated programs

─ 0.6 GME student to acute beds ratio

Teaching Hospitals – 2 ways to qualify: 25 488

─ 200+ acute beds and 0.03 GME student to acute beds ratio

─ 200+ acute beds and 3 GME affiliated programs

Large Community Hospitals – 250+ beds 20 290

Medium Community Hospitals – 100 to 249 beds 20 914

Small Community Hospitals – 25 to 99 beds 20 843

Totals 100 2752

SOURCES: 2017 cost report – acute beds in service; GME student FTEs. ACGME teaching programs database.

Lee Memorial Hospital &

HealthPark Medical Center

Cape Coral Hospital &

Gulf Coast Medical Center

60

Overall CCH Performance Under the 2019 IBM Watson Top 100 Hospital Publication

Note: 2019 IBM Watson 100 Top Hospital publication is based on 2017 performance using CMS data

61

Overall GCMC Performance Under the 2019 IBM Watson Top 100 Hospital Publication


62

Overall LMH/HPMC Performance Under the 2019 IBM Watson Top 100 Hospital Publication


63

90-Day Action Plan

1. Quantitative assessment by IBM Watson and sharing of prioritized opportunities [Completed].

2. Review insights with Service line leaders.

3. Pull together core team Clinical Transformation, Quality and Safety, Analytics, Clinical Documentation Improvement.

4. Launch prioritized, focused projects.

64

Ambulatory Quality and Safety Scorecard Build

QUESTION:

What is the status of the LPG/Ambulatory Quality and Safety Scorecard Build?

Presented by:Marcelo Zottolo, MSVP Data & Analytics

LPG Executive Dashboard Project Status

Today

PROGRESS SUMMARY

9/30 – 10/2 Collected requirements for the Leadership Dashboard.

9/30 – 10/2 Completed an initial draft of the project initiation document, sprint plan and product backlog.

10/7 – 10/9 Finance and TTNA data was loaded.

10/7 – 10/09 Published first draft of Finance and Patient Access measures to the QA Development stream.

66

67

CelebrationsPresented by:Scott Nygaard, MD, MBAChief Operating Officer

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwiHlq3Cr7_bAhVNvFMKHc6WDcgQjRx6BAgBEAU&url=http://www.edmition.com/school-fests-and-celebrations-of-top-5-schools-of-kolkata/&psig=AOvVaw0M4U2DyY9T1-DwhurA37WL&ust=1528385949392655

Certified Zero Award

Adult In-Patient:

• Must be an adult inpatient unit• Units must be able to sustain ZERO HARM (CAUTI and CLABSI free) since

their initial Certified Zero recognition

Other areas such as Obstetrics are being evaluated for metrics associated with their patient population

Children In-Patient:

• Must be an infant/pediatric inpatient unit• Units must be able to sustain ZERO HARM (CAUTI, CLABSI, C. diff and MRSA

free) since their initial Certified Zero recognition

68

Certified Zero Award

69

LMH 4W Gen. Med. - Diane Spears

24 monthsPlatinum Certified Zero Recipient

70

GCMC 4W General Surgery- Stratton Washington


71

GCHSWF 7 Surgical – Erin Oconnell


72

2018: FHA Safety Award

Three FHA Quality and Service Awards: Award of Excellence in Patient Safety

- Gulf Coast Medical Center

Significant Achievement in Patient Safety- Lee Memorial Hospital

- Cape Coral Hospital

73

2019: FHA Safety Award

Three FHA Quality and Service Awards: HIIN Achievement Award

- Gulf Coast Medical Center

- HealthPark Medical Center

HIIN Chasing Zero Award- Cape Coral Hospital

These Awards was presented to our hospitals on October 24, 2019

74

A HUGE…..

Thank Youfor your continued commitment to excellence by sustaining ZERO HARM!

75

#3400.1

59 R

ev. 1

0/1

6

Readmission Goal Proposal

All-Cause Readmission Goals: Current State

Our FY19 all-cause Medicare readmission goals were established to adjust for variation in performance as captured by Trendstar versus performance reported by CMS. The goals are the best estimations of national performance benchmarks with the assumptions that we can not replicate calculations by CMS 100% accurately.

The internal measurement of readmissions will in FY20 change with the introduction of the Readmission Application in Qlik. The use of Epic logic shifts us towards more accurate capture of readmissions, thus the adjustment of goals does not need to be as dramatic.

77

Readmission Application

More refined calculation criteria allows us to accurately measure performance pertinent to CMS Star Rating and Readmission Reduction Program

78

Moving Closer to CMS

Moving from Trendstar to Epic brings us closer to CMS, the ultimate source of truth. This is a result of a more refined inclusion/exclusion logic. Planned readmissions, discharges AMA and proper attribution of transfers all improve measurement accuracy within Qlik.

79

FY20 Proposed Goals and Impact

Meets: 14.32% Exceeds: 13.47%

New goals are proposed by adjusting the difference in performance between CMS hospital-wide readmission performance (data source CMS FY20 IQR July 2017-June 2018) and Epic-based Qlik performance for the same time period.

This results in shifting the CMS benchmarks “down” 0.93 to account for calculation differences between the system average CMS rates and our internal calculations. This downward shift is an effort to account for CMS risk-adjustment, so the most stringent delta is used.

80

Proposed Goals and Impact: Campuses

FY19TD campus performance (data source Qlik/Epic) in relation to FY20 proposed goals closely resembles most recent data from CMS .


81

Proposed Goals and Impact: System


82

Committee Member Report/ Meeting Evaluation

83

Adjournment

84

Date of the Next Meeting:

QUALITY, SAFETY, & PATIENT EXPERIENCE COMMITTEE

TBD(Pending approval at the Lee Health Board of Directors meeting on October 31, 2019)

Gulf Coast Medical CenterMedical Office Building

13685 Doctors WayFort Myers, FL 33912