1. Improving the Value of Care We Deliver Bob Pendleton, MD FACP Professor of Medicine Chief Medical Quality Officer University of Utah Healthcare Utah Governor, American College of Physicians Quality & SafetyService Cost

2. EDUCATION School of Medicine College of Nursing College of Pharmacy College of Health School of Dentistry @vivianleemd © Vivian S. Lee, 2016 $3 BILLION Expense Budget FY15 50% GROWTH IN 4 YEARS 1.4 MILLION Patient Visits $270 Million+ Grants in FY2015 2,500 Peer-Reviewed Papers 810+ Grants Received 2015 1 NCI Comprehensive Cancer Center DISCOVERY ACCESS 4 Hospitals 11 Community Clinics 18 Regional Partners >10% of the Continental U.S. >1,600 Physicians

3. Perspective (≈2005)… Surgery Suffering Central-Line Infection Central-Line Infection Communication Lapse Communication Lapse Died Access to Care Readmit

4. High quality Poor quality Average quality o Root Cause Analysis o M&M Conferences o Peer Review o Root Cause Analysis o M&M Conferences o Peer Review QA

5. Standard VALUE BUT- shouldn’t our real goal be for every patient to achieve optimal results? Poor VALUE Optimal VALUE Average VALUE Value Improvement

6. UTAH: patient-centered purpose…

7. UTAH: QUALITY & SAFETY

8. UTAH: SERVICE

9. UTAH: COST

10. UTAH: VALUE

11. QUALITY 1.) Mortality (O/E) 2.) Reduce Infections 3.) Care Transitions QUALITY 1.) Mortality (O/E) 2.) Reduce Infections 3.) Care Transitions SERVICE 1.) Communication 2.) Access to care SERVICE 1.) Communication 2.) Access to care COST 1.) Care pathways 2.) VDO:  waste COST 1.) Care pathways 2.) VDO:  waste SAFETY 1.) Event response 2.) Medication Safety SAFETY 1.) Event response 2.) Medication Safety

13. UTAH: SAFETY GOALS Improving medication safety Use your pharmacists Communicate with your nurses Discuss/Educate your patients Improving our process for after event review (RCA) Report safety events (harm & near misses) in RL Actively participate in RCAs when asked

14. All Healthcare Encounters All Errors “Near Misses” All Errors “Near Misses” Patient Harm (“AE’s”) Preventable Non-preventable Patient Harm (“AE’s”) Preventable Non-preventable Negligence Safety: 200k Americans Die per year due to Preventable Medical Error

16. UTAH: QUALITY GOALS Eliminate Hospital Acquired Infections Hand Hygiene Personal protective equipment (PPE) Avoid and/or prompt removal of foleys and central lines when feasible Antimicrobial stewardship More Effective Care Transitions Discharges & hand-offs require extra time, thought, teamwork, & tools Improve (already excellent) O/E Mortality mEWS system Accurate documentation

17. Risk-Adjusted Mortality OBSERVED EXPECTED

18. Modified early warning score (mEWS): a system designed to recognize sick patients earlier A weighted score of vital sign abnormalities Calculated on all patients Add it to your list in Epic Leads to a two-tier system response Utah modified Early Warning Score (mEWS) Measure3210123 Temperatur e <35.035.1-35.5 35.6-38.038.1-39.039.1-40.9 >41.0 Resp Rate<8<8 9-1112-2021-2526-29 >30 Pulse <3031-3940-100 101-110111-130 >131 Systolic BP<8081-9091-100 101- 180181-200201-220>221 Sepsis: #1 killer of hospitalized patients

19. Need time to explore the chart, Or not the primary team? Already treating sepsis? Not sepsis but you know VS are abnormal?

20. A 2 tiered response system…for both tiers Charge nurse calls primary team MD/DO/PA/NP to see patient within 15 minutes Nursing staff initiates blood cultures, lactate, urine sample Vitals repeated q 2 hours x 3 Is it sepsis? Yes  antibiotics and fluids No  why is patient acutely ill? Lower tier (a mEWS of 5-7 on most units) Epic pages charge RN only High tier (a mEWS of 8 or greater on most units) Epic pages charge RN and RRT When you get a mEWS Alert

21. Unit charge nurse or nurse manager Sepsis Coordinator in SmartWeb Need help?

22. Why Documentation/Coding Matters We need accurate DATA to know where our improvement opportunities are. Patient severity (=EXPECTED Values) & clinical DATA comes from our DOCUMENTATION We take care of very sick patients. CODING: coders can only code on what is documented. If we don’t document accurate and complete DIAGNOSES/CONDITIONS then our patients don’t appear as sick as they are and our & our ability to get accurate outcomes data is limited Sometimes our documentation doesn’t align with coding rules. When this happens a coder may send a QUERY. You are responsible to promptly respond to queries Answering queries helps us to ensure we get credit for the work we are doing

23. Make a Diagnosis- not just a list X

24. Top 10 Common Diagnoses List 1. SIRS, Sepsis, Severe Sepsis 2. Shock 3. Encephalopathy 4. Heart failure (including acute/chronic and systolic/diastolic) 5. Obesity 5. Malnutrition and Severe Malnutrition 6. Acute renal failure due to XX 7. Acute or Chronic Respiratory Failure 8. Specific electrolyte/acid-base abnormalities 9. Coagulopathy 10. Complications of Diabetes

25. Example: Malnutrition Query

26. 7 routine things we need you to do (engage in the system support): ① Be respectful –success is a team sport ② Communicate effectively with patients ③ RL to keep your patients SAFE ④ Hand Hygiene & PPE ⑤ Use mEWS & see sick patients promptly ⑥ Document accurately & thoroughly ⑦ Order thoughtfully