1. February 16, 2011 Quality & Patient Safety at Vanderbilt Department of Biostatistics 1

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3. Crossing the Quality Chasm 6 AIMS S safe T timely E effective E efficient P patient-centered E equitable 3

4. National Priorities Partnership Convened by National Quality Forum National Priorities and Goals: 1.Engage patients and families in managing their health and making decisions about their care 2.Improve the health of the population 4

5. 3. Improve the safety and reliability of America’s health care system - infection - adverse events - hospital level mortality rates - 30-day mortality rates post hospitalization 4. Ensure patients receive well-coordinated care within and across ALL healthcare organizations, settings, and levels of care 5

6. 5. Guarantee appropriate and compassionate care for patients with life-limiting illnesses 6. Eliminate overuse while ensuring the delivery of appropriate care 6

7. Triple AIM 1.Health of the Population 2.Reduced Costs in Health Care 3.Improve Safety, Reliability, and Experience - D. Berwick Dr. Donald Berwick

8. Quality Pillar We relentlessly pursue and measure ourselves against the highest quality performance in all areas, from patient care to scholarship 8

9. Quality Pillar: Q2 FY2011 Results Goal Q1 FY2011 Results Q2 FY2011 Results Q3 FY2011 Results Q4 FY2011 Results FY2010 ResultsThresholdTargetReach Reduce O/E Mortality* 0.71*0.78* Data through Nov 2010.73 (FY11-0.75)* 0.76*0.73*0.71* Reduce Healthcare Associated Infections 0.820.85 Data through Nov 2010 1.211.171.110.98 Reduce Adverse Events 9.249.429.508.087.677.27 Achieve Top Performance in Clinical Programs 86%89% 85%90%95% Improve System Reliability 410Not Applicable 6 - 78 - 910 - 12 Establish Quality Improvement Learning System ProgressingDeveloping Curriculum Not Applicable Develop curriculum Develop standard tools and methods Deliver to identified target group *Statistics for O/E reflect recalibration in October 2010, resulting in change to FY2011 goal to reflect Top 10, Top 5 and Top 3 of the US World & News Report peer group 9

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11. Reduce Healthcare Acquired Infections Goal Q1 FY2011 Results Q2 FY2011 Results Q3 FY2011 Results Q4 FY2011 Results FY2010 ResultsThresholdTargetReach Ventilator Associated Pneumonia 1.191.111.691.431.261.09 Central Line Associated Blood Stream Infections (ICU) 1.010.691.691.451.280.85 Surgical Site Infection 0.850.91 Data through Nov 2010 1.121.151.090.96 Catheter Associated Urinary Tract Infection 0.420.530.740.670.630.56 Hand Hygiene79%80%77%85%90%95% 11

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14. Hand Hygiene Area Numerator YTD FY2011 (Jul-Dec) Denominator YTD FY2011 (Jul-Dec) Compliance Rate YTD FY2011 (Jul-Dec)ThresholdTargetReach Adult Outpatient4407473393%85%90%95% Pediatric Outpatient1005122382%85%90%95% VPH118 100%85%90%95% VCH4355600073%85%90%95% VUH 3019423271%85%90%95% TOTAL129041630679%85%90%95% 14

15. Overall Historic Trend Improvement Gap per trend

16. Reduce Adverse Events Goal Q1 FY2011 Results Q2 FY2011 Results Q3 FY2011 Results Q4 FY2011 Results FY2010 ResultsThresholdTargetReach Pressure Ulcers (per 1,000 pt days)0.871.081.110.910.860.82 Falls (per 1,000 pt days)3.573.753.623.163.002.84 Medication Errors (per 1,000 pt days)4.804.594.614.013.813.61 16

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18. Achieve Top Performance in Clinical Programs Goal Q1 FY2011 Results Q2 FY2011 Results Q3 FY2011 Results Q4 FY2011 Results FY2010 ResultsThresholdTargetReach Stroke85% (Data through Aug 2010) 89% (Data through Nov 2010) 91%86%91%95% Pneumonia79%72% (Data through Nov 2010) 82%83%90%95% Heart Failure93%97% (Data through Nov 2010) 90% 95%100% SCIP95%Not Available 91%90%94%99% OPPS86%Not Available 92%91%94%99% 18

19. Vanderbilt Performs in Top Decile of Leapfrog Hospitals (1,184 hospitals in 45 States)

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21. Reliable Process Design Goal Q1 FY2011 Results Q2 FY2011 Results Q3 FY2011 Results Q4 FY2011 ResultsThresholdTargetReach Medication Reconciliation 0 (Progressing) 1 Develop prototype based on admission Expand prototype to include discharge Establish baseline and compliance measures Blood Management 0 (Progressing) Build data set for process Establish internal baseline Implement monitoring system Universal Protocols 22 Disseminate and spread electronic process Implement quantitative and qualitative analysis of process Zero defect in surgical site Handovers22 Finalize standardized infrastructure and tools Disseminate and spread process to 3 areas Target plus 2 additional areas 21

22. 22 Building Collaborations to Improve Safety and Quality in Health Care Challenge: Awards for the best graphical displays of data related to patient safety or quality improvement Submission: Hang poster in the hall between offices of Frank and Lynda Deadline: April 15, 2011