1. Family Medicine HealthNet Inpatient Service
Quality Report and Unit Dashboard: BMC E6W
QuEST: (Quality, Efficiency, Satisfaction and Total Revenue)
October 03, 2014

2. Leadership Team
Christopher Manasseh, MD Assistant Professor Vice Chair for Inpatient and Hospital Services
Toyin Ajayi, MD Hospitalist Medical Director Director of Transitional Medicine Commonwealth Care Alliance
Aram Kaligian, MD Assistant Professor Assistant Inpatient Director 
Ted Constan Chief Administrative Officer, Department of Family Medicine
Jonathan Bunker, BSN, RN Nurse Manager
Erica Cuevas, MPH Administrative Coordinator
Eileen Mullaney, RN RN Care Manager
Gwyneth Jones, MBA Administrative Manager
Charlotte Cuneo, MSN, RN, CCAP Clinical Nurse Educator
Brian Jack, MD Professor Chair, Boston University Department of Family Medicine Chief, Boston Medical Center Department of Family Medicine
_______________________________________
Jessica Martin, MA, MPH Program Director

3. Introduction
This is a Quality Report describing the activity of the Family Medicine - Boston Health Net (FM-HN) Inpatient Service located on 6W of BMC’s East Newton Campus.
The purpose for this Dashboard is to document and share the quality of the service with senior leaders and other constituents
FM-HN service accepts admissions from the family medicine practices at BMC and the CHCs and from the Boston Community Health Group (BCMG) which cares for high risk frail elders and disabled/homebound patients in our communities.
As we continue with rapid PDSA (Plan-Do- Study- Act) cycles of improvement, and show improvement -- some graphic elements are dropped and are replaced by other priorities.

4. Introduction
These reports show areas in which we are doing well – and not so well – but that through this process we hope to continuously improve.
The idea for collecting these data metrics emanated from the concepts of teamwork and the desire to provide high quality services among the partners.
To begin, we organized a weekly meeting among the stakeholders designed to define the mission and the members of the team and to identify clear objectives that we would try to achieve.
The principles of collaboration and objectives for the inpatient team are listed on a poster that hangs in the entry of the unit (shown on the next slide).
The metrics developed that are shown in this report are an attempt to quantify each of these principles.
The data are organized according to the BMC QUEST pneumonic (Quality, Efficiency, Satisfaction, Total Revenue).

5. Principles of Collaboration for E6W

6. QuEST
The Family Medicine HealthNet Inpatient service uses QuEST, the BMC framework to measure outcomes
QuEST stands for:
Quality
Efficiency
Satisfaction
Total Revenue

7. QUALITY: Mortality Analysis For Family Medicine
Attending Note Compliance for Non- Surgical Departments
All-Cause 30-Day Readmission Rate

8. EFFICIENCY: Daily Workload by Care Team (Census Counted at 8am)
Weekly Average Discharge Time
Average Length of Stay Of Inpatient Discharges by Care Team
Average Length of Stay Of All BMC Admissions
Average Length of Stay Of Observation Discharges by Care Team
Monthly Length of Stay (Observed/Expected Ratio)
Average Length of Stay (Observed and Expected)
Percentage of Patients Admitted to E6W

9. Satisfaction: HCAHPS Quarterly Patient Experience Trends: E6W
Communication Standards

10. Total Revenue:
Total Number of Patients Admitted and Discharged by Care Team
Monthly Total Number of Patients Admitted by Care Team
Average Total Admissions and Discharges by Day of Week
Percent of Admissions and Discharges in Observation Status by Care Team
Percent of All Admissions by Patient Class
Patients Lost
HealtHNet Patients’ Admissions For All Services
Monthly Percentage of HealthNet Patients’ Admissions to FM-HN
HealthNet Patients’ Admissions by Health Center
CCA Patients Lost
HealthNet Patients Lost to Cardiology

11. Mortality Analysis for Family Medicine
FM-HN continues to have Om < Em
Note: Discharges with non-viable neonates, or point of origin is hospice are excluded. Discharges from MICU to floor transfers are included.
Source: UHC, Patient Outcomes Report
Q (N= 625)
Q (N=583)
Q (N= 575)
Q (N=609)
Q (N=576)
Q (N=581)
Q (N=596)
% ICU Cases
9.28
10.46
12.17
11.82
11.11
10.15
9.06

12. Inpatient Mortality Index
BMC wants to achieve a score of .77 or lower. FM has always been significantly lower than that.
Source: UHC, Patient Outcomes Report

13. Case Mix Index
Note: Discharges with non-viable neonates, or point of origin is hospice are excluded.

14. Attending Note Compliance for Non- Surgical Departments
FM-HN attending continue to sign charts according to standard
Source: BMC Administration

15. All-Cause 30-Day Readmission Rate
FM-HN has the lowest readmission rate among all the medical services.
Roshan told me that we shouldn’t use this-
Its not that useful for us
We should compare ourselves to other family medicine practices or just to measure our trend
We can follow up on calculating readmission rate by service  but it may not be accurate because each readmission is calculated by a different algorithm so it may be like comparing apples to oranges.
Note: The attribution is based on the mortality analysis logic
Source: BMC Administration- distributed at July 2014 Readmission meeting

16. Readmissions

17. Daily Workload by Care Team (Census Counted At 8AM)
CCA volume peaked for a day, but then went back to average
PA and FM team have the same average number of patients
Source (both graphs): SDK Combined Census Report and confirmed with EPIC census on weekdays

18. Weekly Average Discharge Time
FM-HN continues to lead hospital in average discharge time.
Source: Weekly hospital reports (From Jonathan Bunker)

19. Total Number of Patients Admitted and Discharged in November by Care Team
For FM team
#admissions < # discharges
For PA team
For CCA team
#admissions= #discharges
Source: EPIC, Department of Medicine Admissions and DOM Discharges by Month report

20. Monthly Total Number of Patients Discharged by Care Team
FM-HN continues to maintain a constant volume about 8 admissions per day.
Annual Volume
Source: EPIC, DOM Discharges by Month report

21. Average Total Admissions and Discharges in November by Day of Week
Monday and Tuesday had the highest number of admissions
Monday and Tuesday had the highest number of discharges
Monday and Tuesday were the busiest days in November
Source: EPIC, Department of Medicine Admissions and DOM Discharges by Month Report

22. Percent of November Admissions and Discharges in Observation Status by Care Team
The FM 1 team admitted < patients in obs status than it d/c
The FM 9 (PA) and the CCA teams admitted > patients in obs status than it d/c
Source: EPIC, Department of Medicine Admissions and DOM Discharges by Month Report

23. Admissions in November by Patient Class
64.9% of all admissions were in inpatient status.
Source: EPIC, Department of Medicine Admissions

24. Average Length of Stay of Inpatient Discharges in by Care Team (In Days)
Based on Mean- CCA has always had a longer ALOS and the ALOS for CCA, and FM 1 increased since October
Based on Median- CCA usually has a higher ALOS but was similar to FM1 and FM 1 in August and September ALOS for FM 1 increased since October
Source: EPIC (From DOM Discharges by Month report)

25. Average Length of Stay of Inpatient admissions in October by Day of The Week (In Days)
From date of admission
From date of discharge
People admitted on Wednesday, Thursday and Saturday have a longer LOS and people admitted on Sunday and Monday have a shorter LOS
People discharged on Friday, Sunday, and Monday longer LOS & people discharged on Saturday and Tuesday have a shorter LOS
Source: EPIC (From Department of Medicine Admissions and DOM Discharges by Month report)

26. Average Length Of Stay by Day of Discharge in September
FM-HN ALOS is always lower than the ALOS for BMC and
Source: UHC, Patient Outcomes by Discharge Day

27. Average Length of Stay of Observation Discharges in October by Care Team (In Hours)
Based on the Mean- the ALOS for all three teams decreased since October
Based on the Median- the ALOS for CCA and FM 2 decreased but slightly increased for FM 1
Source: EPIC , DOM Discharges by Month report

28. Average Length of Stay of Observation Admissions in October by Day of The Week (In Hours)
ALOS from Admission Date
ALOS from Discharge Date
Admissions on Friday and Sunday have a longer LOS and admissions on Thursday and Monday have a shorter LOS
Discharges on Monday and Tuesday have a longer LOS and discharges on Sunday, Saturday and Wednesday have a shorter LOS
Source: EPIC (From Department of Medicine Admissions and DOM Discharges by Month report)

29. Comparing ALOS for Inpatient and Observation Admissions in October: With and Without the CCA team
Inpatient Admissions
Observation Admissions
Inpt ALOS is .3 hours less when CCA is excluded
Obs ALOS is .04 hours less when CCA is excluded
Note: ALOS is based on mean

30. Percentage of Patients Admitted to E6W
In November FM-HN admitted about 88% of patients to E6W. The percentage of Admissions to E6W has increased since October
Source: EPIC, Department of Medicine Admissions

31. Percentage of Patients Discharged from E6W

32. HCAHPS: Quarterly Patient Experience Trends: BMC & E6W
E6W had a higher percentage for recommending the hospital
Note: The percentage presented in these graphs are the top box score percentages
Source: BMC Administration (From Inpatient Dashboard)

33. HCAHPS: Quarterly Patient Experience Trends: BMC & E6W
E6W had a lower score than BMC for communication with nurses and communication with doctors
Note: The percentage presented in these graphs are the top box score percentages
Source: BMC Administration (From Inpatient Dashboard)

34. HCAHPS: Quarterly Patient Experience Trends: BMC & E6W
E6W had a lower score than BMC at both responsible of hospital staff and pain management
Note: The percentage presented in these graphs are the top box score percentages
Source: BMC Administration (From Inpatient Dashboard)

35. HCAHPS: Quarterly Patient Experience Trends: BMC & E6W
E6W had a lower score than BMC for both communication about medicines and discharge information
Note: The percentage presented in these graphs are the top box score percentages
Source: BMC Administration (From Inpatient Dashboard)

36. HCAHPS: Quarterly Patient Experience Trends: BMC & E6W
E6W had a slightly higher score than BMC for cleanliness but had a lower score for quietness
Note: The percentage presented in these graphs are the top box score percentages
Source: BMC Administration (From Inpatient Dashboard)

37. Communication Standards
About 91% of PCPs are contacted upon admission and 95% upon discharge
Source: Communications Excel Tracking Sheet

38. Patients Lost HealtHNet Patients’ Admissions For All Services
Monthly Percentage of HealthNet Patients’ Admissions to FM-HN
HealthNet Patients’ Admissions by Health Center
HealthNet Patients Lost to Cardiology

39. HealthNet Patients’ Admissions for ALL Services In October
About 57% of HealthNet patients were admitted into the FM-HN Service in November
Goal: ??
Source: Individual SDK Inpatient and Observation admissions by Health Center report
Note: This graph includes patients with a PCP in Family Medicine Yawkey

40. HealthNet Patients’ Admissions In October by Health Center
FM-HN loses the least patients from Geiger/Neponset, Mattapan, South Boston,and East Boston (n>5)
Will update after feedback from leadership team- do we still want this?
FM-HN ER
Cardiology
Medical Teams
Source: Individual SDK Inpatient and Observation admissions by Health Center report

41. HealthNet Patients’ Admissions In October by Health Center (Cont.)
FM-HN loses the most patients from Whittier, Roslindale, and Harvard
Will update after feedback from leadership team- do we still want this?
FM-HN ER
Cardiology
Medical Teams
Source: Individual SDK Inpatient and Observation admissions by Health Center report

42. APPENDIX

43. Average discharge time Average daily discharges
Variability in staffing patterns, operations, and processes results in significant differences in discharge timing
Service
Average discharge time
Average daily discharges
Cath Lab
1:22:41 PM
1.2
Family Medicine – PA
1:40:15 PM
4.9 EP
1:41:27 PM
0.5
Ambulatory Surgery
1:42:00 PM
2.0
Surgical Subspecialty
2:20:02 PM
10.1
Neurology
2:34:41 PM
0.4
Pediatric Surgery
2:40:00 PM
0.6
Maternity
2:42:19 PM
8.0
Family Medicine – Resident
2:46:47 PM
3.7
Newborn
2:47:40 PM
5.7
General Surgery
2:48:13 PM
8.7
Medicine – Hospitalist
2:49:41 PM
6.4
Gynecology
3:05:39 PM
1.7
ED OBS
3:07:57 PM
CHF
3:15:15 PM
1.9 ID
3:17:36 PM
2.9
Medicine – Resident
3:22:59 PM
11.0
Oncology
3:27:45 PM
2.1
General Neurology
3:31:36 PM
2.4
General Cardiology
3:50:23 PM
3.1
Renal
4:01:25 PM
2.8
General Pediatrics
4:11:13 PM
5.2
Geriatrics
4:12:30 PM
3.3
Average discharge time: 2:58 PM
Advancing all these teams to the current mean would save a total of 25.6 bedded patient-hours each day.

44. 30 Day All-Cause Readmission by Service

45. Lack of clinical practice standardization across services results in variable LOS for patients with similar DRGs …
LOS for Observation admissions with primary diagnosis of non-specific chest pain
Average hours
Source: SDK dataset, 8/1/2013-1/31/2014.