Quality Improvement Department Stony Brook University Hospital 3/2017

Our Vision for Quality & Safety of Care: Overview of Strategy for Quality Management Our Mission: improve the lives of our patients, families, and communities, educate skilled healthcare professionals, and conduct research that expands clinical knowledge. Our Vision: Stony Brook University Hospital will be: A world-class healthcare institution, recognized for excellence in patient care, research and health care education The first choice of patients for their care and the care of their families An academic medical center that attracts educators and students with the desire and ability to provide and receive the highest quality, innovative education One of the top ranked institutions for scientific research and training. Our Vision for Quality & Safety of Care: We will be a Top Decile performer within 3 Years Strategic Vectors Clinical Outcomes Patient Safety Patient Experience Top Decile Outcomes Zero Preventable Harm Best Place to Receive Care Foundational Enablers Physician Engagement Technology Throughput Optimization Organization & Staffing Culture Physician Driven Quality Program Technology Accelerated Care No Wasted Time or Resources Quality Management At Your Service Culture of Excellence & Accountability Our Values  ICARE: Integrity, Compassion, Accountability, Respect, Excellence

Quality Management Teams Patient Safety NSQIP VTE Readmissions Mortality Sepsis Diabetes Coding & Documentation SB Safe C diff Handwashing CAUTI CLABSI SSIs NPSGs Patient Experience 101 Service Standards Communication Noise Environment Pain Physician Engagement Throughput Optimization Culture Technology Organization & Staffing Medical Directorships Clinical Department Quality Oversight Physician Quality Orientation Geographic Location of Patient Cohorts Physician Engagement Survey Current Participation Survey Admission Process Discharge Process Psychiatry Throughput OR & Surgical Throughput End of Life ED Throughput ICU Just Culture Patient Safety Cultural Survey Daily Huddle Respect. Administration working on these directly Increasing staffing Changes to technology where needed Teams meet every 2 weeks. Tactical plan summary to Administration to discuss opportunities identified, solutions, actions and barriers

Quality Improvement (QI): A journey to satisfy the needs and exceed the expectations of our customers A means of performance improvement Aligned with our Mission to deliver world class, compassionate care, advance our understanding of health and disease and to educate healthcare professionals 4

What does QI Encompass? Patient Care Patient Safety Employee Satisfaction Administrative & Operational function Regulatory Requirements Employee Safety Patient Satisfaction What does QI Encompass? 5

QI Principles All work is part of a process Quality is achieved through people Decision making is done with facts Patients and customers are our first priority Quality requires continuous improvement QI focuses on the process not the person 6

Find a process to improve Administration, Program of Distinction (POD) Groups, other Committees charter a QI team Criteria used to prioritize opportunities for improvement High Risk High Cost High Volume Problem Prone Patient Safety related 7

Methodology for Improving a Process U S Find a process to improve Organize a team that knows the process Clarify current knowledge about the process Understand causes of process variation Select the process improvement P D C A 8

Sentinel Event Root Cause Analysis A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Examples include: Suicide - Rape - Loss of limb - Elopement -Death Root Cause Analysis A process for identifying the contributing factors that underlie variations in performance; includes the occurrences of the sentinel events, adverse event or close calls. Process that features interdisciplinary involvement of those closest to and/or most knowledgeable about the situation to find out: What happened? Why did it happen? How can we prevent it? How do we know we made a difference? 9

Joint Commission Requirement Failure Mode and Effects Analysis (FMEA) Proactive risk assessment A team based, systematic approach for identifying the ways a process or design can fail, why it might fail, and how it can be made safer. Joint Commission Requirement What performance improvement initiative has our department implemented recently? Hint: It MUST be supported by data 10

Robust Performance Improvement Tools of the Quality Trade FOCUS PDCA Lean Methodology Six Sigma Analytics Proactive FMEA RCA Reviews Robust Performance Improvement 11

Core Measure of Excellence CMS (the Center for Medicare & Medicaid Services) established the Core Measures in 2000 and began publicly reporting data in 2003 Addresses clinical care, person and caregiver-centered experiences and outcomes, safety, efficiency and cost reduction, care coordination and Community / population health. The overarching goal of CMS quality reporting programs are to support the National Quality Strategy’s goal of: Better health care for individuals Better health for populations Lower costs for health care CMS ties some parts of reimbursement to reporting the data; in some cases reimbursement is tied to how well we deliver specific elements of care, known as Value-Based Purchasing

Core Measures of Excellence… …are evidence-based, scientifically-researched standards of care which have shown to result in improved clinical outcomes for patients. Children’s Asthma: specific medication use Stroke, Acute Myocardial Infarction & Heart Failure: medications prescribed upon admission and discharge Emergency Department : departure/admit times, timeliness to diagnosis, pain management Severe sepsis – early management, bundle compliance Imaging Efficiency: MRI for Lumbar spine; mammography follow up, use of contrast material Central Line Associated Bloodstream Infection (CLABSI) Catheter Associated Urinary Tract Infection (CAUTI) 30-Day Risk adjusted readmissions AMI – aspirin and statin at discharge Immunization – Influenza & Pneumonia before discharge Tobacco use – treatment at discharge HF – discharge instructions, ACEI/ARB for LVSD

Any untoward event noted throughout the day: Hand off ● Code Blue ● Medication errors ● Equipment Unexpected OR occurrences ● Patient Care Transfer ● Lab / Specimen Mortalities ● Safety / Security ● Provision of care ● ID/ Documentation Use of system taught at the unit level “See Something – Say Something” Collaborative analysis among Nursing Leadership Cases identified for peer review Issues identified presented monthly with proposed solutions & actions. Reported to Nursing Quality Council

Quality of Care Physician Review Quality issues identified through: Patient Guest Relations Mortality and Morbidity reports SB Safe Events Referrals from Departments or Leadership Collaborative review of specific events between physicians and nursing Results referred to appropriate department Can also identify educational information as an example of excellent care to share hospital wide

High Reliability Unit (HRU) – Multidisciplinary Unit Based Quality Teams Reviewed monthly by team and administrators Physicians, Nurses, SW/ CM, Respiratory therapists, Pharmacy, HED, QI Quality metric can be unit specific or a hospital wide initiative Prevent a breakdown in patient care or operations Hospital Metrics Preventing CLBSI / CAUTI Falls Pressure Ulcers DVT’s Sepsis Best practice guides reviewed for each metric Do you have the tools you need to be successful in the care you give to patients ● Unit specific Metrics Drug/ ETOH screen ED Door to Doctor times Restraints Post op complications for spinal surgery TAVR – acute kidney injury

Examples of QI projects Decreasing Sepsis Mortality Decreasing Surgical Site Infections Post-operative glycemic control in our CTICU population Improving patient throughput for ED Admissions Preventing Central Line and Catheter Associated Urinary Tract Infections Specimen mislabeling FMEA Core measure compliance: AMI, HF, Stroke, VTE, Psychiatry e-documentation Avoiding Readmissions within 30 days Enhancing Cardiac Arrest and Post Cardiac Arrest Care Timely referrals and effective requests for organ donation (LONY) Asthma Action Plan use on our inpatient pediatric units 17

Reducing Central Line-Associated Infections Efforts to improve the quality of care also can reduce the cost of care!

How to contact the QI Department If you have any questions or ideas for a potential QI project in your department, please call us at (631) 444-4289 Or enter a request (Performance Improvement Requests) via the Intranet under the My Requests section