1. Family Medicine HealthNet Inpatient Service QUALITY REPORT AND UNIT DASHBOARD: BMC E6W QUEST: (QUALITY, EFFICIENCY, SATISFACTION AND TOTAL REVENUE) April 2015

2. Leadership Team Christopher Manasseh, MD Assistant Professor Vice Chair for Inpatient and Hospital ServicesChristopher Manasseh, MD Aram Kaligian, MD Assistant Professor Assistant Inpatient Director Aram Kaligian, MD Jonathan Bunker, BSN, RN Nurse Manager Eileen Mullaney, RN RN Care Manager Charlotte Cuneo, MSN, RN, CCAP Clinical Nurse Educator _______________________________________ Toyin Ajayi, MD Hospitalist Medical Director Director of Transitional Medicine Commonwealth Care Alliance Ted Constan Chief Administrative Officer, Department of Family Medicine Erica Cuevas, MPH Administrative Coordinator Gwyneth Jones, MBA Administrative Manager Brian Jack, MD 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 7

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 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 FM-HN continues to have O m < E m Q1 2013 (N= 625) Q2 2013 (N=583) Q3 2013 (N= 575) Q4 2013 (N=609) Q1 2014 (N=576) Q2 2014 (N=581) Q3 2014 (N=596) Q4 2014 (N=644) % ICU Cases9.2810.4612.1711.8211.119.938.8110.40

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

13. Case Mix Index Note: Discharges with non-viable neonates, or point of origin is hospice are excluded. CCA patients are included in the denominator but not the numerator because CCA patients are not billed for therefore, the CMI for FM may be inaccurate.

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

15. All-Cause 30-Day Readmission Rate Note: The attribution is based on the mortality analysis logic Source: BMC Administration- distributed at July 2014 Readmission meeting FM-HN has the lowest readmission rate among all the medical services.

16. Readmissions Source: UHC; All-Cause Readmissions by Discharge Quarter All-Cause 30 Day readmission for FM- HN is significantly lower than readmission rate for GIM, but higher than readmission rate for BMC

17. Daily Workload by Care Team (Census Counted At 8AM) CCA volume picked up and peaked at the end of the month The average number of patient per Care Team was relatively similar Source (both graphs): SDK Combined Census Report and confirmed with EPIC census on weekdays

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

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

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

21. Total Admissions and Discharges in February by Day of Week Wednesday and Monday had the highest number of admissions Tuesday and Monday had the highest number of discharges Monday was the busiest day in March Source: EPIC, Department of Medicine Admissions and DOM Discharges by Month Report

22. Percent of March Admissions and Discharges in Observation Status by Care Team Source: EPIC, Department of Medicine Admissions and DOM Discharges by Month Report FM 1 and CCA admitted < patients in Obs status than they d/c FM 2 (PA) admitted > patients in Obs status than they d/c The % of d/c in Obs status incrased for all three teams

23. Admissions in March by Patient Class Source: EPIC, Department of Medicine Admissions 63.8% of all admissions were in inpatient status.

24. Average Length of Stay of Inpatient Discharges by Care Team (In Days) Source: EPIC (From DOM Discharges by Month report) Based on Mean- the ALOS for all three teams decreased since Jan. Based on Median- the ALOS for FM 1 and 2 decreased and increased for CCA Since Feb.

25. Average Length of Stay of Inpatient admissions in February by Day of The Week (In Days) FROM DATE OF ADMISSIONFROM DATE OF DISCHARGE Mean: pts admitted Fri & Tue have a longer LOS & pts admitted Mon and Thurs have shorter LOS Median: Pts admitted Tues and Wed have longer LOS & pts admitted Sun and Mon have shorter LOS Mean: pts d/c on Sun and Mon had a longer LOS & pts d/c Sat and Wed have shorter LOS Median: pts d/c on Mon and Thurs had a longer LOS and pts d/c on Fri and Sat had 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 February Source: UHC, Patient Outcomes by Discharge Day Patients admitted to FM-HN on Tues and Thurs-Sun have a shorter LOS than patients admitted to GIM on those days

27. Average Length of Stay of Observation Discharges by Care Team (In Hours) Based on both the mean and the median, the ALOS for FM 1 and FM 2 decreased since Feb and increased for CCA Source: EPIC, DOM Discharges by Month report

28. Average Length of Stay of Observation Admissions in February by Day of The Week (In Hours) ALOS FROM ADMISSION DATEALOS FROM DISCHARGE DATE Based on the mean, pts admitted on Sat and Sun have a longer LOS and pts admitted on Fri and Mon have a shorter LOS Based on the median, pts admitted Sat and Sun have a longer LOS and pts admitted on Mon and Tue have a shorter LOS Based on the mean, pts d/c on Fri and Mon have a longer LOS and pts d/c on Thurs and Sat have a shorter LOS Based on the median, pts d/c on Mon and Fri have longer LOS and pts d/c Sat and Tues have shorter LOS Source: EPIC (From Department of Medicine Admissions and DOM Discharges by Month report)

29. Comparing ALOS for Inpatient and Observation Admissions in February: With and Without the CCA Team INPATIENT ADMISSIONSOBSERVATION ADMISSIONS Mean: Inpt ALOS is.4 days less when CCA is excluded Median: Inpt ALOS is.3 days less when CCA is excluded Source: EPIC; Discharges Mean: Obs ALOS is 2.2 hours less when CCA is excluded Median: OBS ALOS is.9 hours hours when CCA is excluded

30. Percentage of Patients Admitted to E6W Source: EPIC, Department of Medicine Admissions In February FM-HN admitted 83.1% of patients to E6W. The percentage of Admissions to E6W has increased since February

31. Percentage of Patients Discharged from E6W In February FM-HN discharged about 83.2% of patients from E6W. The percentage of discharges from E6W has increased sin February

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

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

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

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

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

37. Communication Standards About 96% of PCPs are contacted upon admission and 98% 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 February About 54% of HealthNet patients were admitted into the FM-HN Service in March Source: Individual SDK Inpatient and Observation admissions by Health Center report Note: This graph includes patients with a PCP in Family Medicine Yawkey

40. APPENDIX

41. Variability in staffing patterns, operations, and processes results in significant differences in discharge timing Service Average discharge time Average daily discharges Cath Lab1:22:41 PM1.2 Family Medicine – PA1:40:15 PM4.9 EP1:41:27 PM0.5 Ambulatory Surgery1:42:00 PM2.0 Surgical Subspecialty2:20:02 PM10.1 Neurology2:34:41 PM0.4 Pediatric Surgery2:40:00 PM0.6 Maternity2:42:19 PM8.0 Family Medicine – Resident2:46:47 PM3.7 Newborn2:47:40 PM5.7 General Surgery2:48:13 PM8.7 Medicine – Hospitalist2:49:41 PM6.4 Gynecology3:05:39 PM1.7 ED OBS3:07:57 PM4.9 CHF3:15:15 PM1.9 ID3:17:36 PM2.9 Medicine – Resident3:22:59 PM11.0 Oncology3:27:45 PM2.1 General Neurology3:31:36 PM2.4 General Cardiology3:50:23 PM3.1 Renal4:01:25 PM2.8 General Pediatrics4:11:13 PM5.2 Geriatrics4:12:30 PM3.3 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.

42. 30 Day All-Cause Readmission by Service

43. 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.

44. HealthNet Patients’ Admissions In October by Health Center Source: Individual SDK Inpatient and Observation admissions by Health Center report FM-HN loses the least patients from Geiger/Neponset, Mattapan, South Boston,and East Boston (n>5) FM-HN ER Cardiology Medical Teams

45. HealthNet Patients’ Admissions In October by Health Center (Cont.) Source: Individual SDK Inpatient and Observation admissions by Health Center report FM-HN loses the most patients from Whittier, Roslindale, and Harvard FM-HN ER Cardiology Medical Teams