QI & Patient Safety Update Department of Medicine Unit Directors Meeting May 23, 2016

Agenda Department QI and Patient Safety Goals QA&I Committee Update FY2017 UVMMG Quality Metricss Shameless Plugs: Biostats support High value care proposals Future Website Content

QI Goals for Dept of Medicine Create infrastructure and resources within the department to support scholarly QI activities Develop faculty skills in QI methodology and cultivate a cadre of faculty experts in QI Enhance innovation and scholarly productivity in QI and high value care Align and promote collaboration in QI efforts across divisions

Medicine QA&I Committee Group Member Administration Allen Mead Cardiovascular Medicine Dr. Mark Capeless transitioning to Dr. Peter Van Buren Chief Residents Dr. Jon Halevy Dermatology Dr. Julie Lin Endocrinology Ann Gotham, ANP Fellows Drs. Krysti Spiess (ID), Patrick Hohl (Cards), Sean McMahon (Cards) Gastroenterology Dr. Jim Vecchio General Internal Medicine + Geriatrics Dr. Marie Sandoval Hematology/Oncology Dr. Farrah Khan Hospital Medicine Dr. Mike Latreille Infectious Disease Dr. Mary Ramundo Jeffords Institute for Quality Pam Stevens, RN Nephrology Dr. Jeff Rimmer Nursing Tammy Berrings, RN (B4), Susan Bellemare, RN (M5), Peg Gagne, RN Patient representative Walter Grant Pharmacy Maria Airoldi, RPh PRISM ad hoc Pulmonary Disease & Critical Care Dr. Yolanda Mageto & Dr. Gil Allen Residents Dr. Susanna Thach Rheumatology & Clinical Immunology Amanda Kennedy, PharmD

Medicine QA&I Committee “Usual” activities Case reviews Adverse events, mortalities Reports on institutional initiatives Patient experience, length of stay, core measures, mortality Specific institutional or department initiatives e.g., sepsis

Medicine QA&I Committee New Activities Forum for review UVMMG Quality Metrics Engage divisional representatives in process of developing Develop “themes” to align UVMMG quality metrics Monitor progress, ensure timely submission Identify need for support (e.g., baseline performance, ongoing reporting) Defining specific metrics still up to individual divisions Divisional reports Divisional presentations about QI and patient safety activities within division High value care projects – adjudication of proposals

UVMMG FY2017 Metrics Medicine QA&I Committee Generated approximately 30 potential “themes” - broad categories to align the FY2017 QI initiatives across divisions Factors: current QI initiatives, UVMMC strategic goals, cross-divisional, measurable, meaningful Identified 3 themes: Transitions of Care Advance Care Planning Patient Experience

UVMMG Quality Metrics - Considerations Two measurement periods Measurement Period 1: October 1, 2016 - March 31, 2017 Measurement Period 2: April 1, 2017 - September 30, 2017 SMART Criteria: Specific Measurable Attainable Relevant Time bound Can build on current initiatives Requires “active participation by physicians” Requires achievement of target performance (not just documentation of participation) No such thing as perfect

Shameless Plug #1: Biostats Initial funding for 100 hours of biostats Focus = scholarly QI projects led by junior faculty as well as mentored resident and fellow QI projects Application process Simple, 1 page (handout) Compels consideration of key elements for project Identifies scholarly product Submission to yours truly. Review by Renee Stapleton and me. Based on initial demand, will determine need for dedicated %FTE for biostats

Shameless Plug #2: High Value Care Seeking next round of HVC proposals Program entering its 5th year  14 projects undertaken Projects focus on: reducing harm, reducing cost and/or improving patient outcomes or experience 1 page application – recently circulated via e-mail Evaluated on a rolling basis  Selected projects receive: Project Management for Jeffords Institute for Quality Data analytics from Jeffords including collecting background and follow up information (no second application needed) Resources from the clinical steering committee to develop a system change, including PRISM alterations

Future Website Content List of divisional QI and Patient Safety activities Application for biostats support High Value Care proposal form “Guide to QI” in Department of Medicine Faculty development and publishing resources