Always Caring. Always Here.

Always Caring. Always Here.
Quality Management 2015
In Memory
of Jill Hickman
According to Webster’s Dictionary, the word “quality” means having “a high
level of excellence” (Merriam-Webster, 2015). When I think of “quality”,
Jill Hickman comes to mind. She was the epitome of quality in both her
personal life and her professional life. Jill held high expectations and never
asked something of you that she would not do herself. She was meticulous in
her work and was good at detail. There are nurses working today who became
better nurses than they ever dreamed they could be due to her guidance and
mentoring. She truly believed in the art of nursing and was loyal to the hospital
where she was born, where she worked for 40 years. Jill also contributed her
time to her community and was always willing to help others. She is truly
missed by those who knew and loved her.
TABLE OF CONTENTS | QUALITY MANAGEMENT 2015
TABLE OF CONTENTS
Welcome
............................................................................
Quality Champion Program
..............................................
p2
p3
Quality Committee Structure ............................................... p4
Patient Safety and the Joint Commission ............................. p5
Organizational Performance Improvement Goals 2015 ........... p7
Quality Measures Program .................................................... p8
Infection Prevention Program
........................................... p10
Stroke Program .................................................................... p12
Catheter–Associated Urinary Tract Infection (CAUTI) ........... p14
Clinical Alarms ....................................................................... p15
Fall Prevention ...................................................................... p16
Readmission Reduction ....................................................... p18
Patient Satisfaction ............................................................... p19
Throughput ......................................................................... p22
“Aim for the Stars” .............................................................. p23
Thank You ........................................................................... p24
References ............................................................................ p24
1
QUALITY MANAGEMENT 2015 | WELCOME
WELCOME
Welcome to the Quality Management Department. Quality Management is responsible for the
facilitation of programs such as Stroke, Patient Safety, Nursing Peer Review, Mortality and Morbidity,
Infection Prevention, American Heart Association Programs, Quality Measures, Meaningful Use, Joint
Commission Survey Preparation, and various Performance Improvement projects. Our hopes are that
this information will provide a better understanding of our role in patient care and in promoting a
safe environment for everyone. Thank you for the services that you provide and your impact on our
community.
Quality Management
Back (left to right): Jean Conn, Pam Benton, Lilia Kulmaczewski,
Ray Fulkrod, Victoria Norris, Cathy Marketto
Front: Kimberly Adkins, Kimberly Fischer, and Amber Brown
Quality Management is guided by Nanticoke Memorial Hospitals’ Mission and Strategic Plan. Our
focus is to work with staff to improve quality, patient safety, and organizational performance. Efforts
are directed at exceeding the expectations of our patients and customers. We provide a framework for
performance improvement and patient safety to everyone in the organization. Quality Management
serves as a resource to staff. It is the department that aggregates, analyzes, and communicates data to
regulatory agencies, insurers, our staff, and leadership.
2
QUALITY CHAMPION PROGRAM | QUALITY MANAGEMENT 2015
QUALITY CHAMPION PROGRAM
Effective April 2015, Quality Management with approval from Nursing, instituted a Quality Champion
Program. This program was designed to provide nursing areas a designated quality management
representative who would serve as the Quality Champion.
The Quality Champions role includes tasks such as chart reviews, interdisciplinary rounding, safety
rounding, and assistance with staff education. The program’s purpose is to enhance communication
with staff about quality and safety initiatives. It will also serve to begin to integrate the Quality
Management staff into the nursing units. Through this closer relationship, greater collaboration on
quality and safety initiatives can occur.
Kimberly Fischer, RN
Amber Brown, BSN, RN
CARE AREAS: ICU, PCU, SSU
CARE AREAS: CDU, PSSU, MSU
Kim started her career in health care while in the
army. She served as a laboratory technician for four
years. Following her military service, Kim worked
in the Intensive Care Unit as Unit Secretary while
completing nursing school. After graduation, Kim
worked in both the Intensive Care Unit for six years
and specialized in Neonatal/Pediatrics for two years.
Kim’s Quality Management experiences started
in Trauma as she previously served in the Trauma
Department at Peninsula Regional Medical Center.
We are fortunate to have Kim as part of our team as
she brings a plethora of experience and expertise.
Amber completed her nursing training at Gloucester
County Community College and her Bachelors of
Science in Nursing from Rowan University. Amber
started her professional nursing career in a family
practice setting. Following a move to Delaware, she
focused her career in the area of Medical-Surgical
nursing in our organization. Amber has functioned
in the Charge Nurse role and completed quality
projects on the unit specifically with the bed-side
reporting committee. Amber has an interest in
working on her Master’s Degree in the future and
continues to focus her expertise on Medical-Surgical
Nursing. We are excited to have Amber as part of
our team and her experience in applying nursing
principles in quality projects.
3
QUALITY MANAGEMENT 2015 | QUALITY COMMITTEE STRUCTURE
QUALITY COMMITTEE STRUCTURE
It is essential that you understand the quality structure within our organization. This information
allows for a clear understanding of how data is analyzed, reported, and how performance improvement
projects can be generated. As mentioned earlier, the Board of Directors has a subcommittee that
evaluates quality projects.
This committee, called the Quality and Professional Affairs Committee (QPAC), is responsible
for the organization’s performance and strategic planning. This committee is composed of members
from Quality Management, Administration, and the Board of Directors. The committee meets quarterly
and reviews various quality measures to monitor that the organization’s performance improvement
activities are structured to provide safe quality care to our patients.
Quality and Professional Affairs Committee (QPAC) Responsibilities:
• Monitor the performance of medical staff in carrying out its responsibilities for evaluating the
improvement of patient care, including a summary of the peer review process.
• Monitor trends in such areas as complications, length of stay, readmissions, resource utilization,
staffing/productivity, patient satisfaction.
• Monitor effectiveness, safety, and efficiency in treating the most common diseases, conditions, and
procedures, as well as new or high-risk procedures.
• Monitor compliance with accrediting agencies and national initiatives.
• Monitor critical occurrences such as sentinel events, near misses, unanticipated deaths, and
occurrences reported to regulatory or state bodies.
• Make recommendations involving the Medical Executive Committee (MEC) to the Board and
approve recommendations for performance improvement and patient safety initiatives. Responsible
for medical staff appointments, reappointments, privilege delineation, and any medical staff
disciplinary or corrective actions.
The Interdisciplinary Performance Improvement Committee (IDPIC) is a working quality
committee structured with several interdisciplinary members from the organization. Information
reported to IDPIC is disseminated to QPAC. The committee is made up of Senior level administration,
Directors, Managers, Network staff, Quality Management, and ad hoc members. This committee meets
monthly and examines various data measures to determine the level of compliance, quality and safety
of care being delivered.
4
PATIENT SAFETY & THE JOINT COMMISSION | QUALITY MANAGEMENT 2015
Interdisciplinary Performance Improvement Committee (IDPIC) Responsibilities:
•
•
•
•
•
Recommendations for performance improvement and patient safety activities.
Creates interdisciplinary process groups.
Analyzes performance data and Patient Safety Program oversight.
Reports activities to QPAC.
Disseminates quality data and the results of performance improvement initiatives through the
Leadership Coordinating Council (LCC) which meets monthly.
Interdisciplinary Performance Improvement Committee
Back (left to right): Dr. Robert Ferber, Kim Darling, Lisa Wile, George Schwobel, Kathy Marketto,
Lilia Kulmaczewski
Middle: Rachel Gardner, Kin Fischer, Lori Lee, Tres Pelot,Jean Conn, Kimberly Adkins, Amber Brown
Front: Victoria Norris, Kimberly Pickinpaugh, Anja Ziemba, Peter Rosin, Janan McElroy
PATIENT SAFETY &
THE JOINT COMMISSION
The Joint Commission (TJC) is an “independent, not-for-profit organization” which offers accrediting
services to over 20,000 health care organizations throughout the country. This organization is designed
to ensure proper quality and safety practices (Joint Commission.org, 2015). Nanticoke Health Services
contracts with the TJC to comprehensively review our services, processes, and procedures to determine
whether the best quality of care is being delivered to our patients while maintaining safe practices
within our facilities. TJC accredits the entire organization every three years, the laboratory every two
years, and the Stroke Program every two years (www.jointcommission.org, 2015).
5
QUALITY MANAGEMENT 2015 | PATIENT SAFETY & THE JOINT COMMISSION
One of the chapters within the standards manual is The National Patient
Safety Goals chapter. These goals are developed in response to safety issues
TJC sees across the country. In 2015, TJC added an additional chapter titled
Patient Safety Systems. This chapter is designed to help an organization develop
or redesign their Patient Safety Systems/Programs.
As one of our nursing champions, Florence Nightingale stated: “The very first
requirement of a hospital is that it should do no harm.” The World Health
Organization defines patient safety as “the prevention of errors and adverse
Jean Conn, Patient
effects to patients that are associated with health care.” The public expects
Safety Officer
a Joint Commission accredited organization to be a safe place. This chapter is
written to help inform and educate hospitals about the importance of a well-integrated patient safety
system. A well-integrated system means that everyone within the organization has a part in establishing
safety within its organization.
The standards cited in this chapter are taken from the following chapters:
• Leadership
• Medical Staff
• Medication Management
• Performance Improvement
• Provision of Care
• Rights of the Individual
• Human Resources
• Infection Control
• Environment of Care
• Accreditation Participation Requirements
And words used include:
• Learning Organization
• Safety Culture
• Accountability
• Data (“effective use of” and “drive to improve”)
• Proactive Approach
• Patient Engagement
TJC provides numerous resources to help hospitals create highly reliable patient safety systems including:
Center for Transforming Health Care, Standards Interpretation Group, Sentinel Event Alerts, Quick
Safety Tips, Standards Booster Packs, leading Practice Library, and Webinars/podcasts.
6
ORGANIZATIONAL PERFORMANCE IMPROVEMENTGOALS | QUALITY MANAGEMENT 2015
Our organization strives to ensure that we are compliant with the standards that are set forth by TJC.
If you are not familiar with this process, we offer a program where staff members of the organization
actively participate in a “tracer”– an activity that reviews the current policy and procedure for a particular
activity or process.
For example: You may have seen tracer teams rounding in the Operating Room, Emergency
Department, Outpatient Facilities, and other areas. Once completed, the teams submit their findings
to the organization’s Joint Commission Liaison, who in turn provides data to various committees
throughout the organization to ensure compliance.
Overall, these activities are designed to ensure that Nanticoke Health Services remains in continuous
readiness for a Joint Commission survey. The Stroke Program was last accredited in 2013 with an
upcoming survey this year. Nanticoke Health Services and the Laboratory program were last accredited
in 2014.
ORGANIZATIONAL PERFORMANCE
IMPROVEMENT GOALS 2015
Goal 1: Inpatient Falls
Concentrate on decreasing falls
Goal = 3.7
Goal 2: Length of Stay (LOS)
Concentrate on decreasing LOS of all sepsis patients
Goal = Average LOS 5.20
Goal 3: Team Building
Goal = Three individuals are scheduled to attend the AHRQ National Master
Trainers Course on June 1 & 2
Master Trainers will then develop a program/plan to implement TeamSTEPPS throughout the organization.
Goal 4: NPN/NMH (Infection Prevention) Hand Hygiene
Hand Hygiene continues to be one of the struggles in health care compliance.
Goal = 2015 Continue with goal of 80%
Goal 5: Throughput
A recommendation was made by Quality Management which included: Examine the time
from order for admission to time the patient is placed in bed with proper handoff.
Goal = 60 minutes
7
QUALITY MANAGEMENT 2015 | QUALITY MEASURES PROGRAM
QUALITY MEASURES PROGRAM
a r e
T h e
a n d
Quality Measures, formerly known as Core Measures, are nationally-standardized
performance indicators that are part of the Centers for Medicare & Medicaid
Services (CMS) Hospital Inpatient Quality Reporting Program. These measures
based on clinical studies that have demonstrated improved patient outcomes.
goal is to lower the risk of surgical complications, lower the risk of mortality
morbidity, reduce readmissions, and implement the best practice healthcare
standards that will improve the quality of care provided to hospital patients.
Quality measures are comprised of data elements captured from the inpatient
and outpatient electronic medical records. The Quality Management
Kimberly Fischer,
Quality Improvement Department is responsible for the abstraction of that data and its submission to
Specialist
both the Joint Commission (TJC) and CMS.
CMS and The Joint Commission review the data submitted by hospitals nationwide and adjust the
number of quality measures annually. For 2015, a number of chart-abstracted measures have been
deemed “topped out” by CMS and TJC. For this reason, four inpatient measures have been discontinued:
Acute MI, Pneumonia, Heart Failure, and Surgical Care Improvement. We will continue to report:
ED Throughput, Stroke, VTE, and Immunizations. One outpatient measure has been discontinued:
Surgical Care. Acute MI, Chest Pain, ED Throughput, Pain with Long Bone Fractures, Stroke, and
Colonoscopy Screening continue to be reported.
Quality Measures data is posted on the Hospital Compare website as released by CMS. Performance
on quality measures is part of the Value-Based Purchasing (VBP) Program. The VBP program is a
CMS incentive program for health care organizations. It provides incentive rewards to those hospitals
that meet or exceed the quality care guidelines and withholds a percentage of the payment if care
standards are not met. The percentage increases slightly every fiscal year. In fiscal year 2017, 2% of total
payments are at risk for each hospital. In 2015, the VBP calculation weighs quality measures results
at 20% Mortality, Readmission rates, and Central Line Associated Blood Stream Infection (CLABSI)
at 30%, Patient Satisfaction survey at 30% and Efficiency at 20%. We are proud to report that our
performance score was above both the State and National average. This in-turn, translates to an
increased Diagnosis-Related Group (DRG) payment amount.
The Physician Quality Reporting System (PQRS) includes quality measures for all physicians who bill
Medicare for payment of services provided. The Quality Management department assists the Hospitalists
group in data collection, compliance, and reporting to CMS for the selected quality measures. By
submitting this data, we ensure that physicians are following the best practice in health care. No
penalties were received as part of this program; incentives were identified as a result of performance.
8
QUALITY MEASURES PROGRAM | QUALITY MANAGEMENT 2015
Myocardial Infarction
Goal
3-Q
2014
2-Q
2014
1-Q
2014
4-Q
2013
Immunization
Measures
Goal
3rd
Q
2014
2nd
Q
2014
1st Q
2014
4th Q
2013
MI Aspirin within 24 hours of
arrival
100%
100%
100%
98%
100%
Pneumococcal
Vaccine
95%
92%
98%
97%
85%
Aspirin prescribed at discharge
100%
97%
100%
94%
100%
Influenza Vaccine
95%
n/a
n/a
96%
93%
ACEI prescribed at discharge for
documented LVF < 40% EF
100%
100%
83%
100%
100%
Venous
Thromboembolism
(VTE)
Goal
3rd
Q
2014
2nd
Q
2014
1st Q
2014
4th Q
2013
PCI within 90 mins of hosp arrival
100%
100%
100%
93%
100%
VTE Prophylaxis
90%
97%
92%
94%
83%
Statin Prescribed at Discharge
100%
100%
100%
94%
100%
ICU VTE Prophylaxis
90%
95%
100%
93%
89%
VTE pts. with
anticoagulation
overlay therapy
90%
90%
92%
100%
60%
90%
100%
100%
100%
100%
CONGESTIVE HEART FAILURE
LVF Assessment
ACEI Prescribed at Discharge
100%
100%
100%
99%
100%
VTE pts. receiving
UFH with
dosages/platelet count
monitoring by protocol
or nomogram
100%
92%
100%
100%
100%
VTE D/C Instructions
90%
100%
100%
100%
86%
Stroke
Goal
3rd
Q
2014
2nd
Q
2014
1st Q
2014
4th Q
2013
PNEUMONIA
Blood cultlures performed within
24 hours prior to or 24 hours after
hospital arrival for pts who were
admitted or transferred to ICU
ICU pneumonia inpatients who
received an initial antibiotic
regimen consistent with current
guidelines during the first 24 hours
of their hospitalization
Non-ICU pneumonia inpatients
who received an initial antibiotic
regimen consistent with current
guidelines during the first 24 hours
of their hospitalization
100%
100%
100%
100%
88%
VTE Prophylaxis or
documentation of
contraindication
95%
93%
96%
92%
86%
100%
100%
no
cases
100%
80%
Assessed for
rehabilitation
95%
100%
100%
96%
100%
100%
100%
100%
100%
97%
Discharged on
Antithrombotic
Therapy
95%
100%
100%
100%
100%
Anticoagulation
Therapy for Atrial
Fibrillation/Flutter
95%
100%
100%
100%
100%
SURGICAL CARE (SCIP)
Prophylactic antibiotic received
within 1 hour prior to surgical
incision
95%
94%
97%
88%
100%
Thrombolytic Therapy
60%
100%
100%
100%
80%
Prophylactic antibiotic selection for
surgical patients – overall rate
95%
100%
100%
94%
100%
Antithrombolytic
Therpay by end of
hospital day 2
95%
100%
100%
96%
100%
Prophylactic antibiotics
discontinued within 24 hours after
surgical end
95%
100%
97%
93%
89%
Dsicharged on Statin
medication
95%
100%
100%
100%
100%
Beta Blockers during Perioperative
Period
100%
96%
80%
100%
100%
Stroke Education
95%
96%
100%
95%
100%
Appropriate Hair removal
100%
100%
100%
100%
100%
Patient ID
Observations
100%
100%
98%
99%
100%
Urinary Cath removed on POD 1
or POD 2
95%
96%
98%
90%
98%
Timeliness of Recommended VTE
Prophylaxis
95%
100%
100%
100%
88%
9
QUALITY MANAGEMENT 2015 | INFECTION PREVENTION PROGRAM
INFECTION PREVENTION PROGRAM
The Infection Prevention Program is focused on surveillance, prevention,
and the control of infections. The program uses effective processes to identify
and reduce the risks of acquiring and transmitting infections. The program’s
oversight is the Infection Prevention Committee, a multidisciplinary committee,
composed of nurses, physicians, pharmacy, and staff.
Our Infection Preventionist (IP), Kimberly Adkins, conducts surveillance and
reports healthcare associated infections (HAI’s) along with communicable
diseases. The IP is also responsible for developing and implementing policies
Kimberly Adkins,
related to the control and prevention of infections and communicable diseases.
Infection Preventionist (All healthcare staff are responsible for following infection prevention policies
and procedures.) The IP facilitates development, implementation, evaluation,
and improvement practices to prevent HAI’s.
The Infection Prevention Program identifies goals and strategies annually from its risk assessment.
Current projects include: Improving hand hygiene compliance, proper personal protective equipment
(PPE) use, and reducing sharps injuries. Improving hand hygiene, PPE compliance, and improving
disinfection/cleaning of the environment are some of the strategies developed to reduce hospital
acquired C. difficile infections, which are a serious health risk to our patients.
Catheter-Acquired Urinary Tract Infections (CAUTI) are another risk that was targeted and reduced
through the development of a CAUTI investigation tool by the CAUTI committee. This tool is used
to investigate root causes and prevention activities associated with each infection. The IP reports all
inpatient CAUTI data to the Centers for Disease Control and Prevention’s (CDC) National Healthcare
Safety Network, along with data on Central Line Associated Bloodstream Infections (CLABSI), Surgical
Site Infection data including colon and abdominal hysterectomies and data on Methicillin-resistant
Staphylococcus aureus (MRSA) and C. difficile infections.
The Infection Prevention Program continues to work on reducing the CLABSI rate to 0.8 CLABSI
/ 1,000 central line days. The IP encourages active participation by all staff members to ensure that
proper procedures are being followed to ensure patient safety and compliance with all prevention
measures.
10
INFECTION PREVENTION PROGRAM | QUALITY MANAGEMENT 2015
Surgical Site Infection (SSI)
Surgical Site Infection (SSI)
Goal: 0.5% OR Clean/Clean Contaminated
Goal: 0.5% ORSSIClean/Clean Contaminated SSI
2.0%
Surgical Site Infection (SSI)
1.5%
Goal: 0.5% OR Clean/Clean Contaminated SSI
1.0%
0.5%2.0%
0.0%1.5%
1.0%Jan Feb Mar Apr MayJune July Aug Sep Oct Nov Dec Jan Feb Mar Apr MayJune July Aug Sep Oct Nov Dec
'13
'14
%SSI
Mean Jan '13 - Dec '13
MeanJan '14 - Dec '14
0.5%
Outcome:
Surgical
site infections
from clean
and clean
contaminated
procedures
remain
0.0%
Outcome:
Surgical
site infections
from clean
and clean
contaminated
procedures
remain
low.low.
NMH
had
0
hysterectomy
surgical
site
infections
and
1
colon
surgical
site
infection
in
Feb Mar Apr MayJune
Sep Oct and
Nov Dec
Jan Feb
Mar Apr
JulyinAug
Sep2014.
Oct Nov Dec
NMH had 0Jan
hysterectomy
surgicalJuly
siteAug
infections
1 colon
surgical
siteMayJune
infection
2014.
'13
%SSI
'14
Mean Jan '13 - Dec '13
MeanJan '14 - Dec '14
Infection-related Ventilator-Associated Complication (IVAC)
Infection-related
Ventilator-Associated
Complication
(IVAC) remain low.
Goal:
0 IVAC/1,000
ventilator
days from
2014:clean
0 and clean contaminated
Outcome:
Surgical
site infections
procedures
NMH had 0 hysterectomy surgical site infections and 1 colon surgical site infection in 2014.
0 IVAC/1,000
days 97.3%
2014:compliance
0
Healthcare worker seasonalGoal:
Influeza
Vaccinationventilator
Participationfor the
2014-2015
flu
season.
Infection-related Ventilator-Associated Complication (IVAC)
Healthcare
worker
Hand
Hygiene
Goal:
0 IVAC/1,000
ventilator
days seasonal
2014: 0Influeza Vaccination Participation:
97.3% compliance for the 2014-2015 flu season.
Goal:
80% compliance
Healthcare
worker seasonal Influeza Vaccination Participation- 97.3% compliance for the
2014-2015 flu season.
Hand Hygiene
Hand Hygiene
Goal: 80% compliance
Goal: 80% compliance
Hand Hygiene continues to be a national struggle for all health care organizations. The Infection
Preventionist has identified and is actively working on measures to help positively impact
compliance.
HandHygiene
Hygienecontinues
continuestotobebea anational
nationalstruggle
strugglefor
forall
allhealth
healthcare
care organizations.
organizations. The
The Infection
Infection
Hand
Preventionist
working
onon
measures
to help
positively
impact
compliance.
Preventionisthas
hasidentified
identifiedand
andisisactively
actively
working
measures
to help
positively
impact
compliance.
11
QUALITY MANAGEMENT 2015 | STROKE PROGRAM
STROKE PROGRAM
Nanticoke is committed to decreasing the health risks within our community.
Stroke is the fifth leading cause of death and one of the leading causes of longterm disability in America. In addition, a stroke occurs about every 40 seconds
and someone dies from a stroke approximately every 4 minutes (American
Stroke Association, 2015).
Stroke is a “brain attack” that occurs when the blood supply to a part of the
brain is cut off by a blockage or busting of a blood vessel. When this occurs,
the brain cells in that part of the brain begin to die from a lack of oxygen and
Victoria Norris,
nutrients. How a person is affected by a stroke depends on what part of the
Stroke Program
brain was damaged by the lack of blood flow and how big the area in the brain
Coordinator
became injured by the “attack”. This damage causes that part of the brain to lose
the ability to do its job or control a specific function.
Nanticoke Memorial Hospital is certified by The Joint Commission as a Primary Stroke Center. The
mission of the Stroke Program is to positively impact our communities’ quality of life through providing
optimal stroke care while increasing public awareness regarding stroke. The Stroke Program strives to
provide education on the prevention of stroke by attending community health fairs, providing Stroke
guest speakers in the community and hospital, and establishing a community Stroke Support Group.
To further assist with meeting the mission of the Stroke Program, Nanticoke Memorial Hospital uses
American Heart Association and American Stroke Association guidelines to direct the care of people
who experience Stroke and/or Transient Ischemic Attacks (TIA). These guidelines are utilized to
develop care based on the final recommendations and the approval of the Stroke Committee.
One main objective of the Stroke Program is to administer a “clot busting” (thrombolytic) medication
to appropriate stroke victims to “open up” the brain’s blood vessels, thus potentially preventing a
permanent disability from a stroke. The committee reviews all data surrounding this process with the
goal to increase the number of appropriate stroke victims who receive this medication in the shortest
time safely possible. In the year 2014, 13% of people who came to Nanticoke Memorial Hospital with
an ischemic stroke received this medication. This is a positive trend compared to all other Delaware
hospitals, in which 10% was the average to receive the medication and 9% received the medication
nationally.
Another main objective of the program is to ensure that patients at Nanticoke Memorial Hospital
receive appropriate precautionary care, such as prevention of further blood clots, and are educated on
the prevention of further stroke injuries. On average in the year 2014, these goals were met over 95%
of the time. Education and streamlining of systems to improve these goals are continuously ongoing.
The recommended treatment and care of stroke victims is continuously changing based on current
12
STROKE PROGRAM | QUALITY MANAGEMENT 2015
research. Our Stroke Program makes every effort to evolve based on the most current accepted
The recommended
andwill
carecontinue
of stroketovictims
is the
continuously
changing
based
recommendations.
The Stroketreatment
Committee
monitor
current health
care practices
related
to Stroke
while looking
towards
the future
strokeeffort
management.
on current
research.
Our Stroke
Program
makesofevery
to evolve based on the most current
accepted recommendations. The Stroke Committee will continue to monitor the current health
care practices related to Stroke while looking towards the future of stroke management.
Stroke Demographics
Stroke Demographics
Gender
Q4 2014
Q3 2014
Q2 2014
Q1 2014
41%
59%
38%
62%
43%
57%
50%
50%
Q4 2014
Q3 2014
Q2 2014
Q1 2014
64%
34%
2%
77%
15%
8%
81%
16%
3%
74%
24%
2%
Q4 2014
Q3 2014
Q2 2014
Q1 2014
4%
30%
52%
14%
15%
30%
40%
15%
4%
34%
47%
15%
4%
44%
39%
13%
Male
Female
Race
White
Black/African American
Hispanic/Other
Age
18 - 45
46 - 65
66 - 85
> 85
2014 t-PA (Medication) Administration
2014 t-PA (medication) Administration
2014 t-PA Infusion
4
3
2
1
0
Jan Y14 Feb Y14 Mar Y14 April
Y14
May
Y14
Jun Y14 July Y14 Aug Y14 Sep Y14 Oct Y14 Nov Y14 Dec Y14
Number of t-PA Given
Number of t-PA Given < 60 minutes
Number of t-PA Given < 45 minutes
Number with Documented Reasons for Delay
13
QUALITY MANAGEMENT 2015 | CAUTI
CATHETER-ASSOCIATED URINARY
TRACT INFECTION (CAUTI)
The Catheter–Associated Urinary Tract Infection (CAUTI) group was formed in 2014. It began with an
informal meeting with Administration and an Educator. The group met in an effort to review, control,
and respond to elevated CAUTI rates. Our CAUTI rate had increased and our organization responded
by establishing a team to look at system improvements. This CAUTI project was immediately started
focusing on getting “Back to the Basics”. The work group’s initial meeting was in January 2014 and
included both Nursing Unit and Quality Management staff. It was important for unit staff to attend
as they were the primary users of the catheters and could communicate what specifically was occurring
on the floor.
The committee requested that BARD, a company that specializes in the production of a catheter,
conduct a basic assessment of Nursing and Patient Care Technicians skills. The committee wanted to
know where staff were compliant and what skills sets needed improvement. As a result, changes were
made in the device tray being used by the staff. Concurrently, the Information Technology (Informatics)
staff began reviewing documentation. Charting was examined and significant changes were made to
documentation in the EMR with greater emphasis placed on multidisciplinary rounding. House–wide
education was completed and the new device trays were rolled out to the floor in July of 2014.
CAUTI Committee
Back (left to right): Lisa Schirtzinger, Kasey Moore,
Alina Horne, Kimberly Pickinpaugh, Robert Monaghan
Front: Dr. Christine Hannaway, Kimberly Adkins, Dr. Elizabeth Kornfield
14
CLINICAL ALARMS | QUALITY MANAGEMENT 2015
Since those efforts, CAUTI rates have improved and the committee continues to meet on
a routine
basis.efforts,
The committee
nowhave
has expanded
include
a physician
presence.toCurrent
Since those
CAUTI rates
improved to
and
the committee
continues
meet on a routine
efforts
positively
impact
rates include;
additional
changes
in documentation,
basis.toThe
committee
nowCAUTI
has expanded
to include
a physician
presence.
Current efforts to positively
reviewing
and updating
policies,additional
and a re-education
for all staff.
Evenand
though
impact CAUTI
rates include:
changes incampaign
documentation,
reviewing
updating policies,
and
a
re–education
campaign
for
all
staff.
Even
though
significant
ground
has
been
covered
significant ground has been covered and rates have improved, it is essential for quality
of careand rates
have
improved,
is essential
that we
efforts
toall
prevent
CAUTIs.
and
patient
safetyitthat
we continue
ourcontinue
efforts toour
ensure
that
is being
done to prevent CAUTI.
Catheter–Associated Urinary Tract Infections (CAUTIs)
Catheter Associated Urinary Tract Infection (CAUTI)
Goal: < 1.5 CAUTI/1,000 urinary
catheter
days
Goal:
< 1.5 CAUTI/1,000
urinary catheter days
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
Jan Feb Mar Apr MayJune July Aug Sept Oct Nov Dec Jan Feb Mar Apr MayJune July Aug Sep Oct Nov Dec
'13
'14
CAUTI Rate
2.0
Mean Jan '14 - Dec '14
Outcome: The annual mean CAUTI rate decreased from 2.1 in 2013 to 1.4 in 2014.
Outcome: The annual mean CAUTI rate decreased from 2.1 in 2013 to 1.4 in 2014.
CLINICAL ALARMS
One of the National Patient Safety Goals is to “improve the safety of clinical alarm systems.” Clinical
alarms have been a concern for years. Alarms are meant to alert caregivers of potential patient problems.
As patients become sicker, the number of machines and alarms increase as these devices are required
for patient care. Alarms may be individual, such as a personal alarm, or connected to an electronic
system like telemetry. As the number of alarms grow, so does the tendency to become desensitized
to the sounding event. Currently, hospitals across the country are addressing the risks for patients
associated with these devises that alarm and are working on ways to prevent alarm fatigue for staff.
The Clinical Alarms Committee is an interdisciplinary group with representation from Nursing,
Facilities, Biomed, Information Technology, Respiratory, Quality Management, and Administration.
Individuals from other departments may be requested to attend based on the policy or procedure that
is being addressed. The goal of the committee is to address clinical alarms by reducing the number
of alarms, standardizing default settings, and educating staff to these changes. The committee has
15
QUALITY MANAGEMENT 2015 | FALL PREVENTION
identified specific clinical alarms that require policies and procedures for managing alarms. As theses
policies are completed, education to staff will be provided.
As of January 2016, The Joint Commission will require clinical alarm system policies and procedures
that are established with education to staff. The committee is working diligently to comply with the
regulations outlined by The Joint Commission. To this date, the committee has made great strides
in recognizing our current alarms, creating a foundation for policies, and examining all care areas to
ensure that future alarm awareness is being identified to prevent this potential patient safety hazard.
Clinical Alarms Committee
Back (left to right): Tres Pelot, Lisa Miller, Dr. Robert Ferber,
Rachel Gardner, Laura Cooper
Front: Lori Lee, Shawn Grim, Amber Brown
FALL PREVENTION
Prevention of falls has long been a struggle for many hospitals. A patient fall may occur in any
department of the hospital and these falls may occur with or without injury. Fall concerns should not
be limited to only nursing but should also include anyone that may have contact with a patient. The
Fall Prevention Committee serves to prevent patient falls through intervention, implementation, staff
education, and post fall review. Members of the group include nursing staff from multiple units, an
educator, and members from our physical therapy and occupational therapy teams. Monthly meetings
are held to determine ways to prevent patient falls, to discuss evidence–based interventions, and develop
techniques to apply this information for use in our own practices.
16
FALL PREVENTION | QUALITY MANAGEMENT 2015
Previous recommendations and interventions from the committee include:
• Additional education for staff through skill days.
• Hourly rounding tasks included in Cerner.
• Additional personal alarms for all units.
• Additional gait belts for patient mobility.
• Development and implementation of post–fall information forms.
• Inviting staff that cared for patients that have fallen to committee meetings to review the fall
occurrence for improvement and suggestions.
• Development and initiation of post–fall power plans.
The current national benchmark for falls is 3.7%. Nanticoke Memorial Hospital noted a 4.0% fall rate,
which was slightly higher than the benchmark. The Fall Prevention Commitee will continue to work
toward the goal of reducing patient falls by utilizing staff ideas and recommendations and reviewing
evidence based information.
Significant work has already been completed in the hope that the number of falls will continue to
decrease. These measures include: private rooms, new beds which allow lower positioning and a more
effective alarm system, track lighting which allows a more visible path to the restrooms, and continued
education for staff.
Fall Prevention Committee
Back (left to right): Rachel Gardner, Bonny King,
Lisa Schirtzinger, Amber Brown, Sarah Russell, Ruth Hill
Front: Elizabeth Hill, Jessica Burton, Ashley Tull
Left to right: Alex Stroup and Jeanie Ruggles
17
QUALITY MANAGEMENT 2015 | READMISSION REDUCTION
READMISSION REDUCTION
The passage of the Affordable Care Act led to many changes in health care throughout the country. As
a result, processes and procedures were re–examined and the way care was delivered changed, which
led to the creation of the Readmission Reduction Program by the The Centers for Medicare and
Medicaid Services (CMS). This program allows CMS to make several reductions in reimbursement to
organizations whereas excessive readmission rates are noted following October 2012 (CMS.gov, 2015).
It is critical to understand the components of this program. CMS defines a readmission as “any
admission to a hospital following discharge from the same or another hospital based on a specific
condition.” In Fiscal Year 2013, readmission was limited to Acute Myocardial Infarction (AMI), Heart
Failure, and Pneumonia. This requirement did not change in Fiscal Year 2014, but in Fiscal Year 2015,
CMS added two additional measures: Chronic Obstructive Pulmonary Disease and Total Arthroplasty/
Total Knee Arthroplasty.
One of the most confusing aspects is that this program is based upon CMS’s payment year versus
the health care organization’s fiscal period. Regardless, the impact of these programs translates in to
financial dollars for any organization. The objective is to ensure that decreased Readmission rates are
noted across the organization.
This reduction translates into the following:
• For (CMS) Fiscal Year 2013- 1% Reduction
• For (CMS) Fiscal Year 2014- 2% Reduction
• For (CMS) Fiscal Year 2015- 3% Reduction
Having recognized the potential impact on Nanticoke Memorial Hospital (NMH), several working
groups within the organization began focusing on this potential impact while several factors including
patient compliance, access to care, means for transportation, and so forth were identified.
An interdisciplinary committee, the Readmission Reduction Committee, was formed to focus on some
of the barriers identified. This committee has been tasked with examining what is currently occurring
within the organization, specifically the patients being transfered out and any activities that are associated
with the process. The focus of the committee is to ensure proper education, care coordination, and
team collaboration so that patients are not unnecessarily readmitted to our facility.
18
PATIENT SATISFACTION | QUALITY MANAGEMENT 2015
Readmission Reduction Committee
Back (left to right): Penny Short, Cynthia Morrison, Wendy Corkran, Lara Hudson,
Dr. John Appiott, Ray Fulkrod, Lisa Miller, Marcy Columna, Michelle Elzey, Kathy James
Front: Nancy Saveikis, Michele Bell, Dr. Robert Ferber, Rachel Gardner,
Amber Brown, Victoria Norris
PATIENT SATISFACTION
PATIENT SATISFACTION
CATHY
MARKETTO
Providing our patients with the best healthcare experience possible is one of the most PICTURE
Providing
our patients
the best Memorial
healthcare experience
possible No
is one
of thewhat
mostservice
important
important
goals ofwith
Nanticoke
Hospital (NMH).
matter
a goals
of Nanticoke
Hospital
(NMH).
No matter
service a ispatient
in patients
the Nanticoke
network
patient inMemorial
the Nanticoke
network
utilizes,
our what
expectation
for our
and families
utilizes,
our
expectation
is
that
our
patients
and
families
always
experience
both
excellent
clinical
and
to experience excellent clinical care always delivered in a compassionate, caring
compassionate
manner. care.
Overall Rating of Hospital
72
70
68
66
64
62
60
NMH
Beebe
BH Kent BH Milford Christiana St. Francis
PRMC
DE
Average
National
Average
One of the ways our patients let us know what they thought about their patient
19
QUALITY MANAGEMENT 2015 | PATIENT SATISFACTION
One of the ways our patients let us know about their patient experience is
through the Patient Satisfaction Survey. Throughout the year, NMH surveys
random inpatient, emergency department and outpatient surgery patients.
Selected patients are asked to rate their communication with nursing and
physicians, their satisfaction with the environment, and staff responsiveness
to their needs. The survey also asks for patient feedback about how their pain
was addressed, educating them about the purpose of their medications and
preparing them for discharge from the hospital.
Cathy Marketto
Patient Advocate
The survey gives patients the opportunity to write in any additional comments
regarding their stay. Our patients love to recognize staff for providing extra
kindness to them. They are also quick to tell us what may have disappointed
them or if they felt the staff did not meet their expectations.
Patient Satisfaction Committee
Back (left to right): John Cullen, Tres Pelot, Lana Gillespie, Lori Lee,
Ray Fulkrod, Elisabeth Wile, Penny Short
Front: Cathy Marketto, Rachel Gardner, Alina Horne, Shawn Grim
Transparency is an important part of Nanticoke’s patient satisfaction process. This information is
available at staff meetings, the Patient Satisfaction Portal on the hospital intranet, and through monthly
updates sent directly to staff email accounts.
As part of the Affordable Care Act, patient satisfaction results have become a focal point in the CMS
Value–Based Purchasing program beginning in 2012. Satisfaction data from hospitals across the
country is available on the website www.hospitalcompare.hhs.gov. As a hospital receiving Medicare
and Medicaid funds, Nanticoke’s patient satisfaction scores are used in the equation to determine if
the hospital will receive full reimbursement each year.
20
Transparency is an important part of Nanticoke’s patient satisfaction process. This
information is available at staff meetings, the Patient Satisfaction
Portal on| QUALITY
the hospital
PATIENT SATISFACTION
MANAGEMENT 2015
intranet, and through monthly updates sent directly to staff emails.
part of2015,
the Affordable
Care Act, patient
satisfaction
results
have
point
As As
of Spring
emergency department
and outpatient
surgery
patients
arebecome
surveyed aasfocal
part of
the
in
the
CMS
Value
Based
Purchasing
program
beginning
in
2012.
Satisfaction
data
financial payment process. This survey is referred to as the HCAHPS (Hospital Consumer Assessment
from hospitals
across
country
is available
on thedepartment
website and outpatient surgery survey
of Healthcare
Providers
andthe
Systems)
survey.
The emergency
www.hospitalcompare.hhs.gov. As a hospital receiving Medicare and Medicaid funds,
data will be displayed on the public website within the next 12 to 24 months and will be financially tied
Nanticoke’s patient satisfaction scores are used in the equation to determine if the
to Nanticoke’s reimbursement.
hospital will receive full reimbursement each year.
The
patient’s inpatients,
experience isemergency
the responsibility
of each and
and every
Nanticoke
staff patients
member, physician
and
Although
department
outpatient
surgery
are
volunteer.
Each
member
plays
a
unique
role
in
how
our
patients,
visitors
and
families
perceive
surveyed as of Spring 2015, only the inpatient survey is part of the financial payment the
hospital.
A positive
attitudeisand
behaviors
canthe
be HCAHPS
the difference
in the This
individual
lives
our patients
process.
This survey
referred
to as
survey.
stands
forofHospital
andConsumer
families. Assessment of Healthcare Providers and Systems. The emergency
department and outpatient surgery survey data will be displayed on the public website
within the
to twenty-four
months.
The results
will be and
financially
tied to
A next
smile,twelve
greeting,
acts of kindness
in difficult
situations,
providing
Nanticoke’s
reimbursement
as well.
excellent
clinical care
is what determines the Nanticoke difference!
Communication about Medications
70
65
60
families perceive the hospital. A positive attitude and behaviors can be the difference in
the
55 individual lives of our patients and families.
50
NMH
Beebe
BH Kent BH Milford Christiana St. Francis
PRMC
DE
Average
National
Average
A smile, a greeting, showing kindness in difficult situations, as well as providing
excellent
clinical
care is what
theofNanticoke
The
patient’s
experience
is thedetermines
responsibility
each anddifference!
every Nanticoke staff member,
physician and volunteer. Each of us play a unique role in how our patients, visitors and
Communication with Doctors
85
80
75
70
65
60
NMH
Beebe
BH Kent BH Milford Christiana St. Francis
PRMC
DE
Average
National
Average
21
QUALITY MANAGEMENT 2015 | THROUGHPUT
THROUGHPUT
The Throughput Committee is a multidisciplinary group tasked with the collection and review of
our hospital’s transition of care times between patient arrival through admission to our facility. Data
is analyzed so that patients are moving smoothly through our facility’s admission process in a timely
manner. This information is shared with several committees in an effort to improve processes and
procedures affecting patient care.
The committee meets monthly and has explored several ways in which these times, patient flow, and
communications can be improved. Some of the information explored includes time of arrival in the
Emergency Department to time seen by a provider, time patient recommended for admission to time
bed assigned, and time from admission orders received to patient transferred to the floor. All of this
information is essential in providing quality care to our patients as well as ensuring timely delivery of
services.
Throughput Committee
Back (left to right): Sandy Destler, John Cullen, Victoria Norris,
Ray Fulkrod, Dianna Wedman, Kathleen Davis, Rachel Gardner
Front: Vicki Strohmaier, Linda Wheatley, Elisabeth Wile,
Jean Conn, Amber Brown
22
AIM FOR THE STARS | QUALITY MANAGEMENT 2015
“AIM FOR THE STARS”
Nanticoke Memorial Hospital is pleased to announce that it is
the only hospital on the Delmarva Peninsula and in the State of
Delaware to receive a 4-star rating by the Centers for Medicare
and Medicaid Services (CMS). All other hospitals on the Eastern
Shore, received a 3-star rating or below.
Knowing it can be difficult for consumers to compare hospitals on
quality of care and patient experience, the Centers for Medicare
and Medicaid Services (CMS) tracks a number of clinical quality
and patient satisfaction measures using the HCAHPS (Hospital
Consumer Assessment of Healthcare Providers and Systems)
Survey.
As a part of the HCAHPS Survey, CMS provides a snapshot of patient experience using 11 key indicators.
CMS collects data for each indicator by randomly surveying both Medicare and Non-Medicare adult
patients. Survey questions are related to nurse communication, doctor communication, pain control,
explanation of medications, cleanliness of the room, and the patient’s understanding of care received
at the hospital as well as care needed once the patient returns home. As a way to make it easier to
compare these survey results, CMS recently released its first Patient Experience Star Ratings, much
like star ratings used in other industries. Nanticoke received a 4-Star rating, the highest on the Eastern
Shore.
“We are very proud of our entire team that works every day to provide the best possible patient
experience,” said Steven Rose, RN, MN, President/CEO of Nanticoke Health Services. “While there
is always more work to be done, receiving the only 4-Star rating on the Shore re-enforces all the great
work we’ve done so far to continuously improve clinical quality and patient experience. It’s our goal to
put our patients at the center of all we do.”
According to CMS, “the star rating is compiled based on information collected from July 1, 2013
through June 30, 2014. HCAHPS star ratings enable consumers to more quickly and easily assess the
patient experience of care information that is provided on the Hospital Compare Web site. HCAHPS
star ratings allow consumers to more easily compare hospitals using a five star scale, with more stars
indicating better quality care. CMS recommends you consider multiple factors when making decisions
about your health care and comparing hospitals. The HCAHPS star ratings summarize patient
experience, is one aspect of hospital quality.” (www.hospitalcompare.hhs.gov)
“We could not be where we are today without the dedication of our entire Nanticoke family,” said Kent
Peterson, Chairman, Nanticoke Health Services Board of Directors. “The community provides us so
much support and the staff, physicians and volunteers work together so well. It really is about providing
kind, compassionate care to those we serve.” (www.nanticoke.org, 2015)
23
QUALITY MANAGEMENT 2015 | THANK YOU / REFERENCES
THANK YOU
We want to take this time to thank everyone who is part of our family here at Nanticoke.
Without you all, the successes that occur here each and every day would not be possible.
Thank you for what you do, the impact you have on our community, and for choosing
Nanticoke as a place to provide service, grow as a professional, and help provide the best
care possible.
Best regards,
Penny Short, RN, MSN
Chief Operating Officer
Chief Nursing Officer
REFERENCES
www.jointcomission.org (2015) The Joint Commission. Retrieved from: http://www.jointcommission.
org/about_us/about_the_joint_commission_main.aspx
www.CMS.gov (2015) Centers for Medicare & Medicaid Services. Retrieved from: http://www.cms.
gov/About-CMS/Agency-Information/History/index.html
www.strokeassociation.org (2015) American Heart Association & American Stroke Association.
Stroke. Retrieved from: http://www.strokeassociation.org/STROKEORG/AboutStroke/
About-Stroke_UCM_308529_SubHomePage.jsp
www.nanticoke.org (2015) “Nanticoke Memorial Hospital Rated Best on Delmarva for Patient
Experience by CMS”. Retrieved from: http://www.nanticoke.org/our_blog/nanticoke-
memorial-hospital-rated-best-on-delmarva-for-patient-experience-by-cms/
24
801 Middleford Road | Seaford, DE 19973
302-629-6611 | www.nanticoke.org
Nanticoke Health Services includes Nanticoke Memorial Hospital and the Nanticoke Physician Network. Nanticoke Health
Services has been named one of the Best 150 Places to Work in Healthcare by Becker’s Hospital Review for five years in a
row. Nanticoke Memorial Hospital holds a Level III Trauma Center certification and is the only hospital on the Delmarva
Peninsula to receive a 4-star rating by the Centers for Medicare and Medicaid Services. Nanticoke is nationally certified by
the Joint Commission as a Primary Stroke Center and is a Gold Plus Award performer according to the American Heart/
American Stroke Association’s Get With The Guidelines® program. Nanticoke’s Cancer Care Services holds Accreditation
with Commendation from the American College of Surgeons Commission on Cancer and is a member of the Association of
Community Cancer Centers. Nanticoke’s medical staff includes over 150 active and community affiliate health care providers
practicing in 40 different specialties.