1. Presented to IHA Quality Encounter “Delivering Measurable Results Through Process Improvement” June 16, 2009 Robin Oakley, Manager CCU Susan Eller, Manager ED Kevin O’Leary, MD Hospital Medicine Pneumonia Core Measures Northwestern Memorial Hospital ®

2. Pneumonia Core Measures Project Overview Linkage to BPE/BP/Finance: BPE – Deliver the most effective care based on clinical evidence Problem Statement: Adherence to core measures guidelines helps improve patient outcomes. In FY2007, NMH compliance with the aggregate pneumonia core measure set was 65%; 8% below the internal compliance goal of 73%. The ‘Initial Antibiotics within 4 Hours’ and ‘Pneumococcal Vaccination Assessment’ individual measures, 78% and 72% compliance respectively, were the most detrimental to achieving the overall goal. These two metrics are especially important as administering antibiotics in a timely manner has been shown to reduce 30 day mortality rates and the pneumococcal vaccine has proven up to 75% effective against pneumococcal bacteremia. These and the other pneumonia metrics must improve if we are to attain our goal of top decile performance in the pneumonia core measure set in FY2008. Goal/Benefit: By 6/2008, work with the ED, the inpatient units and other relevant groups to improve compliance with the all pneumonia core measures to above 95% compliance. Scope: The pneumonia metrics for all patients meeting core measure inclusion criteria. Deliverables: New processes, protocols and/or tools needed to achieve the stated goals. Resources Required: Leadership and staff from Nursing, the Emergency Department, the Department of Medicine, Clinical Quality, a Pulmonologist and Clinical Informatics. Fast-track changes to relevant Powerchart rules / forms. Key Metric(s) Compliance with Pneumonia Overall Guidelines (%) Initial Antibiotics Delivered within 4 / 6 Hours (%) Pneumococcal Vaccination (%) Blood cultures performed in ED prior to initial antibiotic received in hospital (%) Antibiotic selection for immunocompetent patients (non ICU) (%) Influenza Vaccination (%) Executive Sponsor: Sponsors: Clinical Sponsors: Process Owner: Improvement Leader: Dan Derman Corrine Haviley / Deb Livingston Kevin O’Leary / Mike Schmidt Robin Oakley / Susan Eller Mark Schumacher Project Charter

3. Why Were We Focused on Pneumonia? Influenza kills 36,000 people in the US per year Community-Acquired Pneumonia (CAP) kills 10,000 people in the US per year Over 1400 pneumonia patients admit to NMH each year; over 100 patients with a diagnosis code indicating pneumonia die The Centers for Medicare & Medicaid Services (CMS) measures our ability to meet evidence-based care guidelines In FY2007, NMH compliance with the aggregate pneumonia core measure set was 65% D M A I C

4. What are the CAP Core Measures Again? CMS measures to ensure that for all CAP patients we…  Assess oxygenation within 24 hours of arrival  Perform blood cultures prior to initial antibiotic administration  Administer the initial antibiotic within 6 hours of arrival  Administer the right antibiotic per best practices  Administer the pneumococcal vaccine prior to discharge  Administer the flu vaccine prior to discharge  Counsel patients with a history of smoking on smoking cessation prior to discharge We need focused improvement in administering the vaccines D M A I C

5. Pneumonia: Measuring the Problem To meet the NMH goal of top decile performance (>95% compliance) in all publicly reported metrics we needed to improve in 5 / 7 pneumonia core measures D M A I C Notes: *Pneumonia patients 4.1.2007 – 9.30.2007 The pneumococcal vaccination and antibiotic timing metrics accounted for 70% of the failures Five total metrics required either improvement or stabilization: pneumococcal vaccine, antibiotic timing, blood cultures in ED, appropriate antibiotic selection and influenza vaccine Pneumonia Core Measure Failures Stratified*

6. Pneumonia: Setting a Goal Top decile performance requires a nearly error free process D M A I C Notes: Pneumonia patients 4.1.2007 – 9.30.2007 Performance Required for 95% Compliance Pneumococcal VaccinationInitial Antibiotic within 4 hours Compliance Rate81.2% Goal Success Rate95.0% Average Metric Failures / Month4.84.7 Permitted Metric Failures / Month1.31.2 Achieving 95% compliance allows approximately 1 metric failure per metric per month We needed to reduce failures by more than 75%

7. Pneumonia: Building The Team Success requires a carefully built, inclusive team with engaged sponsors. ED Nurses Inpatient Nurses ED Nurse Manager Inpatient Nurse Managers ED Director Nursing Director ED Physicians Medicine Physicians Pharmacists Quality Staff IS Staff Registration Staff Registration Manager

8. Pneumonia: ED Wait Times The teams analyzed potential failure drivers for the ED metrics and identified ED wait times as the primary driver D M A I C ED Wait Time (Arrive to ED Bed) and Antibiotic Timing Compliance Patients waiting for a bed for more than 90 minutes did not receive antibiotics within 4 hours

9. Pneumonia: Turn Wait Time into Care Time The ED team members implemented a new triage / registration process to facilitate early x-ray orders D M A I C Implemented new parallel triage / registration process to reduce processing time by 40% (4 minutes) for ALL patients Trained RNs on protocol x-ray orders from triage and revised the Powerchart x-ray order process to turn ED wait time into productive time New Triage / Registration Process

10. Pneumonia: Antibiotic Ordering Delays The team analyzed additional failure drivers for the ED metrics and identified the antibiotic order process as another key driver D M A I C Antibiotic (ABX) Order Method and Antibiotic Timing Compliance Ordering an antibiotic via the tube, versus the Omnicell, increased turnaround time by 20min (median 57 versus 37min) In addition, there were no warnings / triggers to ensure a blood culture was drawn prior to antibiotic administration

11. Pneumonia: Antibiotic Ordering Flow The ED team members implemented a new antibiotic ordering process to reduce turnaround times D M A I C Implemented new antibiotic order process to reduce turnaround times: Removed MD from the Pharmacy contact role, introduced a new antibiotic phone line and leveraged the Omnicell to improve process flow Reduced turnaround time by an average of 18 minutes for ALL patients Introduced a reminder on the Omnicell to ask about cultures prior to release Also implemented a new ED MD protocol to improve blood culture and appropriate antibiotic selection compliance New Antibiotic Order Process Note: CMS also changed the antibiotic timing requirement from 4 hours to 6 hours

12. Pneumonia: ED Results D M A I C Antibiotic administration within 6 hours improved, but a CMS documentation requirement dampened results until a new documentation system was implemented in FY09 Q1. ED Metric Q1 to Q4 Comparison MetricFY08 Q1FY09 Q1GAIN Timelines ABX76.7%93.3%16.6% Blood Cultures in ED90.7%95.0%5.0% ABX Selection89.7%92.0%2.3% *Note: Threshold changed from 4hrs to 6hrs in April Implemented ED interventions in May and June Compliance with the time to antibiotic requirement increased by 16.6% and the median time to 1 st antibiotic decreased by 39 minutes Compliance with the blood culture and antibiotic selection measures increased by 5% and 2.3% respectively

13. Pneumonia: Myths, triggers and orders The teams analyzed potential failure drivers for the vaccine metrics D M A I C Pneumococcal / Influenza Vaccination Failures Failure DriverVolume% Vaccine order never charted against847% Vaccine order charted against incorrectly424% Patient profile never completed318% Other212% The team analyzed 3 months of vaccine failures to determine the key drivers: Commonly held myths about vaccine safety / efficacy Problems with Powerchart trigger architecture Problems with Powerchart order behavior

14. Pneumonia: Education Discussions with nurses identified five commonly held myths The team educated ALL inpatient nursing staff using an online course and quiz: 1.Can the Influenza Vaccine Cause the Flu? 2.Is the Influenza Vaccine is Safe for Sick Patients? 3.Is the Influenza Vaccine Only for the Elderly? 4.Do Flu Shots Work? 5.Does the Pneumococcal vaccine work? D M A I C The team implemented an annual education program to overcome common vaccine myths.

15. Pneumonia: Order Triggers Error-proofed, required questions on the nursing patient profile trigger the vaccine orders Question design ensures that ALL appropriate patients receive a vaccine order D M A I C Use electronic documentation as a tool

16. Pneumonia: Daily Snapshot Report The team members also implemented a suite of PowerChart changes and the new Daily Snapshot Report. D M A I C Daily Snapshot Report –The report provides daily actionable information to the bedside nurse – It provides information on vaccine compliance, patient profile status, medication reconciliation status, fall risk and pressure ulcer risk / treatment –The report provides information using exception criteria to minimize waste and re-work

17. Pneumonia: Inpatient Results D M A I C Improvements resulted in an almost 15% improvement in the Pneumococcal Vaccine Assessment measure. Pneumovax Q1 to Q4 Comparison FY08 Q1FY08 Q4GAIN Pneumovax78.7%93.3%14.6% Implemented all pneumococcal vaccine interventions by July Almost 15% improvement realized in FY08 Q4 (June – August) and sustained in FY09

18. Pneumonia Core Measures: Results D M A I C Overall Compliance demonstrated greater than 30% improvement Overall Q1 to Q4 Comparison FY08 Q1FY08 Q4GAIN Overall58.3%90.3%32.0% Implemented new processes in May, June and July 32% improvement realized in FY08 Q4 (June – August) and sustained in FY09 Pre and post implementation variability reduced by over 80%