Future in Focus: One Clear Vision: The 2020 Vizient Connections Education Summit Report : American Journal of Medical Quality

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Future in Focus: One Clear Vision: The 2020 Vizient Connections Education Summit Report

Future in Focus

One Clear Vision

The 2020 Vizient Connections Education Summit Report

White, Cindy MBA, RN; Latimer, Karen MS, MSMI, LSSGB, RRT

Author Information
American Journal of Medical Quality 36(4S):p S1-S129, July/August 2021. | DOI: 10.1097/01.JMQ.0000755648.57078.39
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2020 Virtual Summit Snapshot

Total registered attendees 6206

Member registered attendees: 3856

Power Huddles: 84

Poster Presentations:61

Member overall meeting score (Continuing Education): 9.25/10.00

Vizient® members, suppliers, and others came together virtually at the 2020 Vizient Connections Education Summit to share and discuss innovative and creative solutions to meeting marketplace demands for cost reduction, better access to care, higher quality, and performance improvement. The first Vizient virtual summit drew record interest, with over 6200 attendees, more than doubling attendance at the 2019 in-person event. Attendees participated from across the country, including representatives from academic medical centers, large systems, community hospitals, children’s hospitals, nonacute and ambulatory care providers, and supplier organizations. They had the opportunity to hear from—and in many cases share ideas and interact with—presenters and panelists in live plenary sessions and Power Huddles, and to access a multitude of prerecorded Power Huddles, poster sessions, and member stories. While the live telecast was held September 15–17, 2020, the virtual format provided a unique opportunity for the summit to live on long after those dates, providing members and suppliers with the opportunity to view summit materials and earn continuing education credits at their convenience. Access to the opening plenary and other educational content continues via vizientinc.com.

The material represented the best of the best from Vizient members, who submitted a record-breaking 724 abstracts. This overwhelming response clearly demonstrates a heightened level of passion and dedication to sharing stories and helping others through the many challenges facing health care. A rigorous scoring and selection process, including careful review by multiple subject matter experts, helped identify the summit’s member-driven educational content.

Chosen before the pandemic, this year’s theme, “Future in Focus: One Clear Vision,” could not have been more appropriate for framing the sessions and discussions. As Byron Jobe, president and chief executive officer of Vizient, noted in his opening remarks, health care leaders and frontline workers are among the smartest, most innovative, and most collaborative people in the world. Amid this once-in-a-century crisis, they have come together in unprecedented ways to focus on the future.

Recognizing health care workers as true heroes

Jobe recognized and thanked member health systems and frontline workers for their extraordinary efforts, calling them “real heroes who have made enormous sacrifices and overcome monumental challenges to help others in need.” Like firemen running into the flames, these workers risk everything on behalf of others, ignoring the potential consequences to themselves and their loved ones. They do so because of their unrelenting dedication and commitment to caring for patients. The nation understands their sacrifice, as evidenced by countless examples of people honoring frontline workers, such as the well-publicized story of a man standing outside an emergency room holding up a sign thanking staff for saving his wife.

Sekou Andrews, CEO and founder of SekouWorld, Inc., put it best in his eloquent and moving final presentation. Talking about frontline health care workers, he noted: “The results are in and you test positive for a level of quiet courage that most of us could not bear…you are afflicted with a heroic, stubborn, almost delusional level of commitment to improving the world’s health, wellness, and vitality.”

Supporting these heroes

As frontline staff work heroically, the leaders of their organizations labor tirelessly to support them. For example, as part of the opening plenary panel, Janice Nevin, MD, MPH, president and CEO of ChristianaCare (a community-based system serving Delaware, Maryland, and New Jersey), highlighted the critical importance of “taking care of our people.” Early in the pandemic, ChristianaCare treated over 1000 COVID patients. The physical and mental toll on staff became evident, including notable increases in depression, post-traumatic stress disorder, and general burnout. Five years earlier, the health system had created its Center for WorkLife Wellbeing, a program dedicated to helping caregivers flourish and thrive. As Nevin noted, “when we care for ourselves, we are better able to care for others.” The center promotes a culture of well-being, including physical and psychological safety, connection and camaraderie, meaning and purpose, and choice and autonomy. During the pandemic, ChristianaCare quickly ramped up its services and capacity to meet the unique needs of staff during this pandemic. For example, leaders installed a sanctuary room for caregivers dealing with difficult challenges and directed peer supporters to seek out colleagues daily to provide support.

Health system leaders are not the only ones stepping up to support frontline heroes. Many vendors, suppliers, and consultants are doing so as well. Since the pandemic outbreak, Vizient began partnering with multiple suppliers to dramatically expand the supply of personal protective equipment, vital drugs, and other supplies. Vizient has sourced staff from around the country to augment the workforce in areas facing surges in infections, including staff for newly constructed field hospitals in pandemic hot spots. Vizient has made clinical and operational resources available to deal with the pandemic, including disseminating emerging best practices for patient care (eg, testing, visitation), supply chain management, and demand forecasting (eg, intensive care beds, ventilators). Vizient also accelerated its advocacy efforts in Washington, DC, making recommendations on how to avoid drug and supply shortages and promote telemedicine and digital health. Vizient, with the analytic expertise of its company Sg2®, is taking the lead in supporting members in their strategic recovery and stabilizing operational, clinical, and financial performance, with publications such as “Guidance for Resumption of Electively Scheduled Surgery and Procedures in the COVID-19 Era” and tools such as the Sg2 Surge Demand Calculator and the Sg2 Financial Recovery Calculator.

Focusing clearly on the future

Health care has changed forever because of the coronavirus. As devastating as the pandemic has been, health care will emerge stronger and better because of it. Technologies such as virtual health that might normally take years to implement have achieved broad scale in a matter of months, thanks in part to federal and state governments taking actions to remove barriers to telehealth services during the pandemic.

Virtual health, however, is just one example of what needs to be done to improve health and health care. As Nevin noted, the goal must be to provide “the right care, at the right time, in the right place, with the right people, so that people are healthier and care becomes affordable.” Care must address not just the biological and medical issues faced by patients, but also mental health issues and underlying social determinants of health. Addressing social determinants of health will not be possible without efforts to enhance health equity, as too many racial and ethnic minorities lack access not only to care, but also to adequate housing, food, education, and recreational opportunities. To succeed, health systems need to invest in robust virtual and physical care platforms that reach underserved populations, along with data platforms that generate actionable insights for improving care. The result, according to Nevin, will be revolutionary, not evolutionary, creating a whole new world for health care. Success will not be easy. As Jobe commented, changing the world requires great minds and passionate hearts working together.

The Secret Sauce of Achieving and Sustaining Top-Notch Performance

Julie Cerese, PhD, RN, MSN

Group Senior Vice President, Performance Management and National Networks, Vizient

David Levine, MD, FACEP

Group Senior Vice President, Advanced Analytics and Product Management, Vizient

Supporting members in achieving and sustaining strong performance for the past 15 years, Vizient has developed a robust understanding of what it takes to succeed, including the specific organizational characteristics required.

The University of Utah Health, for example, is an excellent case study in what an organization must do to produce sustainable top-notch performance in reducing preventable mortality. System leaders put in place a safety learning system around mortality that incorporates the following: a deep dive into every death to understand if and how it could have been prevented; a rapid response team tailored to the patient and unit that intervenes quickly with decompensating patients; an inpatient program that provides hospice care to patients without the need to change beds (ie, the bed is switched from inpatient to hospice care); and an intense focus on preventing hospital-acquired conditions, such as acute respiratory failure and catheter-related bloodstream infections. These activities make the University of Utah Health a high-reliability organization with a culture focused on performance and safety.

Characteristics of high-performing organizations

The University of Utah Health has much in common with other top performers. In fact, in its work, Vizient has identified 5 characteristics that generally exist within high-achieving organizations:

  • Shared sense of purpose: From the board and CEO to frontline workers and support staff, everyone understands and can articulate the goals of the organization, knows how the organization is performing on those goals, and understands their role in achieving them.
  • Cooperative leadership style and atmosphere: Leaders model desired behaviors and values and demonstrate the importance of cooperation and collaboration. Leaders are seen regularly on the floors, conducting rounds during which they talk to and engage with patients and staff to understand the issues and problems they face. Leaders also regularly celebrate successes (even small ones). They do this not only on the day shift, but also on the evening and overnight shifts to make sure these employees understand how important they are to the organization.
  • Results-driven, striving for top performance: The top performers set high aspirational goals, such as zero harm to both patients and employees. They seldom remain content with average performance.
  • Centralized and decentralized accountability structures: At the organizational level, the human resources department puts in place strict hiring standards to make sure that everyone fits into the culture. Similarly, the C-suite develops compensation systems that create incentives for employees at every level tied to the achievement of goals. Every employee has skin in the game. Leaders, middle managers, and frontline staff in every unit and department understand their roles and responsibilities and are held accountable for achieving top performance.
  • Culture of collaboration and respect, with deference to expertise: Top-performing organizations recognize that everyone can and should contribute. Leaders and managers know that employees at lower levels of the organization, particularly those on the front lines, often have the best ideas. These ideas get implemented, regardless of who comes up with them.1

Organizations that exhibit these characteristics have the structures and mechanisms in place to identify problems, find sustainable solutions, and evaluate and adjust as necessary. Collectively, these characteristics represent the secret sauce of achieving top-notch performance.

Sustaining performance over time

Vizient recently initiated a study focused on how to sustain performance over time. The research is assessing organizations that have achieved top performance for multiple years, with the goal of determining if there is something different or special about them.

While still preliminary, initial findings suggest that the key to sustained success seems to lie in large part with staff empowerment. Consistently providing a top-notch patient experience requires staff who understand what that experience looks like and who are empowered to deliver it. Empowering staff, in turn, depends on maintaining consistency in setting goals and reliability in evaluating performance. While specific measures may change, the structure and framework around setting quality, financial, and patient experience goals do not. This consistency gives frontline staff confidence in delivering on the mission and values, even as the nuances of specific metrics change.

Further insights into what it takes to sustain performance can be gleaned by evaluating whether the unprecedented challenges created by COVID-19 have knocked high performers off their game. This year’s Vizient Quality & Accountability (Q&A) study was divided into 2 parts: pre-COVID, with performance evaluated from July 1, 2019, to February 29, 2020, and post-COVID, with performance having thus far been evaluated from March 1 2020, to June 30, 2020 (Q&A Awards for 2020 are based only on the pre-COVID period). A preliminary comparison between the 2 periods shows that the top performers before the pandemic generally continued their success afterwards, while middle performers also tended to stay where they were in the rankings. This early finding suggests that organizations that have the secret sauce discussed earlier (ie, the right processes, systems, and culture) not only succeed over time, but also during the most turbulent and challenging of times. Like all organizations, these top performers have had to make quick changes and pivots in response to the pandemic, but their culture and structure has helped them remain on top.

This year’s Q&A results also highlight the importance of “systemness” in achieving and sustaining top performance. The results show that several health systems have had multiple hospitals achieve top performance, a strong indication that success stems from being part of a larger organization. More information can be found in the article on p. S6 by David Levine, MD, FACEP, and Steve Meurer, PhD, MBA, MHS, entitled “Centralized Data and Analytics Support Locally Driven Change, Systemwide Improvement”). Acting like a system appears to pay dividends during a pandemic as well, enabling flexibility such as the shifting of resources and staff in response to demands. For example, some systems have designated 1 hospital to handle COVID patients, thus minimizing disruptions to other hospitals in the organization. Going forward, pandemic-related challenges will likely accelerate the need to act as a single system rather than a collection of individual silos.

Looking ahead

Over the past year, health systems have responded rapidly to unprecedented challenges, faster than most leaders of those organizations ever thought possible. The industry deserves tremendous credit for turning on a dime; for example, those who once felt that it would take years to pivot to virtual care orchestrated the transition in a matter of weeks. Similar successes have been achieved in ramping up intensive care unit capacity and staffing, securing scarce personal protective equipment, and countless other areas. Armed with these experiences, leaders should not underestimate what they can achieve going forward. They should commit to leveraging this momentum and not going back to old, familiar ways of doing things. The hurdles may seem insurmountable, but recent experience makes it clear that they are not. Incredible things can happen when people put their minds to it.

1.Keroack MA, Youngberg BJ, Cerese JL, et al. Organizational factors associated with high performance in quality and safety in academic medical centers. Acad Med. 2007;82:1178–1186.

Real-Time Learning and Sharing During a Pandemic

Cindy Abel, RN, MSN, CEN

Vice President, Performance Improvement Collaboratives, Vizient

Joan Moss, , RN, MSN

Managing Principal, Sg2 Intelligence

The COVID-19 pandemic has unleashed enormous energy, innovation, and agility among Vizient members. Faced with unprecedented challenges, including surges in patients, shortages of staffing and supplies, and the overnight loss of major revenue sources, these organizations sprung to action to revolutionize care. These changes have the potential to be a turning point in the industry, marking the dawn of a new era of health care in this country. The challenge is to keep the momentum going and not drift back to outdated practices.

Real-time learning on the front lines of care

Vizient members quickly learned about and adapted to a new disease. Countless examples exist of changes, big and small, ranging from the rapid acceleration of virtual health to creative ways to address personal protective equipment (PPE) shortages and peaks and valleys in COVID-19 patients. A great example of this learning and adaptation came from the summit, where Cleveland Clinic chronicled its journey in dealing with an early surge of COVID-19 patients in a video featuring member stories. As patient numbers grew, Cleveland Clinic began isolating infected patients on specific units, both to reduce the risk of spread and to preserve scarce PPE. Even with cohorted patients, PPE shortages quickly became an issue. Innovative frontline staff quickly decided that one way to reduce PPE use was to use extra tubing for intravenous (IV) drips, thus allowing the equipment to be put in the hallway. As a result, staff did not have to enter the room to change the IV, and hence did not need to don and doff PPE. As innovative as this change proved to be, it created another problem—IV tubing now lay across the floor, creating infection control issues. Within days, Jane Hartman, MS, RN, NP-C, a critical care nurse, came up with a solution—use of a little plastic clip device to keep the tubing off the floor, either by mounting it to the ceiling or a wall (the device was adapted from one previously used to walk with pediatric patients with IV tubing). Cleveland Clinic is working to make various versions of the device, known as High-Line, available to other organizations.

The Cleveland Clinic story is one of countless examples of how frontline staff have risen to the occasion to address the unprecedented challenges created by the pandemic. Another comes from Nebraska Health, which faced an acute shortage of N95 masks. Staff figured out a way to sterilize them with ultraviolet light so they could be reused. This stopgap measure proved critical to the organization until mask shortages could be alleviated.

Other examples show the true cooperative spirit of the health care industry. Once it became clear that not every region of the country was going to be hit by the first wave of coronavirus at the same time, organizations began sharing scarce equipment. For example, Seattle area hospitals sent ventilators to New York City. Similarly, nurses and other staff in less-affected areas began traveling to hot spots to serve on a per-diem basis.

Real-time connections and knowledge transfer

Recognizing early on the severity of the pandemic, Vizient sprang into action to understand what was happening at the front lines, bring people together in real time, and disseminate information and resources to help members rise to the challenge.

Seeing articles about the coronavirus in January, Vizient leaders began reaching out through existing networks to better understand its implications. In mid-January, an Emory University epidemiologist was enlisted to speak about the virus to participants in the Vizient Hospital Innovation Improvement Network. Despite there being no cases in the United States, this epidemiologist made it clear that COVID-19 had the potential to be a major disruptive event. Vizient subsequently hosted a webinar for all members, featuring the same epidemiologist, along with supply chain experts. This event made clear the need for more regular networking. To that end, Vizient created an advisory council consisting of roughly a dozen clinical, supply chain, and pharmacy leaders, which in turn launched a weekly webinar series. Sessions featured integrated learning, helping members tackle issues from various perspectives. The first was held as the state of Washington experienced its initial surge of patients in March. It featured Christopher Kim, MD, MBA, SFHM, of the University of Washington, who, despite being in the midst of a surge, volunteered to describe how University of Washington set up an incident command center. He also shared clinical protocols and practices so that others did not have to recreate them. The weekly webinars drew almost 1000 individuals in the first few months. As the virus receded in the summer, the schedule switched to monthly, but by fall the surge in cases created interest in a return to weekly sessions. Hundreds still attend each event, while many others watch and listen asynchronously to recordings.

The power of these networking events can be seen in one relatively early webinar that featured 2 physicians discussing the development of care practices for COVID-19 patients. Thomas Spiegel, MD, from University of Chicago Medicine, emphasized the use of high-flow oxygen and the relatively new practice of turning COVID-19 patients onto their stomachs (a practice known as proning) to allow oxygen to get to the lungs more easily. This approach is now considered a best practice, along with ventilator use only when necessary. This well-attended webinar allowed many people to hear about and implement this practice early, potentially saving a significant number of lives, including patients and staff (ventilating patients can aerosolize the virus, putting staff at risk).

Beyond networking, Vizient has developed other resources to facilitate knowledge-sharing and the spread of innovations. For example, in September 2020, Vizient released “Covid-19 Pandemic Compendium: A Collection of Emerging Practices and Guide for Resiliency.” This publication describes a variety of promising practices on various issues, including managing supplies, clinical care, testing, surge capacity planning, visitation policies, and the impact of COVID-19 on staff. Vizient employs a team of people who continuously scour list servers, databases, and other resources to identify important information to be shared. Staff members also field daily calls from members looking for help with specific issues; early on, one member called to find a recipe for making hand sanitizer, which was in short supply at the time. Vizient quickly found a recipe on the Food and Drug Administration website.

Through the Communities platform and other activities, Vizient regularly facilitates real-time connections, allowing individuals to post questions and make requests of each other. These connections have accelerated the movement of people and supplies across the country, including ventilators and nurses moving from Seattle to New York City after virus outbreaks shifted from the west to the east coast. Through contracts, Vizient has helped members alleviate drug and supply shortages, and has put its own money behind sales guarantees to secure scarce PPE for members. The company continues to pay significant attention to staff-related issues, including how to help staff members maintain their mental health and resilience. Workbooks, speakers, and other resources have been dedicated to this important topic.

Publicly available resources

Critical pandemic-related information and resources are available for members free of charge at COVID-19 resources and updates | Vizient (vizientinc.com).

Continued support through the post-COVID era and beyond

The 2020 Vizient Connections Education Summit represented continued ongoing efforts to support members and the nation during and after the pandemic. These efforts will continue for as long as necessary. For example, Vizient created a dashboard that pairs the surge calculator with models that predict caseloads in specific states and regions, thus allowing organizations to better prepare for inevitable ebbs and flows in the number of cases. Weekly webinars continue to evolve, with recent shifts including a greater emphasis on clinical care and more attention to the care of children. During a once-in-a-lifetime crisis like COVID-19, one should never underestimate the willingness of people and organizations (even competitors) to come together and share successes and lessons learned.

Centralized Data and Analytics Support Locally Driven Change, Systemwide Improvement

David Levine, MD, FACEP

Group Senior Vice President, Advanced Analytics and Product Management, Vizient

Steve Meurer, PhD, MBA, MHS

Executive Principal, Data Science and Member Insights, Vizient

The 2020 Vizient Connections Education Summit highlighted an emerging interest related to a health system’s structure in analytics and improvement, giving credence to Avedis Donabedian’s structure-process-outcome model that points to the importance of having a sensible structure for achieving improved outcomes. For the past few decades, health systems have seen the number of metrics and associated dashboards grow exponentially, which has led to multiple siloes managing multiple data sources. Because this decentralized approach to analytics has not resulted in better overall outcomes, health systems are now considering a more harmonized, simplified structure. They are shifting responsibility for improvement away from siloed departments, units, and facilities to a more systemwide approach. The effort begins with creation of a single, centralized, streamlined leadership dashboard with fewer metrics; this dashboard links to facility-, service line-, and unit-specific dashboards that provide comparisons to appropriate peers and the ability to drill down to ever-greater levels of detail to facilitate the identification and addressing of opportunities for improvement. Without a robust ability to drill down, health systems run the risk of clinicians becoming uncomfortable with and disengaged from the process, including the measures, comparison groups, and risk-adjustment methodologies being used.

Vizient has assisted members with this transition through its Quality and Accountability (Q&A) Study and the transparent drill-down capabilities available in the Vizient Clinical Data Base. Created in 2005, the Q&A Study is used as a “north star” leadership dashboard to guide improvement, allowing members to generate insights from a balanced, timely, ready-made scorecard.

Multiple summit success stories

The summit featured stories of several organizations moving to a centralized improvement structure and using the Q&A top hospitals as their target. Perhaps the best example came from a Power Huddle from Intermountain Healthcare, a 23-hospital system headquartered in Salt Lake City, Utah, that has facilities ranging from a large quaternary medical center to small, rural hospitals. Intermountain had historically been organized as a federation of regions, an approach that worked well for many years. CEO Marc Harrison, MD, and his leadership team decided to revisit this structure in 2017, not because anything was explicitly broken, but rather because they wanted to make sure that it would serve the organization well in the future. After in-depth discussions with physicians, nurses, and other clinical leaders, the team decided to move to a more centralized and streamlined approach. Intermountain created an Office of Patient Experience, which brought together previously siloed functions, including safety, clinical risk management, advocacy, physician advisory services/coding, regulatory affairs, external reporting, antibiotic stewardship, and clinical data management. Having these functions under one roof, they believe, has ensured an aligned, common agenda.

In 2018, Intermountain became part of the Q&A Study. The Office of Patient Experience created an enterprisewide roll-up of the Q&A scorecard, which provides comparison cohorts for each of the 23 hospitals. This flexible system meets the needs of different Intermountain audiences. For example, the system board can view aggregate systemwide measures, while clinical leaders and frontline workers at individual hospitals and units receive monthly drill downs at a very granular level to gauge performance on specific measures and identify opportunities for improvement. The data are kept current through the release of quarterly updates. This approach has clearly worked. Intermountain has seen significant improvements, moving from the 66th to 82nd percentile on overall Q&A Study rankings, from the 37th to 50th percentile in the mortality domain, from the 56th to 76th percentile in patient centeredness, and from the 66th to 80th percentile in safety (driven primarily by a reduction in hospital-acquired infections).

Intermountain is not the only summit participant to pursue this centralization strategy. BJC HealthCare in St. Louis, Missouri, told a similar story. BJC began its journey in 2003 with a 10-metric scorecard. By 2018, that same scorecard had grown to 117 measures, with different parts of the system using completely different measures and methodologies. BJC leaders similarly decided to move to a standardized, streamlined scorecard that focuses on only a few goals, and chose the Q&A Study as their benchmarking “north star.” Armed with this new data infrastructure and reporting platform, BJC has seen meaningful improvements in mortality, clinical documentation, safety, and patient experience. Representatives from Northwestern Memorial Hospital in Chicago, Illinois, and from Memorial Hermann in Houston, Texas, shared similar stories during summit Power Huddles. The Memorial Hermann story is particularly interesting—the organization created a drill-down tool that eliminates the need to comb through multiple reports or tables to find opportunities.

Beyond anecdotal successes

Beyond anecdotes, systematic evidence is beginning to emerge that this centralized approach works better than a decentralized approach. Since 2005, the Q&A Study has identified top-performing hospitals. Originally just for academic medical centers, the Q&A Study has expanded in the last 5 years to 4 categories: comprehensive academic medical centers; large, specialized complex care medical centers; complex care medical centers; and community hospitals. In the past few years, organizations that act more like systems, with centralized performance improvement infrastructure and dashboards, tend to have multiple winning hospitals across categories. In fact, in the most recent year, 7 organizations had top-performing hospitals in 3 of the 4 categories, while 1 (Mayo Clinic) had top performers in all 4. Overall, just 5 health systems made up 45% of all top-performing hospitals (Mayo, Methodist Houston, Memorial Hermann, Intermountain, and University of Pennsylvania), and all 5 employed a centralized approach driven from the highest levels of the organization. These organizations used a systemwide approach to produce more uniform performance across hospitals, while their peers that operate in a siloed manner tended to see more uneven performance.

More than data and analytics

The centralized data and analytics functions represent a necessary but not sufficient part of the performance improvement effort. Success requires change management leadership and support at both the system and local levels. From a system perspective, leaders must create the accountability to improve through appropriate incentives and provide the necessary education to increase the organization’s capabilities to drive improvement. Service line leaders, unit managers, and frontline workers must understand the improvement goals and have a stake in achieving them. This approach can perhaps best be illustrated in the story of a recent visit by Vizient to a member organization. While riding an elevator to a meeting, a Vizient team member met a patient transport person, who quickly reminded the Vizient team member to wash his hands to reduce the risk of spreading infection. The transport person knew that it was an organizationwide and unit-specific goal to reduce such infections, understood the importance of handwashing in reaching that goal, and had a stake in achieving success.

Local change

While the system provides the infrastructure and accountability for improvement, actual change and innovation still occurs at the local level. Success requires having a well-respected local leader driving change, and staff members who truly believe that improvement is part of their role. For example, a dashboard might identify patient falls as a problem area on a unit. But only local leaders and staff on that unit can figure out how to reduce falls. At 1 hospital, nurses put signs outside the doors of high-risk patients so that everyone paid special attention to them. The same unit put up a large banner documenting the number of days without a fall, which created a sense of ownership of the issue.

When local successes occur, the system has a role in spreading and sustaining them. The most powerful approach is to create opportunities for those who spearhead change to tell their stories to peers in other units and facilities. This strategy honors and celebrates those driving change (making them want to do more) and helps others emulate the approach. Top-performing organizations celebrate successes early and often, but then continue to strive for improvement. Senior executives go to the units and congratulate those making the changes. In many cases, it may be wise to look for early, easier wins to create momentum rather than starting with the most difficult problems or most change-resistant units or departments.

Smaller organizations

Leaders of small organizations may feel they lack the resources (particularly staff expertise) required to provide centralized support and infrastructure. The reality, however, is that this approach conserves resources by leveraging those who have the requisite expertise. Rather than requiring 2 or 3 data and improvement experts in every hospital, the systemwide approach leverages 4 or 5 across the entire organization.

Keys to performance improvement success

  • Engage clinician leaders in choosing metrics and improvement goals early in the process.
  • Be transparent with the methodology, including risk-adjustment models and composition of the comparator group.
  • Provide monthly dashboards.
  • Offer drill-down and root cause analysis capabilities to identify opportunities for improvement.
  • Focus on the system holistically rather than singling out a doctor or unit that may be struggling.
  • Make sure that everyone understands the goals and has an incentive to improve.

Member awards 2020: taking a different approach

Vizient is assessing member performance a little differently in 2020 to allow for the varying effects of the pandemic on members across the country. The goal is to enable members to see progress made on performance improvement initiatives before the pandemic, and to understand the pandemic’s impact on performance and quality for the non-COVID-19 patient population during the pandemic’s early months.

To that end, Vizient is evaluating data for 2 separate periods: July 2019 through February 2020 (pre-COVID), and March 2020 through June 2020 (early pandemic). The overall and domain performance rankings for both clinical and supply chain categories will be based on the 8 months of Vizient Clinical Data Base data from the pre-COVID period. Data for the early pandemic period will be evaluated for informational purposes only. In addition, please note the following:

  • There was no in-person or virtual awards ceremony at the 2020 Vizient Connections Education Summit.
  • Performance rankings will be provided for July 2019–February 2020 (pre-COVID). Vizient will not externally communicate about the rankings and requests that top-ranked members refrain from external self-promotion as well.
  • Vizient expects to return to the regular program for member awards in 2021.

Understanding Market Opportunities in a Post-COVID Era

Joan Moss, , RN, MSN

Managing Principal, Sg2 Intelligence

Madeleine McDowell, MD, FAAP

Principal and Medical Director, Sg2 Intelligence

The COVID-19 pandemic has given rise to or accelerated a variety of issues that will affect utilization in both the short and long term, with some services and care sites experiencing significant increases while others see major declines. Many of these issues are already affecting the market; a few may not manifest for several years but will have a lasting impact.

Key issues affecting utilization

Sg2, a Vizient company, has identified 6 such issues, as detailed in the sections below.

Issue 1: erosion of commercial coverage

COVID-19 has led to millions of people with commercial insurance losing their jobs, leaving many uninsured or with no option other than public programs such as Medicaid. These dynamics are accelerating trends already in place, such as more people aging into Medicare. Declines in insurance will lead to less use of insurance- and price-sensitive elective services and could exacerbate chronic conditions as people delay or avoid care.

Issue 2: weakened consumer confidence

Many health systems were forced to shut down elective surgeries and procedures temporarily to reserve capacity for COVID-19 cases. Even after organizations reactivated their electives, lingering concerns about infection risks left some consumers reluctant to seek in-person care. While many Vizient members are seeing volumes approach 90% of pre-pandemic levels, some leaders question if they will ever get back to 100%. As specific markets experience additional waves of cases, consumer confidence may wane again, leading to additional declines in utilization, perhaps through most of 2021.

Issue 3: accelerated site-of-care shifts

Shifts from in-person care to other settings—virtual care in particular—have accelerated. The opening panel of the summit featured leaders from ChristianaCare (Wilmington, Delaware) and Ochsner Health System (New Orleans, Louisiana) discussing the unprecedented increase in virtual visits that occurred over a few months. ChristianaCare, for example, expanded from 1 to 170 virtual practices. Power Huddles and poster presentations highlighted similar trends at other Vizient member locations, many of which reported that 50% or more of all visits were virtual during the early days of the pandemic. As cases waned, the shift to virtual health has moderated, but there is no doubt that it is here to stay and will grow markedly from pre-pandemic levels. The increase will depend in part on decisions by governments and insurers related to regulations and payments. More importantly, perhaps, long-term growth will depend on the degree to which health systems use technologies and data systems to figure out which services can be delivered remotely in a high-quality, patient-centered way, and which patients benefit most from remote care. Successful organizations will be those that abandon legacy systems (designed to promote in-person care) and move instead to a hybrid model in which staff work with patients to educate them on their options and allow them to decide what is best for their circumstances.

Issue 4: permanent adoption of COVID-developed innovations

Some innovations and efficiencies developed in response to COVID-19 will become permanent as they manifest into long-term changes in clinical guidelines that will accelerate utilization declines in some services. For example, the pandemic jump-started adoption of hypofractionation for radiation oncology. Because this approach enables fewer sessions at a higher intensity, recent uptake of this protocol to limit potential exposure for cancer patients curtailed radiation oncology by 13% between March 2020 and September 2020, compared with the same period in 2019. A similar pattern was seen in cardiovascular diagnostic testing. COVID-19 has given a boost to appropriate use guidelines for electrocardiograms, echocardiograms, stress tests, and diagnostic catheterizations. Use of these 4 tests declined 27% from 2019 levels, according to Strata Decision Technology’s National Patient and Procedure Tracker. Sg2 projects that this level of demand destruction will continue over the long term.

Issue 5: increases in long-term disease burden

Millions of COVID-19 survivors face increased risk of cardiovascular, neurological, kidney, respiratory, and other COVID-related diseases and complications. In addition, decisions made during the pandemic to delay or avoid care, such as cancer screenings, will likely translate into increased disease burden in the future, including patients presenting with later-stage disease.

Issue 6: further exposure of health inequities related to social determinants of health

The pandemic has brought to light the terrible inequities that exist in access not only to health care services, but also to other social determinants of health, including housing, food, and education. Addressing these inequities will become a major focus going forward, and those efforts will affect utilization of health care and other services. For its part, Sg2 (a membership-based strategic intelligence and analytic firm that is part of Vizient) is aggressively engaging with subject matter experts and members on how to better serve vulnerable populations by addressing social determinants of health and reducing inequities. Sg2 recently released a publication entitled, “Social Determinants of Health: Stitching Together Solutions,” which examines the role of health systems in tackling health inequities. As part of this work, Sg2 did a pro bono consulting engagement with West Side United, a collaborative of 6 health systems and numerous community organizations working to improve health equity and economic vitality in Chicago’s West Side, with a focus on maternal/infant health. This work highlighted the critical importance of listening to local stakeholders talk about their community’s inherent strengths and challenges. The issue of health equity surfaced repeatedly at the summit as well. One example came from Brigham Health, which discussed how organizational leaders decided to treat health inequity as a patient safety emergency and embed efforts to promote equity throughout the organization.

Utilization forecasts for the coming decade

Sg2’s “2020 Impact of Change® Forecast” predicts significant short-term hits to inpatient and outpatient utilization and a long-term transformation in where care is delivered. COVID-19 has led to dramatic short-term declines in inpatient discharges (19%) and outpatient visits (25%). By 2029, the inpatient market will still not have fully recovered, with discharges being 1% below 2019 levels. On the outpatient side, volumes will recover by 2029 to levels 10% above those of a decade earlier, but that increase still lags behind population growth (13%) over the same period. Similarly, emergency department volumes will not fully recover from their initial 23% drop by 2029, when visits will still be 4% below 2019 levels.

There are areas, however, that will see robust growth. For example, home visits by nurses are forecast to surge 17% over the next decade, outpacing growth in any other service. Home-based care will grow across various services and acuity levels, including home infusions, hospital at home, and ambulatory diagnostics, as technologies (eg, monitoring devices, wearables) allow high-quality services to be offered in the home. The rise of virtual visits sparked by the pandemic will also shift long-term practice patterns. By 2029, Sg2 projects that virtual visits will represent a third of total evaluation and management visits.

Leveraging telehealth uptake for long-term digital strategy

COVID-19 forced many organizations to launch or expand virtual health offerings on the fly. Long-term sustainability, however, requires leaders to invest strategically in a robust digital health program, of which telehealth is only 1 element. Digital health entails use of advanced information and communication capabilities to enable more cost-effective and consumer-friendly care selection, delivery, and monitoring.

The vast menu of solutions that comprise this space can be confounding. Success requires understanding how specific tools map to various stages of the patient journey and adopting those that best align with a provider system’s strategic priorities (see diagram; examples are illustrative and not intended as a comprehensive list).


Abbreviation: RPM, remote patient monitoring.

Source: Sg2, a Vizient company.

Some elements of this tool kit are merely table stakes in today’s environment, while others are true differentiators. In both categories, technology alone is insufficient. Organizations must forge programmatic solutions from the capabilities adopted. Effective care redesign and full integration into the process of care delivery will be key to execution.

Additional resources

Sg2 has developed a variety of resources and projections related to specific specialty services, covering the short- and long-term utilization impact of COVID-19 and the implications for organizations offering these services. For more information, access Sg2’s industry-leading scenario planning tool for COVID-19 surge demand.

The Power of Networking During a Pandemic

Tom Spindler, MHA

Group Senior Vice President, Executive Member Connections, Vizient

Robert Dean, DO, MBA

Senior Vice President, Performance Management, Vizient

The 2020 Vizient Connections Education Summit featured multiple opportunities for formal and informal networking. During the typical in-person summit, the first 2 days feature breakout sessions, with boards for C-suite executives and networks for clinical and other leaders to meet in various configurations—sometimes with each other and other times mixing and matching titles to hear different perspectives. With 2020’s virtual format, summit opportunities for networking looked a little different. Given the many time-sensitive challenges facing hospitals and health systems due to COVID-19, the benefits of these networking opportunities have never been greater.

Bringing clinical leaders together

The pandemic led to a rethinking of clinical networking opportunities for 2020. The goal was to provide more opportunities and reach more people. To that end, Vizient hosted a 2-day pre-summit networking event on September 1–2 for clinical leaders, including clinician CEOs, chief nursing officers (CNOs), chief quality officers, chief medical officers, and chief human resource officers. The first day featured remarks by Zeev Neuwirth, MD, chief clinical executive for care transformation and strategic services at Atrium Health in Charlotte, North Carolina. Neuwirth facilitated a discussion on strategic changes related to the future of health care, with a focus on the implications of COVID-19. Topics included the future of virtual, inpatient, and ambulatory care; the impact of the pandemic on operational flows (eg, personal protective equipment [PPE], social distancing, ventilation systems); and the need for better partnerships with—and greater investment in—public health. The day also featured various breakout sessions on the impact of the pandemic, particularly with respect to the workforce. Among others, topics included resilience, adaptability, and use of interim staff. Day 2 featured a moderated discussion with 3 clinician CEOs who discussed how COVID-19 has affected day-to-day operations and the strategic planning and budgeting processes. The session touched on various strategic issues, including whether to proceed with inpatient expansion plans, how to build a bigger and better ambulatory footprint, and how to pivot to virtual care without negatively affecting quality and the patient experience.

Another session focused on new opportunities for advanced practice providers due to changes in regulations and payment rules, including the ability to enhance access to care and improve teamwork. While many organizations are seizing these opportunities, questions remain as to whether the new regulations and reimbursement practices will stay in place. Additional sessions surfaced other important topics, such as the increase in new payment models and the associated challenges of remaining too reliant on fee-for-service medicine. Many participants noted the advantages of the more stable revenue flows that accompany risk- and value-based contracts in a time when elective surgeries, procedures, and visits are being canceled or postponed.

Discussions from the pre-summit event fit squarely into major themes that surfaced at the full summit. The opening plenary session touched on many of the same issues, as did a variety of networking events held during the week. These included a CNO session focused on workforce resilience strategies and a gathering of chief quality officers who discussed the need for a systemwide approach to quality that brings together data and improvement infrastructure across the care continuum. The summit also featured a vulnerable patient populations network that focused on COVID-19’s impact on health equity. The pandemic has again brought to light the tremendous disparities in health outcomes across racial and ethnic groups and the critical importance of addressing social determinants of health. A related networking session looked at new business models for addressing social determinants of health, while a post-summit session brought together chief human resource officers to assess their role in promoting equity and justice for employees, an issue that has become more important due to the pandemic. For example, some employees may feel that their organizations have not been equitable in terms of mitigating the risk of working during the pandemic and/or in addressing the financial burden created by layoffs and furloughs. Several other sessions dovetailed with this discussion by focusing on how best to protect and support the workforce. These sessions highlighted the need for leaders to communicate with staff more regularly, via both virtual town halls and regular emails and intranet postings. This focus on communication will last well beyond the pandemic, as many leaders discussed the benefits of enhancing employee engagement and helping staff access vital support resources. To further assist members in this area, Vizient has published several papers—one on crisis resilience and a second on team culture.

Finally, the summit’s clinical networking opportunities featured a variety of service line-specific networks. For example, the cardiovascular network came together to discuss issues related to COVID-19, particularly tackling the backlog of elective surgical cases. To support this and other service line networks, Vizient published a paper on clinical considerations related to resuming elective surgery, with a focus on patient and staff safety and the potential impact on productivity.

Bringing C-suite leaders together

The summit featured many opportunities for C-suite leaders to discuss the challenges and opportunities created by COVID-19. Separate boards exist for leaders from various geographic regions and for different types of organizations, such as academic medical centers and community-based hospitals. These boards met to discuss a wide array of topics, including workforce strategy and management, physician coverage and coordination (with representation from medical staff leaders), delivery of services and impact on facility use, managing community health, clinical staffing challenges (particularly as they relate to the shift from in-person to virtual care), planning for facility expansion and modernization, shutting down and restarting elective surgeries and procedures, and the impact of such shutdowns and of federal emergency funding on organization finances.

Networking outside the summit

Given the fast-moving events of 2020, the need to bring people together to share ideas has never been greater. Vizient hosts network and board activities throughout the year, including weekly calls with supply chain, pharmacy, clinical, and hospital leaders. For example, 1300 hospital executives participate in a call every Wednesday. Other networking activities consist of list servers and various tools available 24/7 to let people post, answer questions, and otherwise connect. For example, a CNO list server allows nurse leaders to connect on pressing issues such as how to support burnt-out staff.

Not surprisingly, COVID-19 has raised unique issues that have created the need for new networking activities. For example, a pop-up network formed to focus on how organizations can restart elective surgeries. Network participants have access to a calculator and other resources to support a safe restart.

Knowing it works

Most people love to network, particularly when it involves the opportunity to travel to nice places like Las Vegas for the annual summit. But 2020 proved that networking is about much more than socializing with others. Stripped of the niceties of an in-person conference, people are showing up in record numbers to virtual network activities. Despite a pandemic that has every health care executive being tugged in a million directions, 90% of member CEOs participate in Vizient weekly 90-minute networking sessions. CEOs who get hundreds of emails a week requesting their time literally never miss this meeting. Feedback makes it clear why this is the case: the CEOs trust and want to hear from each other, and they get immediate access to ideas that can literally save lives. For example, 1 CEO learned about the potential life-saving benefits of not automatically intubating hospitalized patients with severe COVID-19, instead using high-flow oxygen combined with proning—that is, turning the patient on their stomach (more details about this webinar can be found in Real-Time Learning and Sharing During a Pandemic, by Cindy Abel, RN, MSN, CEN, and Joan Moss, RN, MSN). Similarly, network participants report hearing about and quickly implementing other powerful ideas, such as having coaches stand outside the intensive care unit to help staff take PPE on and off without contaminating themselves, and placing intravenous lines outside a patient’s room so that staff can change tubes without going into the patient’s room (and hence avoid changing scarce PPE).

Don Berwick, MD, former head of the Centers for Medicare & Medicaid Services and the Institute for Healthcare Improvement, often encourages health care organizations to “steal shamelessly” when it comes to best practices. The various networking activities at Vizient support members in doing exactly that.

Identifying and Addressing Vulnerabilities to Disruption

Tom Robertson

Executive Director, Vizient Research Institute

Vizient Research Institute’s 2019 study, “A New Look at an Old Business Model: Viewing Disruption Through a Different Lens,” takes an unconventional approach to disruption. Rather than focusing on external forces that might threaten business as usual, it takes an inside-out approach by identifying inherent vulnerabilities—that is, aspects of health care most at risk of being disrupted.

As shown in the chart below, the typical provider organization—be it a health system, academic medical center, or independent hospital—serves 3 categories of patients: a relatively small cohort that generates significant profits, a similarly sized group that incurs large losses, and the rest (representing the vast majority of patients) on which the organization breaks even.


The first group tends to be commercially insured individuals who require one or more hospitalizations each year. Those on which the organization loses money also tend to be sick, but they typically have no insurance or are covered by Medicaid or Medicare. The large group of breakeven patients are generally healthier and rely on the organization’s huge ambulatory footprint. Each of these categories is vulnerable to a distinct type of disruption.

The ambulatory middle: innovative disruption

Health systems commonly handle over 1 million ambulatory encounters each year. Early in 2019, Vizient assessed these visits to see if anything made them vulnerable to disruption. Researchers identified a large category (representing roughly one-third of ambulatory encounters) of “reconnaissance” visits—that is, visits with existing patients that focus on information gathering rather than rendering treatment or therapy. The study excluded first-time encounters and visits just before or after a major procedure. To be considered reconnaissance, the visit must fall within the scope of practice of an advanced practice provider such as a nurse practitioner or physician assistant. Reconnaissance visits are prone to disruption because emerging technologies increasingly allow them to be conducted without the patient and provider being in the same room. The prevalence of reconnaissance visits varies by specialty, accounting for most psychiatric visits, roughly half of cardiology visits, and 10% to 20% of neurosurgery and orthopedic visits.

Health systems have built an enormous infrastructure to handle in-person ambulatory care. Between 2005 and 2016, the number of outpatient centers increased by roughly 50% in the United States, from approximately 27 000 to over 40 000. Some of that expansion was strategic geographically, while other components involved enlarging existing facilities. Utilization of these facilities varies dramatically. An examination of typical use patterns uncovered an interesting phenomenon. Clinic space was heavily used early in the week, but volumes dropped significantly later in the week. Evening and weekend utilization was negligible.

This economic model becomes difficult to maintain in a business with high fixed costs like ambulatory care. Just as an airline could not afford to ground expensive planes from Friday to Sunday, ambulatory centers will find it increasingly difficult to afford such sporadic utilization patterns. At a minimum, more efficient and evenly distributed use of existing facilities should precede expansion plans.

As noted, Vizient identified this vulnerability in 2019, before the pandemic struck. By spring 2020, the ambulatory disruption became a reality, as roughly 70% to 80% of in-person visits disappeared or switched to virtual care, almost overnight. Today, roughly a quarter of visits are still virtual, suggesting the disruption may be here to stay.

The financial core: competitive disruption

The financial core—the cohort of highly profitable patients—is vulnerable to disruption from competitors. Vizient analysis of this segment identified 3 subgroups. The first, representing 40% of core patients and about a quarter of core revenues, consists of 1-time events that are typically unpredictable and unpreventable, such as a heart attack, appendicitis, or trauma. Capturing these patients means being nearby when the unexpected happens; it requires a broad geographic footprint. The second cohort—only 10% to 15% of core patients but over a quarter of core revenues—consists of interhospital transfers to tertiary centers. Attracting these patients requires differentiation—that is, unique or superior capabilities. By far the largest subgroup, representing roughly half of patients and revenues within the financial core, consists of patients with complex and/or chronic health problems that manifest in longitudinal episodes of care. Most provider organizations lack an adhesion strategy to win and retain these patients’ loyalty. In fact, many providers inadvertently make it difficult for patients to access and receive services. Vizient conducted a national survey of these patients and their family members, along with 6 focus groups in 3 cities. Participants articulated frustration with their current care. They want greater communication about the trajectory of their illness—that is, what to expect next. They want physicians to work more closely together—particularly specialists. They want a more holistic approach to their medical needs, including not having to repeat the same information to different people. Finally, more than anything else, they are crying out for help navigating the complicated health care delivery system. At a time when patients are sick and their families are scared, health systems can improve the lives of both by assisting with care navigation.

The typical tertiary center cares for roughly 4000 commercially insured patients with complex and/or chronic health needs that collectively generate about $160 million in contribution margin. A third of these patients get only half their care from that tertiary medical center, with the rest occurring somewhere else. If the medical center provided a larger majority of care for this population, operating margins would rise 15% to 20%.

The financial trough: purposeful disruption

The subset of patients incurring financial losses presents the opportunity for a completely different form of disruption—purposeful. Health systems are, in effect, at risk for overutilization by this population. An innovative approach to care management involves treating this group as if the system operated under a prospective payment contract and asking, “what would we do differently if we were at risk financially?”

One prime opportunity lies with patients transferred from other hospitals, which account for about a fifth of losses in this population. Accepting transfers based on clinical needs with no consideration for payment source is a core component of a tertiary medical center’s social mission. At the same time, vigilance with respect to economically driven transfer requests (those influenced by the patient’s ability to pay) is necessary to protect the tertiary center from shouldering a disproportionate share of the financial burden.

Within any clinical category, if the rate of incoming transfers is approximately the same for commercially insured patients as it is for Medicaid or uninsured patients, there is no evidence of “economic” transfers. If, however, Medicaid and uninsured patients are transferred at a higher rate than clinically similar commercially insured patients, the situation merits attention. To help monitor a health system’s economic balance, Vizient created the transfer index—the ratio of Medicaid and uninsured transfer rates to commercially insured transfer rates. When considered for any clinical category, a transfer index significantly greater than 1.0 should serve as a red flag; while not evidence per se of a problem, the measure should trigger attention. Vizient evaluated 112 tertiary centers nationwide and found more than half with transfer indices above 1.0, with many having ratios between 1.2 and 1.6.

If a tertiary medical center suspects that it is the recipient of “economic transfers,” the best approach is to engage experienced specialists from its medical staff in physician-to-physician conversations with the referring facility to determine the specific clinical rationale for the requested transfer. Proposed transfers that are economically motivated are more likely to surface during such conversations.

Patients admitted to the hospital multiple times a year who have government insurance or are uninsured present significant opportunities for purposeful disruption. These complex, chronically ill patients represent 15% of this category but account for roughly a third of losses, with an average $44 000 loss per patient. They often present in the emergency department one or more times before being admitted, suggesting at least some opportunity to intervene before hospitalization becomes necessary. Vizient analyses found that the best time to identify and start managing these patients is the second emergency department visit. Intervening at this point identifies roughly 3 quarters of all multiple-admit patients. Flagging at the first visit means managing twice as many patients, while waiting until the third visit misses half the targeted patient cohort. Once identified, these high-risk patients can be enrolled in a chronic disease medical home staffed by multidisciplinary professionals who specialize in complex episodes. Many of these patients struggle with issues that go beyond physical health, including poverty, hunger, joblessness, homelessness, language barriers, and lack of education. A large number have mental health and/or substance abuse problems.

Health systems have traditionally struggled with this population cohort because they focused on getting patients to use the system rather than changing the system to adapt to patients. An example of that perspective is the use of transportation vouchers to increase patient compliance with scheduled appointments. Reasoning that patients with limited transportation often miss appointments, health systems took an intuitively rational step and provided vouchers, sometimes even partnering with resources like Lyft or Uber. Such efforts are not without merit, but they miss a critical problem: complex patients commonly decompensate on timetables that do not match scheduled appointments. A chronically ill patient whose condition worsens today will not benefit from a free ride to an appointment scheduled in 2 weeks. Working with member institutions that have extensive experience with this population, Vizient researchers discovered that the more innovative providers had largely abandoned appointments for high-risk patients, instead seeing them immediately when circumstances dictated. Solving the problems facing complex patients with complicating social determinants demands creativity and a willingness to change standard processes rather than expecting patients to follow them.

Another barrier to effective care management for the targeted population is strict adherence to traditional payment methods. Health systems sometimes stop short of taking steps that might benefit patients because there are no funding sources to pay for them. At times, those measures may have avoided expensive utilization of health system resources for which payments fall short of costs. There are times when uncompensated investments in patients pay dividends not in revenues, but in avoided losses.

Short-term steps to consider

The chart below lays out concrete actions that provider organizations might consider within the 3 categories of disruption.



The traditional business model, involving huge subsidies arising from a shrinking minority of patients, has become alarmingly polarized. In 2008, the typical tertiary medical center made $157 million in operating margin on its core patients and lost $112 million on its vulnerable population. Today those figures are $336 million and $190 million, respectively. In other words, the organization has become even more financially dependent on the core and more susceptible to losses on the vulnerable. As an aging population shifts from highly profitable commercial insurance to unprofitable Medicare payment rates, and with downward pressure on private sector prices an eventual probability, health systems would be wise to reduce their economic dependence on a dwindling financial core.

Adhesion strategies and navigation to strengthen the loyalty of profitable patients are essential to avoid competitive disruption. Efficiency gains—measured in terms of output per dollar of labor costs—will be necessary to keep the enormous ambulatory enterprise sustainable as innovative disruption changes the traditional calculus. Purposeful disruption in episodes of care among the most vulnerable populations—including changes that will improve lives while reducing losses—is the third part of the strategy. By shifting the view of disruption from outside-in to inside-out, and by moving from a reactive to a proactive stance with respect to possible disruptors, health systems will be better positioned to face the challenges that lay ahead.

Power Huddles

Ambulatory Safety Nets: Creating High-Reliability Systems to Reduce Missed and Delayed Diagnoses

Sonali Desai, MD, MPH

Alexandra Levie, MPH

Brigham and Women’s Hospital

Background. Missed and delayed diagnoses are a common cause of ambulatory malpractice claims. Diagnostic error is estimated to occur in 5% of ambulatory care, with key factors being lack of appropriate test result follow-up, lack of care coordination, and lack of optimal communication between providers and patients around follow-up care plans.1 We have developed a high-reliability Ambulatory Safety Net program to identify patients at risk for cancer and ensure patients receive the appropriate follow-up care. Our program builds upon Kaiser Permanente’s SureNet program, which has successfully used electronic surveillance systems to address care gaps in the ambulatory setting for many years. Our efforts began with grant funding from our malpractice risk insurer, with an aim of proactively addressing diagnostic error through a focus on test result management. However, within 2 years, the return on investment of ambulatory safety nets became more clear: if you develop a system to ensure appropriate follow-up care is completed, this will generate revenue through increased office visits, imaging, referrals to specialists, and hospitalizations for procedures. Now ambulatory safety nets have become a part of our ongoing quality and safety efforts, with plans to expand our scope and scale to our larger health care network over time. The value of the Ambulatory Safety Net program in 2020 was driven by several factors in health care: increasing provider burnout, rising volume of test results for busy clinicians to review, decreasing usability of complex electronic health record systems, growing efforts to promote patient satisfaction, and the burgeoning of patient health data available online. By designing an innovative program that reduces provider burnout while increasing the reliability that patients will receive appropriate follow-up care, we created timely solutions for real-world problems facing clinicians and patients.

Intervention Detail. The Ambulatory Safety Net program is comprised of several key components: (1) electronic patient registries and artificial intelligence tools for identifying at-risk patients; (2) patient navigators for patient outreach and tracking; (3) multidisciplinary work groups and partnerships with existing ambulatory infrastructures within primary care and specialty departments; and (4) reliable processes and thoughtful workflow redesign for patient outreach and tracking. Our first step with each safety net is to create an electronic patient registry, either leveraging our electronic health record or a custom database. Developing a single registry can take up to 6 months, due to the need for chart review to validate the accuracy of the aggregate data and iterative programming changes to the information technology code to ensure we are only including the correct patients. One of our reports relied on artificial intelligence tools to assist in tracking abnormal radiology findings. Integrating the information derived from automated artificial intelligence tools with chart reviews required input from radiology, quality and safety, and primary care. Lastly, the accuracy of coded data fields that populate electronic reports ultimately is created from human decisions by frontline clinicians and specialists—thus behavior change of how and where clinicians document and communicate in the electronic health record was an essential aspect of each safety net. Our patient navigators serve as project coordinators, conduct patient outreach, and track patient outcomes. The patient navigator role evolved as the Ambulatory Safety Net program grew and matured to meet the needs of the dynamic program. The patient navigator worked in tight collaboration with all facets of the multistakeholder teams within each department, as well as directly with patients and frontline clinicians, to create novel workflows and care redesign to make the process as seamless as possible for clinicians and patients.

Outcomes and Impact. At present, we have 2 safety net programs in maintenance, 1 in pilot phase, and 2 in development. Our team includes a medical director, a project manager, and a project coordinator. Our metrics of success include evaluating the total number of at-risk patients as the denominator with the number of patients for whom we have a documented follow-up care plan (numerator). Our ambulatory safety nets consist of colon cancer and lung cancer programs that have been in a maintenance phase over the past 12 to 18 months. The colon cancer safety net has identified 840 patients needing follow-up over a 2-year period, with 288 colonoscopies scheduled and 261 completed. Our lung cancer safety net has detected 120 incidental lung nodules requiring annual follow-up in primary care, with 94% follow-up completed. Our prostate cancer safety net identifies approximately 112 abnormal prostate-specific antigen tests per month, with 31% needing additional follow-up, and our cervical cancer safety net identifies approximately 68 high-risk abnormal pap smears per month, with 20% needing additional follow-up. This work has been shared at the Institute for Healthcare Improvement Forum and led to the receipt of the Donabedian Award from the American Public Health Association.

1.Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf. 2014;23:727–731.

Equity Is a Patient Safety Emergency

Andrew S. Resnick, MD, MBA

Brigham and Women’s Hospital

Karthik Sivashanker, MD, MPH, CPPS

Brigham and Women’s Hospital

Tam Duong, MS

Institute for Healthcare Improvement

Brigham and Women’s Hospital

Background. To address health equity, we need new strategies and ways of thinking that (1) surface the omnipresent and harmful effects of structural racism and other “isms” on the health and well-being of patients, families, and health care workers; (2) highlight the critical role of health care organizations in either addressing or perpetuating inequities; (3) systematically incorporate equity into the operational DNA of health care delivery and innovation; and (4) encourage responsibility and accountability from health care organizations for inequities experienced by (or inflicted on) patients, families, and staff. We describe a novel approach that leverages safety to advance equity. This makes sense because there is a natural alignment between the framework we use to improve safety and the approach we can take to increase equity. Safety and equity are both fundamental dimensions of health care quality. Both frameworks encourage redesigning systems to make them more reliable and resilient. Both balance this “systems” focus with individual accountability. Both recognize the role of cognitive, often subconscious, biases in contributing to unintentional harm. Both highlight the importance of psychological safety to support difficult conversations. And both avoid excessive focus on individual blame. Patient safety infrastructure and processes are also ideal platforms for advancing equity for several reasons. High-reliability teams, such as patient safety teams, are typically steeped in data, so stratifying by race, ethnic group, and language is a relatively small ask. Also, the widespread use of standardized tools, such as high-reliability algorithms, presents an opportunity for systematically embedding equity concepts and prompts into risk analyses. Existing infrastructure (eg, case review meetings that use root cause analysis) can provide a stage for bringing attention to inequities by using data and stories. Finally, an emphasis on system-level contributors leads to structural solutions.

Intervention Detail. There are numerous related performance gaps that our initiative addresses. These include but are not limited to: (1) developing an integrated and functional model for quality, safety, and equity; (2) creating a new pedagogy for bias and discrimination trainings focused on quality and safety; (3) developing and validating new tools for measuring the impact of bias and discrimination trainings; and (4) building new models for standardized, centralized, and stratified data registries. Our intervention provides a road map for organizations to advance equitable and safe care to all patients by using current patient safety reporting mechanisms to identify events pertaining to explicit, implicit, individual, group, and structural biases. These events are then analyzed in the same way as other patient safety events, by defining the problem, determining the causal relationships, identifying effective solutions (including provider education), and implementing and tracking solutions. We have tested and refined this framework in real-world conditions at Brigham and Women’s Hospital (BWH). This included spreading the use of our framework through education, tools, and practice to other areas of the hospital (eg, Patient-At-Risk Committee; Communication, Apology, and Resolution Committee; safety huddles). We are in the process of performing validity testing of instruments designed to measure the impact of our equity-informed, high-reliability education efforts. Notably, our work will also serve as a core pillar of the October 2020 Institute for Healthcare Improvement (IHI) Pursuing Equity 2.0 initiative, which brings together more than 25 organizations over 18 months to test, share, spread, and scale strategies.

Outcomes and Impact. Over the course of three 90-day waves, scans of current published literature, and key informant interviews, we created an initial theory for eliminating health inequities through focusing on quality/safety/risk events. The 5 key drivers of this framework include (1) integrate equity into all quality/safety/risk analyses; (2) use equity-informed quality/safety education; (3) use data to support equity improvement; (4) enhance leadership awareness and engagement; and (5) increase organizational accountability. As part of our work, we are testing and refining the theory in real-world conditions at BWH. We have emerging data to support the effectiveness of this approach at BWH. At the summit, we presented results showing an 80-fold increase in actions taken from root cause analysis to addressing inequities. We will start testing and spreading this framework with other health systems as part of IHI’s 18-month Pursuing Equity Learning and Action Network (May 2020 through October 2021). The network, led by IHI in partnership with more than 20 participating health care organizations, will underscore the urgency of eliminating inequities; provide improvement methods and tools for testing and learning our way to solutions; create a method for sharing learning across organizations; and disseminate results, challenges, and most effective improvements. Our work will inform a core part of the framework that will be used in that collaborative network. Similarly, we are leading a multi-institutional collaborative that spans leading academic institutions across the country to develop common approaches to eliminating inequities. Finally, Vizient® has been an early adopter and leader in incorporating equity measures into its Quality & Accountability Study, recently reformulating the equity domain. We are in the early stages of collaborating with Vizient to align new ideas, directions, and goals in equity from all of these efforts with data measurement, as improving equity outcomes only at the individual hospital level is of limited value compared with addressing these outcomes nationally.

A Systemwide Approach to Reducing Workplace Violence

Savannah Taylor, MS

Carilion Clinic

Susan Lee, DO, MBA

Carilion Clinic

Christopher Roberts, MSHCA

Mayo Clinic

Carilion Clinic

Background. Reported staff satisfaction regarding organizational commitment to employee safety was low (2.1/5.0). Staff members were not trained in de-escalating agitated patients and had no tools to identify high-risk patients. Other institutions had reduced workplace violence by implementing specialized teams in medical units focused on caring for behavioral patients. We sought to determine the key factors affecting staff perception of safety culture, address knowledge gaps in handling behavioral patients, and examine the qualitative and quantitative impact of implementing a behavioral emergency response team (BERT) at the main flagship hospital and 5 community hospitals. This presentation raises awareness of the need for live, in-person simulations as part of behavioral training and de-escalation techniques, which are a crucial part of reducing workplace violence.

Intervention Detail. Benchmarks and processes were compared with other institutions. Anonymous staff surveys were completed before and after the launch of BERT. Communication was distributed systemwide to raise awareness of reporting tools for accurate data collection. A systemwide policy for the creation and launch of BERT was put into place. The data showed that more staff training on handling behavioral patients was needed. In response to this data, staff members were assigned formal written education regarding de-escalation techniques, the role of BERT, and organizational commitment to employee safety. Simulation trainings and mock drills were led by experts to help employees experience real-world scenarios and solidify comprehension of de-escalation techniques. A high-risk patient identifier was rolled out through the hospital’s electronic medical record platform.

Outcomes and Impact. There has been an average of 24 BERT alerts each month since launch. Eighty-two percent of our 172 BERT members completed required training prior to BERT’s go-live date, with 98% completion by the week of launch. The number of monthly reported employee injuries related to violent patients has decreased from 18 (pre-launch) to 4 (post-launch). BERT continues to be utilized by staff as a solution for de-escalating behavioral emergencies. Staff satisfaction regarding organizational commitment to employee safety has nearly doubled (4.2/5.0) since the BERT launch. More patients are being provided expert care and counseling to meet behavioral needs.

Improving Emergency Department Throughput and Quality Care in an Overcrowded Department

Jason Upham, MSN, RN, CEN

Danielle Ray, MD, FACEP

Cone Health

Background. Moses Cone Memorial Hospital (MCMH) is part of Cone Health, a 5-hospital system. MCMH has 517 licensed beds and is a Magnet-designated institution. The MCMH emergency department (ED) specializes in trauma, stroke, and cardiac care. In 2019, the ED was experiencing overcrowding, with increased inpatient boarding and long patient wait times. The ED had stabilized staffing and significantly reduced its left without being seen (LWBS) rate through numerous improvement tactics. The ED struggled to sustain metrics improvements, especially during times of high inpatient boarding. MCMH implemented a provider in triage to reduce door-to-provider times and its LWBS rate. The provider in triage improved some metrics but created multiple patient moves and handoffs. Patients would see a provider, get care started, and then were handed off to a different provider and nursing staff. The ED was staffed to average patient arrivals as is common in many EDs across the country. Nursing and provider staffing was analyzed to identify incongruence with patient arrivals that led to getting behind, which created exponential waiting. Nursing and provider staffing was found to be behind the 75th percentile patient arrival curve for several hours per day, which created a queuing effect of waiting. Patients were waiting to get to a room and to be seen by nursing and providers. The queuing effect created a backlog of patients waiting for a large portion of the day and night shifts. At times providers were waiting for the next patient despite multiple patients being in the waiting room.

Intervention Detail. The case for change became clear. A better and new way of doing business was needed. MCMH partnered with Vizient to provide analytics tools and expert advice, allowing MCMH to confidently formulate the strategy needed to succeed today, while positioning for tomorrow. A team from Vizient performed data analysis, identifying potential constraining challenges with a granular focus looking hour to hour. The teams deployed on-site to further analyze the ED, performing direct process observations and work content observations that yielded a directional focus of process improvement. A multidisciplinary leadership team composed of providers, nursing, nurse techs, secretaries, pharmacy, radiology, lab, and emergency medical technician staff was formed to redesign patient flow based upon the findings, with a focus on what the customer values. The team deployed Lean methodologies focused on reducing the 8 forms of waste. Waiting, motion, transporting, and excess processing were some of the many opportunities for waste reduction. The nursing staff, provider staffing, and available treatment space were aligned with the 75th percentile of patient flow. The established goal was to have enough nurses, providers, and treatment spaces to accommodate the hourly patient arrival pattern. The front end of the ED was redesigned, reducing excess processing with a focus on getting every patient to a treatment space within minutes of arrival. Ambulance patient arrivals were redesigned with the goal of sending each arriving patient to a treatment space on arrival, reducing the queuing effect of multiple patients. Registered nurse, provider, and treatment spaces were aligned to assure that no variable created a constraint. The staffing model assured enough nurses and providers were available to enable bed placement upon patient arrival. The new design assures patients are routed to a care zone with a focus on swarming each new patient to get care underway.

Outcomes and Impact. Staff and providers were actively engaged in redesigning the steps to get a patient to a care space. Staff and providers were educated (prior to go-live) on the effects of getting behind the patient arrival curve and the exponential effects of waiting in a queue. A go-live event was set, with all changes to occur simultaneously. Vizient team members provided on-site coaching support for staff and providers, assuring adherence to mutually agreed-upon changes. The Vizient team worked with ED and hospital leadership to remove barriers impeding success. Ongoing hourly monitoring of leading indicators to success was measured and reported on an hourly cadence post-go-live. The leading metrics were available open treatment spaces and progression treatment spaces currently utilized. Trailing metrics were also utilized, including arrival-to-room, arrival-to- provider, and length of stay for discharged patients. The ED experienced immediate metric improvement on day 1 and has continued to demonstrate improvement. LWBS was reduced by 4%, arrival-to-room was reduced by 90%, and arrival-to-provider was reduced by 80%, while volume increased by 6%. Patients are waiting less with a lower overall length of stay, which has created incremental capacity in an overcrowded ED.

The Power and Impact of Google+ Ratings

Michael J. Breyer, MD

Nichole Morris, RN

Melody A. Zwakenberg, ANP-BC

Denver Health

Background. In 2016, Denver Health’s urgent care had a Google+ rating of 1.7, low patient volumes, poor engagement scores, and a demoralized staff. We were struggling to find our identity and discussed with senior leadership and marketing how to drive volumes, for example, can we have more marketing dollars to attract more patients? The answer was to focus on patient experience. Our leadership team triad (consisting of a physician medical director, a nurse manager, and an advanced care provider team lead) focused on improving patient experience via several initiatives. The voice of the patient was noted via emails, staff meetings, and huddles with staff. Every employee was engaged and involved. This work involved a total of 15 initiatives, including Lean thinking, progressive metric tracking, detailed communication with staff, and engagement on all levels—from hospital administration to frontline staff to patients. The focus on metric-led patient experience initiatives is not novel; however, the extraordinary impact of driving change via Google+ ratings and online reputation is new to many institutions, including our own. Capitalizing on that work to move the needle on culture and patient experience encourages patients to write about a care area on social media, which, in turn, drives more patients to a care area.

Intervention Detail. As previously noted, our plan included 15 initiatives. Some of the others included a waiting room revamp, a staff workstation room, metric-led patient experience data, direct observation coaching sessions by clinical leadership, courses and lectures, role-modeling, communication, and most notably, celebration of comments and ratings. The interventions were all patient-centered and staff-friendly; in fact, at no time did we sign onto any changes that were one but not the other. We believe the 2 go hand-in-hand. We received an impressive amount of data from our patients via our patient review portal (internal and external), Google+, Yelp, Facebook, and other online reviews. We pushed all of this out to our staff, noting and drawing attention to the positive reviews, while educating and coaching staff when they receive negative reviews. We also attempted to perform service recovery on all negative reviews we received.

Outcomes and Impact. Over the past 2 years, urgent care’s Google+ score has increased more than 250% (from 1.7 to 4.4); our online reputation has improved significantly (via Facebook, Yelp, etc.); our nursing engagement scores have become Tier 1 in our hospital; and volume has increased nearly 20% (despite a change that resulted in 8% of our patients being seen elsewhere). Most of that volume increase is due to our urgent care area seeing new patients for our hospital system, which has significant downstream impact on the hospital’s financials, as those patients often stay in the system and continue their care here. This remarkable culture change occurred at a time in which the hospital’s other acute care areas have experienced flat patient volumes. Our work in this area continues, with 2019 seeing another remarkable increase in the number of patients we saw.

There’s an App for That: Efficient Management of Brain Metastases

Joseph A. Bovi, MD

Froedtert & the Medical College of Wisconsin

Tina Curtis, DNP, MBA, RN, NEA-BC

Froedtert Hospital

Froedtert & the Medical College of Wisconsin

Background. Brain metastases are the most commonly diagnosed intracranial malignancy, with more than 200 000 cases diagnosed annually and the incidence on the rise. Patients with brain metastases are a diverse group involving complex medical decision-making and varied prognoses. Current state workflow is for patients with brain metastases to be discussed at the Froedtert & the Medical College of Wisconsin (F&MCW) Brain Tumor Board, which meets weekly on Wednesday mornings. Participants include providers from neuro- oncology, neurosurgery, radiation oncology, neuropathology, neuroradiology, and neuropsychology. Each patient’s unique case is presented, and a collaborative, multidisciplinary, evidence-based treatment plan is determined. However, inpatients at Froedtert Hospital with a suspicion of newly diagnosed or recurrent brain metastases may wait several days to a week for the next Brain Tumor Board discussion. This scheduling challenge led to delays in generating a multidisciplinary plan of care, contributing to prolonged inpatient length of stay (LOS). This presentation demonstrates using technology to streamline and improve patient care, as measured using data from the Vizient Clinical Data Base. This intervention could be widely applied to almost any area or service line treating complex inpatients.

Intervention Detail. The current pathway for navigating a multidisciplinary discussion for an inpatient with brain metastases was examined by several members of the F&MCW Brain Tumor Board. We identified the need for all disciplines critical for the patient’s management to have a real-time discussion outside of our weekly tumor board, even if those providers were at remote locations. Additionally, attendees scrutinized patients considered to have excessive LOS. It was determined the delay to discharge was caused by not generating a timely, multidisciplinary plan of care outside our weekly tumor board environment. The multidisciplinary care team worked to create an innovative intervention aimed at implementing timely, evidence-based treatment plans to reduce LOS. Our F&MCW team partnered with a local university to develop a secure smartphone application (app) that can be downloaded on any provider’s personal device. We converted our brain metastases treatment algorithm into a digital educational tool housed within the app to help inpatient providers understand comprehensive, data-driven, brain metastases management. A second component of the app is a mechanism that allows our inpatient providers to submit a patient for consideration for a virtual tumor board discussion. This second component will also facilitate faster referrals to expedite patient care. The app’s final component is a tool allowing multidisciplinary virtual tumor board members to communicate in real time to generate consensus opinions to guide the optimal management of the patient. This revolutionary, innovative concept extends the benefits of an in-person tumor board to other providers when they need immediate consultation for their patients. It used to take days to schedule consultations and offer treatment recommendations. Our secure app will make this possible within minutes.

Outcomes and Impact. Our team began a pilot to test both their diagnostic algorithm and their centralized intake and digital care planning intervention. A total of 45 patients were evaluated during the pilot period. The Vizient Clinical Data Base was used to calculate the inpatient LOS index (ratio of observed LOS to expected LOS) for patients with a primary diagnosis of brain metastasis. Baseline performance demonstrated 184 patient admissions with a LOS index of 1.073 (2018 Vizient risk model). Following the intervention period, performance demonstrated 45 patient admissions with a LOS index of 0.850. Using Levene’s test for equal variances, we concluded that the LOS variance in the pilot period was lower than the LOS variance at baseline (P = 0.049). These results demonstrate a 38% reduction in LOS variance for patients following the newly implemented brain metastasis algorithm. Clinicians reported greater ease of access to our team of specialists during the pilot period, specifically stating that the management recommendations for these complicated patients were significantly faster than what they had experienced in the past. Our next phase of this project includes the formal launch of the digital app coupled with the creation of a unique brain metastases program to further facilitate timely inpatient care. This app can be downloaded onto any clinicians’ smart phone for easy access to the brain metastasis team members.

Utilize Physician Advisors to Improve Your Value Equation and Generate Revenue

Grant Sinson, MD

Julie M. Koliniski, MD

Siddhartha Singh, MD

Carrie Alme, MD

Froedtert & the Medical College of Wisconsin

Background. Physician advisor roles were initiated at most institutions to meet federal regulations for case management. While physician advisor programs still serve that function, they can do so much more to generate value and revenue. There are numerous definitions of value, generally including quality and cost. The University of Utah utilizes a variation on this (adapted from a concept by Harvard Business School’s Michael Porter): Value = (Quality + Service)/Cost, wherein Service represents other important aspects unique to health care, such as patient satisfaction and staff/provider morale. This gives these groups an important voice in determining value. Froedtert & the Medical College of Wisconsin, a 700-bed teaching hospital, has created an innovative approach to the physician advisor program. The physician advisors remain committed to maintaining regulatory compliance. In addition, they also have the freedom and administrative support to move nimbly between groups who, in many cases, speak their own professional language, including providers (faculty, advanced practice providers, and residents), administration, data analysts, clinical documentation, finance, contracting, compliance, coding, etc. This has allowed us to aggressively target value components while remaining cognizant of the revenue impact.

Intervention Detail. To impact quality, significant new focuses involved increasing the number of charts touched by our clinical documentation improvement (CDI) team, teaching CDI teams to incorporate and code for quality variables, and engaging CDI directly with providers to guide documentation on the front end (rather than reliance on back-end queries). A portion of this effort necessitated creation of a clinical documentation integrity steering committee as a work group to bring together physician advisors, coding leadership, CDI leadership, and compliance. Also, quality metrics are impacted with physician advisors now integrally involved in our patient safety indicator validation project. Service has been targeted to improve staff/provider morale. Removing our reliance on external consultant utilization review (UR) has allowed us to provide consistent feedback to providers. Another byproduct of removing external review consultants has been gaining complete control of the peer-to-peer process for medical necessity denials. We hired denial specialists who focus on the peer-to-peer process and provide logistical support/coaching for providers. Our providers and CDI team are interested in continuing to increase their partnership. Examples include CDI members rounding with provider teams and creation of a CDI hotline for providers to access CDI input during the day. To improve direct cost, our physician advisors have been able to assist in a hospitalwide prescribing value project. This process targets inconsistencies in care where opportunities are available for cost savings. An example is targeting care outliers’ use of IVIG in myasthenia to standardize our hospital approach in a fiscally intelligent manner. Many of the previous examples have proven extremely beneficial financially: increasing our CDI program impacts case mix index, decreasing use of outside consultants trims exorbitant cost, and improving the peer-to-peer process increases the number of conversions to inpatient status. Additionally, these efforts permit bringing this feedback to our contracting colleagues for use during negotiations with payors.

Outcomes and Impact. Our quality efforts resulted in improved observed/expected Vizient indexes in mortality and length of stay over multiple service lines. The patient safety indicator validation program allowed us to improve our overall safety ranking in Vizient to No. 1 in 2019. Defining service as “staff and provider satisfaction” can make it difficult to measure. However, feedback from our UR group, denials team, and CDI suggests improved job satisfaction often results by helping each of these groups to be more efficient in their unique goals. Providers can be even more difficult from which to elicit positive feedback but eliminating outside reviews and assistance/coaching for peer-to-peer have drawn praise. Also, by improving the initial documentation and CDI/coding process we have been able to decrease the number of provider queries, long a complaint of this group. Decreasing cost was achieved by standardizing use of costly drugs such as IVIG and blood-thinner reversal agents. Eliminating unnecessary physical therapy consults is an additional useful target. Revenue generation has been associated with many of these efforts. Eliminating reliance on external UR consultants by replacing them with improved processes and 2 denial specialist full-time equivalents resulted in $400 000 per year in savings. Our efforts with the peer-to-peer program have increased the number of appeals from 10 per month to 40+ per month, with improvement in the success rate from 30% to 70%. The dramatic difference in cost margin between observation and inpatient status resulted in an estimated $2.5 million per year improved revenue. Finally, improved documentation by growing the CDI program was initiated 1 year ago. Based on estimated improvements in case mix index, our financial team estimates our ultimate growth in net revenue to be $6.2 million per year.

Supporting Our Staff: No One Left Behind

Timothy Klatt, MD

Jessica Sachs, BS

Alicia Pilarski, DO

Froedtert & the Medical College of Wisconsin

Background. Providers and personnel can experience extreme emotional distress following medical errors. This can engender a wide range of negative thoughts and feelings, including self-doubt, anxiety, depression, and thoughts of self-harm. This phenomenon has been termed second victim syndrome. Until recently, the second victim was left to try to recover on their own; however, organizations have recently begun to implement peer support programs to support their staff and/or providers. To date, most such programs have focused on helping staff and providers recover from medical errors. We began our organization’s Peer Support Program in January 2019 with a vision modeled after the 3-tier program developed at the University of Missouri. Before the end of our initial training session, we had begun to expand from that vision in several innovative ways. We have continued that path as we listened to the front lines and customized our program to meet their needs. Our leadership initially specified a program consisting of a small team of trained nurses to support everyone. This is the model used by many organizations. We pushed back, firmly believing that, just as a team is necessary to provide optimal patient care, optimal peer support requires representatives from the entire care team. We then requested that each of the 19 clinical department chairs nominate a faculty physician who was respected and trusted by their peers to lead the development of the peer support program within the clinical areas comprising their department. We asked that nominees possess high emotional intelligence, effective communication skills, and the ability to maintain confidentiality and remain nonjudgmental. Faculty physicians who accepted their nomination were then asked to recruit a hospital administrative partner, ideally no higher than manager level, as we believed these leaders could best understand the stressors experienced by those involved directly with patient care.

Intervention Detail. To launch our 3-tiered program, we invited an outside expert to conduct our initial training session. During this training session, we created our Tier 2 group, the newly trained department peer supporters and program leads, who agreed to proactively support at-risk providers and develop the program in their departments. This group accepted the responsibility for growing Tier 1, to include all interested physicians and staff who, without formal training, would support their peers and refer to Tier 2 as necessary. Tier 3, intended to meet needs beyond the abilities of Tier 2 supporters, was initially envisioned as the Employee Assistance Program (EAP) and Mental Health Services. Before the end of our initial training session, we decided to expand our support efforts beyond the traditional focus of supporting those involved in medical errors. Our peer support focus also included involvement with an unanticipated patient outcome and cases where the team was unable to stop the natural progression of a patient’s medical condition. As we developed the program, we met with the trained peer supporters monthly for the first 6 months. Three months into this series, we identified the fourth and fifth event types that now trigger formal peer support: aggressive behavior by patients or their families toward the care team and death of a colleague or coworker. We first worked with the EAP and strengthened its ability to provide peer support services. Our Tier 2 members then suggested an innovative enrichment for our Tier 3. We identified multiple mental health providers within our organization, including 8 faculty and 3 hospital-associated mental health professionals who had been doing this work already. When approached, each volunteered to serve as a Tier 3 member and agreed to provide an initial advanced peer support session without requesting compensation or utilizing the electronic health record.

Outcomes and Impact. By the 6th month, the program was well-enough established to expand the frequency to quarterly peer supporter meetings and begin quarterly in-house training sessions. Over 150 volunteers requested training as Tier 2 supporters. These self-selected volunteers met our initial criteria for nomination and many attended 1 of the 3 in-house training sessions held to date. Our team now consists of 149 trained peer supporters, including 34 nurses, 7 nurse managers, 15 hospital administrators and support services personnel, 1 hospital security personnel, 20 medical college administration and support services personnel, 38 attending physicians, 9 advanced practice providers, 12 residents/fellows, 4 radiology technicians, 2 clinical techs, 1 therapist, 5 pharmacists, and 1 student. Tier 2 supporters record high-level, de-identified information related to their peer support efforts using a brief weekly survey distributed via email. Between June 1, 2019, and February 7, 2020, Tier 2 reported 185 new and 46 follow-up peer support encounters, as well as 10 group efforts. Event types that triggered each effort included possible medical error (21%), unanticipated patient outcome (36%), inability to stop the natural progression of the patient’s medical condition (28%), aggressive behavior by a patient or their family directed toward a care team member (8%), and death of a colleague/coworker (7%). Sixty-six support events followed a patient death. Twenty-seven referrals were made to Tier 3, including 8 to faculty, 16 to EAP, and 3 to outside mental health services. Sources of peer support activation included 27 requests from the involved provider, 37 requests on behalf of the involved provider, and 121 self-invitations by Tier 2 peer supporters. Professional types supported (including those in groups) included 74 attending physicians, 19 advanced practice providers, 42 fellows/residents, 72 nurses, 6 pharmacists, 12 clinical assistants, 4 nonclinical personnel, 1 technologist, and 16 others (mostly emergency medical services personnel). Leadership has begun to publicly celebrate this program’s effect on our culture.

Value-Based Care Discharge Planning Demonstrates Lower Length of Stay

Norman E. Lancit, MSW, MBA

Houston Methodist Coordinated Care

Zachary Menn, MD, MHA, MBA

Houston Methodist Physicians’ Alliance for Quality

Swetha Mulpur, MPH

Houston Methodist System

Houston Methodist Coordinated Care

Background. Houston Methodist Coordinated Care (HMCC) an accountable care organization (ACO) founded in 2016, participated in a Track 3 Medicare Shared Savings Program (MSSP) with upside and downside financial risk. In 2017, HMCC was the only MSSP in Houston taking downside risk. We analyzed baseline Centers for Medicare & Medicaid Services (CMS) claims data provided by Medicare to identify areas of overutilization and identified post-acute facility spend as an opportunity. HMCC’s long-term acute care (LTAC) hospital utilization was 4.9 times greater than other MSSP ACOs nationally, and 2.6 times greater than Medicare fee-for-service (FFS) patients not in MSSPs. Additionally, our population’s inpatient rehabilitation facility utilization was 2.9 times greater than other Medicare ACOs nationally and 2.6 times greater than other Medicare FFS patients. This CMS claims data identified an opportunity to improve care coordination and standardize discharge planning for patients in HMCC, with strict adherence to Medicare criteria for level of care (LOC) at each type of post-acute facility. The overarching goal was to reduce readmissions and inappropriate utilization of post-acute facilities without significantly increasing length of stay (LOS). A weekly dashboard was developed to track all MSSP post-acute facility discharges by hospital that are presented weekly at our MSSP clinical operations meeting. Monthly trending by post-acute facility type and hospital location was tracked to provide feedback to our value-based care (VBC) discharge planning team. Quality metrics for post-acute facilities were developed and presented at quarterly post-acute collaborative meetings with HMCC leadership and post-acute facility partners. HMCC recruited a geriatrician as our post-acute medical director. HMCC received many letters from patients’ families praising the comprehensive care provided by our VBC discharge planning team, which contributed to increased patient satisfaction. The number of MSSP programs embracing financial risk continues to grow. HMCC’s VBC discharge planning model would be beneficial for health care systems participating in or considering a value-based payment model with financial risk.

Intervention Detail. The systemic intervention that we implemented was the development of an integrated team to provide VBC discharge planning for all MSSP hospitalized patients. Our team’s goals were to coordinate care and develop long-term care plans and to anticipate preventable causes for readmission while simultaneously reducing inappropriate post-acute utilization. CMS claims data combined with electronic health record and PatientPing reports were analyzed to identify opportunities and track outcomes. Our VBC team, with members from different backgrounds, cross-trained to provide the services of 3 disciplines (social work, case management, and utilization review) in a novel approach to discharge planning. They evaluate clinical information and therapy recommendations in collaboration with the medical team to meet patient needs and expectations. Medicare criteria is reviewed with the patient to explain the appropriate LOC. Our VBC team adheres to the Medicare LOC criteria before sending appropriate referrals to post-acute facilities. This reduces inpatient discharge delays due to post-acute facilities declining patients who do not meet Medicare requirements. This care coordination method also decreases the number of inappropriate patients accepted to a post-acute facility. Our goal was to place the right patients in the right facilities at the right time. Weekly tracking and monthly trending for post-acute utilization was extrapolated from our electronic health record and CMS claims data. Our VBC discharge planning teams received feedback from this data to share best practices. In addition to post-acute facility evaluation, our discharge team also sets up home health, durable medical equipment, and hospice, when appropriate. This team also schedules primary care physician follow-up appointments for all patients prior to discharge. Allowing our team to focus on a long-term plan for the patient’s transition from the hospital to home helps curb unnecessary utilization and avoid preventable readmissions.

Outcomes and Impact. Based on 2018 Medicare claims, HMCC’s MSSP utilization of LTAC facilities and inpatient rehabilitation facilities (rehab) decreased significantly compared with the 2016 baseline, according to CMS claims data. MSSP patients utilized LTAC 32.9% less compared with 2016 and rehab utilization was 16.3% less than 2016 baseline. Our all-cause readmission rate decreased from 18.8% in 2016 to 15.8% in 2019. We believe that standardization of discharge planning, adherence to Medicare LOC criteria, and cross-training of staff contributed to the success of our VBC discharge planning method. Serendipitously, systemwide LOS was lower for the MSSP population than its non-MSSP Medicare FFS counterparts (P = 0.000; non-MSSP patient LOS = 5.30 d, MSSP patients LOS = 4.84 d). A statistically significant difference in mean LOS occurred at the flagship hospital and 5 of 6 community hospitals within our health care system. MSSP LOS for top volume medical and surgical service lines (general medicine, cardiology, gastroenterology, and general surgery) was significantly shorter than non-MSSP Medicare FFS patients (P = 0.000, P = 0.000, P = 0.001, P = 0.025). Our VBC team’s original aim of the interventions was to minimize 30-day readmission rates and reduce unnecessary post-acute utilization. Consistently lower LOS for MSSP patients suggested that rigorous post-hospitalization care coordination did not delay discharges. When incorporating the Vizient LOS index for inpatient encounters using the 2019 LOS risk models, the risk-adjusted index LOS of non-MSSP and MSSP patients were 1.00 and 0.96, respectively, at the flagship hospital. While LOS for all admission types was lower for MSSP patients, emergency admissions and medical Medicare Severity Diagnosis-Related Group case type were significantly lower (LOS index: 1.00 versus 0.95 and 1.01 versus 0.96; P = 0.014 and P = 0.008).

Implementing Patient-Facing Digital Pathways to Positively Impact Patient Outcomes

Pat Harrison, RN, MBA, BSN

Roberta Schwartz, PhD

Courtenay Bruce, JD, MA, CPHQ

Houston Methodist Hospital System

Background. Of the 20 hospitals listed on the U.S. News & World Report 2019–2020 Honor Roll, 18 have adapted at least 1 patient-centered digital pathway. At Houston Methodist Hospital System, we sought to assess whether a digital pathway that our organization uses impacts clinical outcomes (readmission and length of stay) and patient-centered care outcomes (patient engagement, patient experience, and patient satisfaction). The patient-facing digital pathway consists of a password-protected, secure, digital education and monitoring platform (CareSense, MedTrak, Inc., Philadelphia, PA) that provides English-speaking patients with text and email messages about their medical condition. In cases where patients do not have text messaging capabilities, the text messages convert to automated phone calls. One or 2 messages are sent each day for the 20 days prior to surgery, then stop when the patient is admitted, and resume once or twice a day for 30 days following hospital discharge. The messages are primarily designed to achieve one of several purposes: (1) provide education; (2) monitor health and recovery; (3) provide key reminders to needed actions or drug taking; and (4) ensure resolution of patients’ listed action items. Presenting this project at the 2020 Vizient Connections Education Summit was important for 3 reasons: (1) the focus of the presentation and discussion was on step-by-step design of pathways and implementation practices—attendees learned how other systems can replicate what we did and achieve similar results; (2) the practical strategies and resource materials we provided should enable attendees to deploy any patient-facing digital pathway, regardless of platform or vendor; and (3) our work is multi-institutional and multisystem in that we implemented the pathway in 7 hospitals of varying sizes, patient demographics, and specialties. We also worked with patients, families, and external hospitals prior to and after implementation for shared learnings and co-design. These practices ensure generalizability and replicability.

Intervention Detail

  • A multidisciplinary, multi-institutional task force selected 7 surgical areas to deploy first based on several considerations.
  • Several members of the task force conducted focus group sessions with families and patients who were undergoing total joint replacement (TJR) or coronary bypass surgery to learn about user preferences and informational needs. Task force members also conducted interviews with 4 external system hospitals that had deployed digital pathways for shared learnings. Interviews were coded using thematic analysis qualitative techniques.
  • Operational leaders and clinicians wrote content for TJR and coronary bypass graft procedures first, detailing each text message and email to send to the patient prior to and following surgery. Patients helped refine scripts.
  • Operational and technology leaders, including vendors, pilot-tested content. They conducted interviews with patients to make revisions prior to wide-scale dissemination.
  • Statisticians conducted a retrospective cohort study to compare 2 groups over a 120-day period from January 2019 to May 2019. In the intervention arm, patients undergoing hip or knee TJR were using digital, patient-facing technology, and in the control arm were patients undergoing TJR who were not exposed to the digital technology during the same time period. Evaluation criteria included hospital readmissions, hospital length of stay, patient engagement, patient experience, and patient satisfaction.
  • Statisticians used the t test and Wilcoxon test for continuous variables and chi-square test for categorical variables to compare baseline characteristics between the 2 groups. The clinical endpoints were compared using chi-square tests. All tests for significance were 2-tailed, using an alpha level of 0.05, with a 95% confidence interval. A multivariate regression analysis was conducted to minimize confounding factors and their potential impacts, such as age, gender, and comorbidities.

Outcomes and Impact

  • Readmissions: within 30 days of surgery, 42 (4.7%) inpatient readmissions occurred for the control group and 4 (1.6%) inpatient readmissions occurred for the intervention group (P = 0.026). Within 60 days of surgery, 66 (7.4%) inpatient readmissions occurred in the control group and 8 (3.2%) inpatient readmissions occurred in the intervention group (P = 0.016). Within 90 days of surgery, 89 (10%) inpatient readmissions occurred for the control group and 9 (3.6%) inpatient readmissions occurred in the intervention group (P = 0.001).
  • Length of stay: for the control group, the average length of stay for inpatient hospitalization was 1.94 days compared with 1.41 days for the intervention group (P < 0.001).
  • Patient engagement: patients read text messages 83% of the time (median). Patients tended to be most inclined to read text messages that included tips on hip precautions, when to stop medications, and what to do the night before surgery. The text message patients were least inclined to read included getting pre-surgery clearance, smoking cessation, and doing preadmission testing.
  • Patient experience: the composite score for the medication questions in the Hospital Consumer Assessment of Healthcare Providers and Systems survey was 65% for the control cohort and 75% for the intervention cohort.
  • Patient satisfaction: 127 patients out of 231 (55%) responded to the satisfaction question. Seventy-three patients (57%) responded that they “strongly agree” that the intervention was helpful; 45 patients (35%) responded that they “agree” that the digital technology was helpful. Five patients (4%) were “undecided” and 2% “disagreed” that the digital technology was helpful. One person “strongly disagreed.”

G.O.T. Game? Game Theory Impacts Surgeon Brief Op Note Compliance

Mehjabeen Momin, BSN, RNIII, CVRN

Trisha Cox, BSN, RN, CPAN

Carla C. Braxton, MD, MBA, FACS, FACHE

Houston Methodist West Hospital

Background. The brief op-note (BON) is a necessary tool for interdisciplinary continuity of care. It highlights risks and complications related to operative procedures. Missing or incomplete notes increase the risk associated with hand-offs and decrease efficiency with post-anesthesia care unit (PACU) transfer of patients to the next level of care. Improvements in electronic health record (EHR) operability, combined with daily courtesy calls to physicians for note completion, resulted in less than 60% compliance with all 9 elements of the BON, which impacted the hospital accreditation evaluation. A more effective, collaborative approach was necessary, which led to exploration of game theory exercises. The PACU staff created a performance improvement initiative to impact BON compliance following the popular Game of Thrones theme. PACU nursing engaged physicians of all specialties to compete for the highest BON completion rates. Initial concerns about transparency of surgeon compliance were resolved when the positive elements of the game were introduced. Specialty and surgeon top performer statuses became the goals of the competition, without any other tangible incentives. Implementation of gaming theory using the Game of Thrones theme resulted in improved BON completion and safer patient hand-offs.

Intervention Detail. Pre-data analysis demonstrated 3 out of 9 elements missed by the majority of physicians: estimated blood loss (EBL), specimens, and grafts/implants (Gs/Is). The approach to improving completion of the BON included multiple technical interventions with collaboration of several clinical disciplines. The first intervention included physician coaching regarding the 9 mandatory elements and the BON elements that were prepopulated as a “pull” from other disciplines involved with the operation. The second intervention was to include confirmation of EBL, specimens, and G/I as part of the postsurgical debrief and as prompts in the BON section of the EHR. A third intervention was to provide the option to enter “none” if a procedure did not include a specimen or G/I. Anesthesiologists accepted the responsibility for EBL data entry but the workflow was misaligned with surgeons for documentation in the EHR. Software enhancements were made that allowed for a stop for each of the elements. Once EHR challenges were addressed we introduced the Game of Thrones board at the main operating room (OR) entrance. Compliance data for the BON was collected daily in real time and posted weekly. “Players” were assigned avatars related to their specialty. The avatars would be moved on the board based on weekly compliance with BON with the goal of getting to the “throne.” Competition between specialties and practitioners became apparent as staff members gathered daily around the board or commented to OR leadership about their improved status in the game.

Outcomes and Impact. Pre-implementation data demonstrated overall compliance for all elements of the BON at less than 60%. Post-implementation of EHR enhancements plus the competitive game environment resulted in overall compliance improvement of greater than 80%. The most improved specialty was plastic surgery (40% pre-implementation to 97% post-implementation), followed by otolaryngology (40% pre-implementation to 92% post-implementation). Calls to physicians for note completion were eliminated from the nursing workload, increasing nursing time at the bedside and improving staff satisfaction. Hand-off safety and efficiency between the PACU and the next level of care was enhanced due to completeness of the data needed for communication. The OR/PACU culture was positively impacted with greater collaboration between surgeons and nursing. The initial reluctance around transparency of compliance data has been replaced with fun competition and positive gamesmanship. Compliance with a mandated element of care was improved and is being sustained. This project has demonstrated that game theory can be implemented in a perioperative setting to impact clinician behavior and improve outcomes.

Quality and Accountability Opportunity Analysis: A System Approach

Nathan Barton, MStat

Guido Bergomi, MHA

Milli West, MBA, CPHQ

Intermountain Healthcare

Background. Intermountain’s mission is “Helping people live the healthiest lives possible.” The Intermountain Governing Board uses Vizient Quality & Accountability (Q&A) Study rankings as key performance indicators for how well the system is accomplishing this mission within the quality fundamental of care. Each year, Intermountain’s executive leadership team sets system improvement targets related to performance in the Vizient Q&A Study. This drives lower-level goals and improvement initiatives out to the point of care, keeping the work aligned with Vizient Q&A Study performance. However, because each hospital is ranked separately in the study, understanding system performance and identifying and prioritizing system opportunities was problematic. Many of Intermountain’s functions are enterprise-led and locally deployed, making system-level opportunity analysis an imperative to drive system initiatives to the front line and avoid duplication of work by local caregivers. Intermountain’s Office of Patient Experience was tasked with developing this systemwide opportunity analysis. With Office of Patient Experience leaders working closely with executive leaders across the enterprise, a methodology was developed and adopted to understand system performance and identify and prioritize system opportunities. This work is relevant to other Vizient members, especially those who may be looking for ways to identify system opportunities in a holistic way. Since the implementation of this methodology at Intermountain, other members have reached out to understand how Intermountain accomplished this analysis and improvement. Vizient is also developing an approach to share more broadly with all members. Intermountain’s work can serve as a guide to those looking to implement something similar.

Intervention Detail. The methodology used to create an overall system ranking is relatively simple, using a volume weighting of Intermountain hospital performance from every Vizient Q&A Study calculator and then aggregating to the system. Weights were created by dividing the number of adult inpatient discharges for each hospital by the total number of adult inpatient discharges for the enterprise. This approach ensured that hospitals with the highest volumes were the primary drivers of system performance. To obtain an overall system ranking, individual hospital rankings were multiplied by the appropriate weight and then summed. Identifying top system opportunities followed a similar weighting approach, but at an individual measure level. Because Intermountain strives to be a top performer in all Vizient Q&A Study measures, a target of top decile was used for evaluating opportunity. Specifically, Intermountain looked at the gap between current measure performance and top-decile performance. Intermountain did this using the difference between the actual percentage of overall score and the top-decile percentage of overall score from the Vizient Q&A calculator. The percentage of overall score was selected because it accounts for the relative weight of the measure within the subscores of the Q&A calculator. To obtain prioritized system opportunities, actual percentage of overall score was subtracted from the top-decile percentage of overall score and then multiplied by the volume weight. This number is called delta and is unique to each measure. If a delta was negative, zero was used instead. These deltas were summed across all hospitals to obtain a set of system deltas. The system deltas were then ranked from largest to smallest. The highest-ranked system deltas were targeted first with performance improvement initiatives. This process was partially automated using an R script to extract relevant information from the Vizient Q&A calculators and perform the weighting and aggregating. The data were updated quarterly with each calculator release.

Outcomes and Impact. Since joining Vizient 2 years ago and creating a whole system measure and opportunity analysis, the Intermountain system has improved from 66th percentile performance in the 2018 Vizient Q&A Study measurement period to 81st percentile performance in the first 2 periods of the 2020 study. The stretch goal for the 2020 period is to progress to the 85th percentile as a system. Multiple system-level initiatives have been completed and are in progress based on opportunities identified through this whole system methodology. In 2019, this approach revealed that Patient Safety Indicator (PSI)-09 was a high-priority opportunity for the system. As a result, a PSI bill-hold process was developed and an electronic medical record-driven risk assessment tool with decision support was implemented to ensure patients receive appropriate anticoagulation. At the conclusion of the 2019 Vizient Q&A Study, PSI-09 was no longer a top opportunity for the system and observed events within the system were reduced by nearly half. In the domains of safety and patient centeredness, focused work that included several 90-day sprint initiatives helped Intermountain significantly improve system percentile rankings. The system safety domain ranking improved from the 60th percentile in 2018 to the 80th percentile in 2019, with significant reduction in hospital-acquired infections across the system. For patient centeredness, the percentile ranking moved from the 56th percentile in 2018 to the 66th percentile in 2019, and to the 75th percentile for the first 2 Vizient Q&A Study data release periods of 2020. In November 2019, system and local leaders aligned around a 90-day sprint to improve performance in the mortality domain, based on system results from the 2019 study. Early results show that this sprint produced a significant increase in the documentation and coding capture of risk variables that impact expected mortality. Extensive work in improving end-of-life care in a patient-centered way was implemented in June 2020 across the system, impacting observed mortality. The system mortality index improved from the 37th percentile in 2019 to the 50th percentile for the first 2 reporting periods of the 2020 study period, with continued improvement through June 2020 discharges.

Mortality: We’re Killing It! A 90-Day Sprint Experience

Sathya Vijayakumar, MS, MBA

Milli West, MBA, CPHQ

Nathan Barton, MStat

Kearstin Jorgenson, MSM, CPC, COC

Intermountain Healthcare

Background. The 2019 Vizient Quality & Accountability Study revealed that Intermountain Healthcare’s top opportunity for improvement is in the mortality domain. As a system, Intermountain was performing at the 37th percentile. In response, leaders from Intermountain’s Office of Patient Experience (OPE) launched a 90-day system initiative to improve our Vizient mortality ranking during the 2020 study measurement period. Vizient Clinical Data Base data showed top opportunities in 5 Vizient service lines: cardiovascular, neurosciences and neurosurgery, general medicine, trauma, and critical care. A common theme with all these service lines was appropriate patient placement (including use of hospice and palliative care) and coding and documentation integrity (CDI) with the appropriate use of problem lists. Addressing these critical issues would help our frontline caregivers provide the best care and positively impact mortality outcomes. Two major purposes of the 90-day sprint were to strategically connect system leaders from various teams, enabling them to work together to improve our Vizient mortality ranking, and to help teams identify and implement the most effective tactics for mortality observed-to-expected ratio improvement.

Intervention Detail. On November 14, 2019, the OPE brought over 100 system leaders together and shared the Vizient mortality opportunity in a morning session with specialized focus groups, addressing more specific issues and tactics in the afternoon. The identified focus groups were appropriate patient placement, CDI, hospice and palliative care, problem lists, template development, and clinical quality. At the end of the day, all teams (cardiovascular, neurosciences and neurosurgery, general medicine, trauma, and critical care) left with a list of actionable items. OPE provided project management support to all teams and held weekly and monthly check-ins with them. All teams chose to implement custom tip cards for documentation and CDI education. Three teams worked on appropriate patient placement, and 4 chose to collaborate with the hospice team to develop better workflows for end-of-life care. Three teams chose reconciliation of problem lists and used information system (IS) support to help with templates and prompts. A critical component of the sprint was the connection of each team to multiple resources across the system. For example, the neurosciences team completed template development for stroke patients after connecting with the IS team during the sprint. The cardiovascular program set up prompts for heart failure patients from the heart failure clinic to palliative care through the connection to IS and palliative care teams established during the sprint. All teams educated frontline caregivers to the specific highest opportunity comorbidities with support from the system CDI team.

Outcomes and Impact. The main objectives of the 90-day sprint outlined in the previous background section were achieved through multidisciplinary teaming and consistent project management. For example, the CDI education tactic that most teams implemented used service line-specific trainings to ensure patient conditions were appropriately documented and captured. Of specific mention is the capture of do not resuscitate w/o vent >96 hours or extracorporeal membrane oxygenation (do not resuscitate component only), which was a top opportunity across the system. Once this issue was identified and addressed with the coding team, an immediate improvement was observed. At the end of the sprint on February 13, 2020, the following 6 tactics were implemented in their entirety: (1) service line-specific tip cards were created and distributed to educate frontline caregivers to the highest-weighted Vizient variables that were under- documented; (2) a workflow was developed and prompts implemented for patients in the heart failure clinic to be referred to palliative care; (3) appropriate patient placement criteria were developed for the neuro stroke population; (4) problem list etiquette was developed; (5) templates and power plans for stroke patients were developed; and (6) emergency department to hospice workflow was developed. Additionally, an end-of-life care process was developed and rolled out systemwide to impact the observed value. An automated resolution process was also implemented to resolve conditions of tonsillectomy and appendectomy from the active problem list and store them as surgical history and a process is in place for pre-bill stroke hold and review. We moved from the 37th percentile in the 2019 Vizient Quality & Accountability Study to the 50th percentile in the first 2 reporting periods of the 2020 study, with continued improvement through June 2020 discharges. In conclusion, a focused, collaborative 90-day sprint was an effective approach at Intermountain to address key areas of opportunity and improve mortality outcomes in a mission-driven, patient-centered way within a relatively short period of time.

Couplets in Verse, Music and…Hospital? The Power of Dyad Rounding

Linda Venner, MD

Melodie Toll, RN, MSN

John Williams, RN, MBA

Intermountain Healthcare

Background. Over 55 000 patients are admitted to Intermountain medical-surgical units annually. Despite our best intentions to provide each of them with extraordinary care and superior service, current research indicates that we may not be keeping them as safe as we think. Ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm. A review of reports from The Joint Commission reveals that communication failures were implicated at the root of over 70% of sentinel events. Safety events are potentially catastrophic for our patients and are also emotionally difficult for providers involved with caring for patients who experience harm. Additionally, as health care pivots to be more consumer-centric, survey data, including Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), is being scrutinized as not only a measure of patient experience, but it also corresponds to our ability to attract and retain our customers. At Intermountain Healthcare, we recognize that to keep our patients safer and provide them with a superior experience, we need to enhance our communication by becoming highly integrated and collaborative. We determined that a structured bedside rounding program would help bridge the communication gap and improve patient safety. Prior to developing our dyad rounding model, we reviewed similar programs in the medical literature to elucidate critical elements that we felt were also scalable across our organization. As we conceptualized dyad rounding, we knew that we could leverage the recent strategic change within Intermountain to “One Intermountain,” which included the creation of a single medical-surgical reporting structure for nurses and hospitalists across our 22-hospital system.

Intervention Detail. Development: Our development team, comprised of our system medical-surgical leadership triad, hospitalist leads, and medical-surgical nursing directors, designed 2 pilot programs—1 within our cardiovascular hospitalist group at Intermountain Medical Center and 1 at Layton Hospital. Initial results from both locations were positive. We refined our dyad rounding program to include 3 critical behaviors: (1) coordinated hospitalist and nurse rounding at the bedside: hospitalists were asked to encourage nurses to run the checklist and to be flexible as they made rounds if a nurse was not immediately available; (2) a nursing-led safety checklist focused on national safety measures: nurses were asked to speak first and present the safety checklist in its entirety; and (3) physician communication training: hospitalists completed 2 days of directly observed communication, scored with a communication scorecard. We kept the emphasis on developing awareness. Implementation: We were intentional about creating a culture of psychologic safety and empowerment to encourage collaboration and accurate reporting of concerns. The resulting engaged participation allowed us to course-correct quickly. We promoted a collective expectation that units would prioritize dyad rounding and work together to enable nurses to be available for rounds. Dyad rounding was rolled out over 3 months to all hospitalist groups and medical-surgical nursing units. Hospitalist and nursing leads were empowered to drive success. Nursing education was multimodal and completed during shift huddles, staff meetings, and through online Facebook workplace text blasts and videos. Hospitalist education was completed through email updates, at monthly staff meetings, and via video links. We embraced our servant leader philosophy to address concerns on a weekly, if not daily, basis. Concerns were escalated through huddles and direct and solicited feedback by our project committee. Tiger teams comprised of hospitalist and nursing leaders were deployed wherever problems were identified.

Outcomes and Impact. At Intermountain Healthcare, we embrace our “Experience Promises” to patients: we partner with them to be Always Safe, Always Present, and Always Together. We also understand that caregiver experience is foundational to executing on high value and high reliability for our patients. Along with our vision and values, we know that we must structure operationally for success. Because of our aligned medical-surgical operations, we were able to scale dyad rounding quickly across 22 hospitals, including 4 trauma, 11 community, and 7 rural hospitals. Our streamlined reporting structure creates accountability and allows for rapid problem- solving. After dyad rounding implementation the following improved:

  • HCAHPS scores: after implementation of dyad rounding, we saw an increase in HCAHPS scores around communication from the 12th to the 27th percentile across our entire system.
  • Patient safety: we also saw a 30% decrease in our reported safety events on our medical-surgical nursing units. After dyad rounding was implemented, hospitalists systemwide ranked our safety culture at 4.25 out of a maximal score of 4.5. For comparison, the national benchmark is 4.04.
  • Nursing engagement: we surveyed nurses before the program and again 1 year after dyad rounding implementation and found an increase from 40% to 88% in the perception that they “always” participate with the patient’s physician team on a daily basis.
  • Hospitalist engagement: after dyad rounding was implemented, hospitalists systemwide ranked their engagement score at 4.38 out of maximal 4.5, which is higher than the national benchmark of 4.04.

Lessons learned:

  • Nursing units need to prioritize rounding.
  • Hospitalists should try to be flexible if the bedside nurse is not immediately available.
  • The nurse should run the complete checklist right after the physician greets the patient and introduces the team.
  • A rounding validation tool and scheduled check-ins help to ingrain the process.

Development and Implementation of Nurse Practitioner-Led Teams to Improve Management of Septic Patients

Lisa Johnson, DNP, RN, CENP

Tarina Kang, MD, MHA, FACEP

Keck Hospital of USC

Background. Sepsis was the leading diagnosis for all inpatient mortality at Keck Hospital of USC in 2018. The nature by which all hospitals across the United States are held to the same SEP-1 standards forced us to reexamine how to align our mindset and practice to improve bundle compliance and outcomes. However, timely completion of these components proved difficult. The following challenges continue to mar efforts: absence of a physical emergency department, late sepsis recognition, untimely initiation of sepsis bundle components, poor team member communication, and alert fatigue/information technology challenges. Several comparable institutions have focused their efforts in strengthening nurse practitioner (NP) and registered nurse (RN) engagement when caring for septic patients. NP-led sepsis teams that included not only the NP and RN, but all providers involved in bundle provision, were able to respond to sepsis patients more quickly and comply more consistently with the SEP-1 bundle. Our approach to creating an NP-led response team centered around the consistent presence of a physician champion, the chief medical officer, and dedicated members of the quality department. Sepsis physician champions stress the importance of engagement, accountability, and continuous education. They also provide face-to-face contact, build trust among colleagues, provide support for the NPs, and leverage talent to create processes that make sepsis management easier and more streamlined. The chief medical officer and quality department are necessary to provide a voice at the leadership level, as well as administrative support to create dashboard performance metrics to track improvement. As part of the 2020 Vizient Connections Education Summit, this presentation provided insight into how our organization worked, in a grassroots way, to (1) understand how to tackle persistent obstacles; (2) highlight opportunities to collaborate; (3) create functional working groups; (4) mandate constant closed-loop communication; and (5) foster engagement, encouragement, and performance.

Intervention Detail. We implemented an NP-led sepsis team that manages septic patients. The NP responds to all alerts, goes to the patient’s bedside, and follows the SEP-1-based protocol for treatment until the 6-hour reassessment is complete. With the help of the bedside RN, the NP uses clinical observation and the electronic health record sepsis alert system to determine if sepsis is present. To provide more consistent oversight, a round-the-clock, NP-led team responds to all electronic health record alerts. Bedside RNs respond by initiating the standardized procedure sepsis order set. A code sepsis is called, which brings lab, pharmacy, and respiratory therapy to the bedside. The NP follows the patient until SEP-1 components are completed, then signs the patient out to the team or unit if the patient needs a higher level of care. Twice-daily reviews of all sepsis patients are performed by the sepsis abstractor, who then sends out emails regarding compliant and noncompliant cases as close to real time as possible. The physician champion can then act upon these cases to intervene and help educate when necessary. We used benchmarking as a measurement tool for monitoring, and the Centers for Medicare & Medicaid Services’ sepsis bundle compliance national benchmarks as our standard to assess the efficacy of our interventions. Our performance was measured and depicted through run charts, presented on a quarterly basis at different service line and quality council meetings. The process utilized the Plan-Do-Check-Act cycle, where changes were made and data was measured post-intervention, and then further changes were made accordingly. Bundle compliance and fallout data were compiled using manual abstraction in real time while the patient was still admitted. The data was then put into a master raw data spreadsheet, including patient information, attributing physician, time zero, time of fallout, reason for fallout, and location. This raw data is then analyzed and pivoted to view the number of fallouts by unit.

Outcomes and Impact. From 2018 Q4 to 2019 Q4, we had 221 sepsis cases. The overall SEP-1 bundle compliance in 2018 Q4 was 22%. The implementation of NP-led sepsis teams started in 2019 Q2. SEP-1 bundle compliance has improved 127%, from 22% in 2018 Q4 to 50% in 2019 Q4, with an overall decrease in sepsis bundle fallouts. Additionally, preliminary data on mortality has decreased in the number of septic patients present-on-arrival. The impact of face-to-face contact among physicians, broader appreciation of bundle components, and communication about cases in near-real time with twice-daily reporting has created a sense of urgency and transparency with data, while also providing insight into the work that the sepsis team is putting in to help providers comply with sepsis care. More important, however, was the presence of nurses and NPs at the bedside to evaluate the patient and determine how to capture and treat sepsis early.

LGBTQ Health and Cultural Competency: Creating an Inclusive Environment

Lindsey (Lawrence) Morrison, MHA

Keck Medicine of USC

Background. Access to culturally sensitive health care can be difficult for many LGBTQ patients. The LGBTQ community experiences high rates of discrimination in health care, including refusal of care and harsh or abusive treatment. Structural discrimination in health care leads to high rates of health disparities, including higher rates of certain types of cancer; HIV and sexually transmitted infections; sexual and domestic violence; suicidal thoughts/attempts; anxiety and depression; and substance use. Many providers lack training and expertise in caring for LGBTQ patients, and many health care systems do not have appropriate policies and trainings to ensure a welcoming, inclusive environment. At each touchpoint in the patient journey, providers can help patients feel welcome and affirmed—or unwelcome and alienated. Keck Medicine of USC implemented an in-person LGBTQ health training program that, over a 3-year period (2017 to 2019), has reached over 1000 care providers, including physicians, residents, nurses, care coordinators, and students. Using national best practices and recommendations, the “LGBTQ Health and Cultural Competency: Strategies for Creating a Welcoming and Inclusive Environment” program incorporates a cultural humility approach to encourage care providers to broaden their knowledge about providing sensitive care to vulnerable patients. Patients’ voices and experiences are captured through the Press Ganey question, “How well the staff respected your needs related to sexual orientation and gender identity” (a 5-point response scale from very poor to very good). This presentation is vital because the LGBTQ population has historically been excluded from conversations about engaging staff and providing exceptional patient care. These are low-cost strategies that can be implemented by all health systems to create meaningful improvements for LGBTQ patients. It is important for health care systems to assess their culture, services, and practices to identify how best to serve vulnerable patient populations.

Intervention Detail. Learning objectives for “LGBTQ Health and Cultural Competency: Strategies for Creating a Welcoming and Inclusive Environment” training include: (1) understand sexual orientation and gender identity; (2) understand social determinants of health and LGBTQ health disparities; (3) learn culturally competent strategies for creating an inclusive environment as a health care provider; and (4) understand the efforts of Keck Medicine of USC toward reducing health disparities in the LGBTQ community and improving overall quality of care. The training was optional, but physician leaders, clinic and department directors, and administrators were encouraged to schedule a 1-hour training session with their staff and faculty. Learning opportunities were provided in diverse settings to accommodate different needs, including grand rounds, department meetings, lunch and learns, and online Zoom sessions. Understanding how communication impacts LGBTQ patients is at the core of the training. Participants learn how to improve their interpersonal communication skills through a cultural humility lens, including challenging personal assumptions; using gender-neutral, inclusive language for individuals, families, and relationships; empowering patients by asking them to let providers know how to refer to them; and avoiding microaggressions. Participants also learn the importance of institutional strategies, including updating systems and forms to be inclusive of patients’ names, gender identities, and family structures; having visible antidiscrimination policies that include sexual orientation and gender identity; creating inclusive restroom access policies; and having compliance trainings that remind staff that LGBTQ status is protected health information. Keck Medicine of USC participates in the Healthcare Equality Index, the national LGBTQ benchmarking tool that evaluates health care facilities’ policies and practices related to the equity and inclusion of their LGBTQ patients, visitors, and employees. The Healthcare Equality Index provides best practices, national and statewide benchmarks, and resources for hospitals to assess their practices for nondiscrimination and staff training, patient services and support, employee benefits and policies, and patient and community engagement.

Outcomes and Impact. Staff reported feeling more confident in understanding different terms and definitions, particularly for transgender and nonbinary people. Patient responses and scores on the Press Ganey survey were also monitored. Mean patient scores in this section have consistently ranged from 91 to 94 (maximum of 100) for all Keck Medicine of USC hospitals. Peer comparison scores are only available for USC Verdugo Hills Hospital Emergency Department (ED), which scored a mean of 92.4 (n = 521) compared with Press Ganey peer ED group 89.7 (N = 2515, visit dates on or after September 4, 2018). To measure impact of training on pharmacy students, Keck Medicine of USC partnered with the USC School of Pharmacy. The LGBTQ Health and Cultural Competency training was provided to first- and second-year students in the spring and fall of 2019. Participants completed pre- and post-surveys to assess knowledge regarding sexual orientation and gender identity terminology, transgender- and nonbinary-specific terminology, health disparities in the LGBTQ community, and social determinants of health. Participants ranked their knowledge on a 5-point scale (1 = no knowledge, 3 = some knowledge, and 5 = extensive knowledge). For both cohorts, participants reported a statistically significant improvement in knowledge in all areas (P < 0.0001). Patients have reached out to hospital leadership to report that the trainings and services have improved their experience. USC Verdugo Hills Hospital received a grateful patient letter from a transgender patient who felt taken care of in the ED. He wrote, “I have had many awful experiences that resulted in me being very afraid of hospital staff…the nurses [at the Verdugo Hills Hospital ED] were very sensitive to my needs, using male pronouns and treating me with such dignity that I felt safe when I was there.” By incorporating inclusivity, everyone from frontline staff to leadership make every effort to make sure LGBTQ patients feel cared for, respected, and known.

Next-Day Feedback to Emergency Department Providers Improves Sepsis Bundle Compliance

Matthew McCambridge, MD, MS, FACP, FCCP, CPHQ

Lehigh Valley Health Network

Background. Sepsis is a major cause of illness and death in the United States, affecting more than 1.5 million Americans each year at an annual cost of over $20 billion.1 At Lehigh Valley Health Network (LVHN), ongoing low performance in the core measure SEP-1 bundle compliance, unfavorable comparative data with other hospitals, and higher-than-expected mortality were the incentives for performing a systematic examination of current protocols and practices. Gaps between current practice and best practices protocols were identified. Protocol deviations were recognized. Using Lean methodology, we conducted a rapid improvement event (RIE). A team of stakeholders across multiple disciplines was assembled in January 2019 for an RIE to discover the root causes of the current state and determine the target future state. A gap analysis was reviewed. A 4-point focus on adequate fluid resuscitation, timely and appropriate antibiotic administration, assessment/reassessment and attention to lactate clearance, and appropriate and prompt admission to the intensive care unit (ICU) led to opportunities identified and countermeasures being developed and implemented. Through leveraging technology, thoughtful planning, and capacity management, changes were made to improve performance and compliance.

Intervention Detail. During the RIE, it became overwhelmingly evident that frontline providers did not have sufficient data to know if they were compliant with SEP-1. Emergency department (ED) providers who attended the RIE requested feedback about their own SEP-1 performance. Creation of a provider feedback report was prioritized and expedited as 1 result of the RIE. A daily Epic electronic sepsis feedback report (ESFR) was designed to inform each attending and resident provider about antibiotics, fluid, lactates, and other metrics, as well as time of arrival, time the patient was seen, and times of key interventions. The report is sent daily (Monday through Friday; weekend forms are sent the next Monday) to the provider(s), the chief quality and patient safety officer, and a sepsis clinical quality specialist. When necessary, providers receive individual clinical education from the chief quality and patient safety officer. The ESFR helps providers and nurses recognize their own response to early diagnosis and prompt, evidence-based treatment of sepsis. The ESFR is also reviewed for waiting room times to help identify any opportunities to better triage patients and reduce delay in sepsis care. Any delays attributed to nursing colleagues are communicated to nursing ED leadership. Other interventions as a result of the RIE included (1) ED and admission order sets were revised and simplified; (2) a process was established to obtain and document sepsis upon ED arrival; and (3) ICU admission criteria were defined.

Outcomes and Impact. The RIE allowed for the voices of frontline ED providers to be heard. When physicians are engaged in a process and real-time feedback about performance improvement is provided, results can be seen and measured. Implementing the ESFR and integrating it into the workflow transformed the ability of providers and nurses to recognize and treat sepsis in the ED. The ESFR (1) heightened awareness for early identification, diagnosis, and more timely care; (2) enhanced recognition for more thorough triage; (3) reduced ED wait times for sepsis treatment; (4) identified opportunities to educate providers to administer a shorter antibiotic infusion first; and (5) identified opportunities to provide education about appropriate transfer from the ED to ICU. Prior to the RIE, data was only provided as aggregate measures. Post-ESFR implementation data shows that providers and nurses are demonstrating an improved understanding about the importance of prompt, appropriate care for patients with sepsis who present to the ED. It also shows that these new strategies and processes are working to improve compliance with the SEP-1 bundle. Specifically, (1) SEP-1 compliance increased from 56% to 66% at LVHN’s academic medical center; (2) SEP-1 compliance increased from 46% to 56% at LVHN’s 180-bed complex community hospital; and (3) both the academic medical center and the community hospital’s SEP-1 compliance control charts show an improved trend line and special cause variation with the adoption of the ESFRs. Prior to the RIE, limited data was available to providers. To strategically leverage the sepsis data, along with the ESFR, a comprehensive, drillable dashboard is being constructed to display relevant information about antibiotics, fluids, lactates, order set compliance, readmissions, length of stay, mortality, and cost per case. It will be used to monitor ongoing compliance with evidence-based sepsis practice.

1.National Institute of General Medical Sciences. Sepsis. 2020. Accessed November 5, 2020. https://www.nigms.nih.gov/education/fact-sheets/Pages/sepsis.aspx.

Eliminating Avoidable Harm: Opioid-Induced Ventilatory Impairment

Thomas McLoughlin, MD

Lehigh Valley Health Network

Background. Opioids administered to hospitalized patients are among the drugs most frequently associated with adverse side effects, the most serious of which is opioid-induced ventilatory impairment (OIVI). Morbidity and mortality due to OIVI can and do occur. A Joint Commission Sentinel Event Alert in 2012 concluded the incidence was higher than previously reported, that OIVI occurred in approximately 0.5% of postoperative patients, and that insufficient patient monitoring is a leading cause of opioid-related adverse events.1 With prospective monitoring, the incidence of prolonged hypoxemia (SPO2 < 90% for 1 h) was 37% in postoperative patients, and 3% developed SPO2 < 80% for over 30 minutes2; pulse oximetry in postoperative patients improves detection of oxygen desaturation compared with intermittent clinical monitoring and may decrease the risk of intensive care unit (ICU) transfer3; however, hypoxemia can be a delayed finding in OIVI, especially in patients receiving supplemental oxygen, because arterial oxygen saturation will be preserved late into the development of bradypnea. Capnography identifies OIVI earlier through quantification of respiratory rate and end-tidal carbon dioxide. The Anesthesia Patient Safety Foundation recommends continuous monitoring of oxygenation for all postoperative patients receiving opiates, and capnography monitoring if supplemental oxygen is being administered.4 However, there are no widely accepted guidelines for monitoring patients receiving in-hospital opioid analgesia, for identification of those at highest risk of OIVI, or for risk-based monitoring. This is especially true for patients hospitalized for treatment of medical conditions (not postoperative) who also are at risk for OIVI.

Intervention Detail. With leadership’s commitment, we began an intensive 4-month process during which we developed an “enhanced respiratory monitoring (ERM) pathway” to substantially reduce risk of OIVI. This pathway was prioritized as the first project following an agreement between our health network and an industry partner for collaboration on safety and value-based programs involving a number of patient conditions. Goals include improved care and lower costs through appropriate utilization of technology solutions. The ERM pathway directs monitoring, including continuous oximetry and capnography, for patients receiving opioids on general care units. The monitoring modalities and duration are targeted to patient type and suspected risk factors for OIVI such as obesity, obstructive sleep apnea, or neuraxial opiate administration. Our bedside monitors permit noninvasive, continuous pulse oximetry, as well as measurement of CO2 concentration in exhaled breath. A key feature is the connection of our monitors to a virtual patient monitoring platform, which provides remote viewing of patient information and facilitates automatic alarm annunciation through an event management paging system. There is no reliance on audible alarms, which avoids noise in the care environment and reduces alarm fatigue—leading to enhanced patient satisfaction. When a pager carried by a clinician displays an alarm indicating a possible OIVI, the patient condition is assessed, with intervention or consultation by a physician if indicated. Naloxone administrations and respiratory rapid response calls are tracked, as well as more severe occurrences like code blue events and ICU transfers. There is full integration with our electronic health record, including device interfaces, order panels, and automated best practice advisories to maximize ordering compliance. A key element enabling success of the intervention was the development of an innovative data collection/analysis framework. A custom dashboard using visualization software integrates data from multiple sources, including the electronic health record, hospital financial data, and insurer claims.

Outcomes and Impact. The ERM intervention went live on January 29, 2019, providing appropriate use of continuous physiologic monitoring technologies targeted to the right times for the right patients. All postoperative patients are monitored, at a minimum, with oximetry overnight following surgery. More intensive monitoring is directed to postoperative patients with morbid obesity, a history of sleep-disordered breathing, those receiving neuraxial opiates, and those receiving supplemental oxygen. Reduction or discontinuation of monitoring is protocol-driven based on time, opioid-dosing, history of alarm conditions, and other clinical circumstances. A separate pathway/order set is driven by best practice advisory upon opiate order for medical inpatients. An online dashboard facilitates alignment between all stakeholders with respect to tracking program progress and impact. The dashboard includes adverse event rates, provider and nursing compliance, and cost/claims data. This is the first time that clinical, cost, and claims data have been integrated into a single dashboard at our facility. Not a single mortality has occurred in a patient monitored by the protocol since go-live—this avoidable harm has been eliminated in this group. A baseline adverse event rate (code blue events and ICU transfers) of 15.4 per 1000 visits was observed in our postsurgical population in the 24 months before implementation. In the first 17 months since implementation, these rates have been 4.1/1000 in patients having 1 of the pathways deployed, and 3.8/1000 in the specific population of patients whose monitoring included capnography. Enhanced predictive modeling (incorporating other historic and clinical data such as frailty, sex, age, other respiratory diagnoses, etc.) is being studied to allow appropriate monitoring with even greater fidelity to hospitalized patients.

1.The Joint Commission. Joint Commission Sentinel Event Alert: Safe Use of Opioids in Hospitals. 2012. Accessed November 3, 2020. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/sea_49_opioids_8_2_12_finalpdf.pdf?db=web&hash=0135F306FCB10D919CF7572ECCC65C84.

2.Sun Z, Sessler DI, Dalton JE, et al. Postoperative hypoxemia is common and persistent: a prospective blinded observational study. Anesth Analg. 2015;121:709–715.

3.Lam T, Nagappa M, Wong J, et al. Continuous pulse oximetry and capnography monitoring for postoperative respiratory depression and adverse events: a systematic review and meta-analysis. Anesth Analg. 2017;125:2019–2029.

4.Anesthesia Patient Safety Foundation. Monitoring for Opioid-Induced Ventilatory Impairment (OIVI) Video. 2011. Accessed November 3, 2020. https://www.apsf.org/videos/monitoring-for-opioid-induced-ventilatory-impairment-oivi-video/.

M Health Fairview: Primary-Specialty Collaboration Improves Diabetes Care

Alvina D. Brueggemann, PhD

M Health Fairview

Peter Harper, MD, MPH

M Health Fairview

Lynn Burmeister, MD

University of Minnesota/M Health Fairview

Anthony Zhu, BS

University of Minnesota Physicians

Mary Logeais, MD, FACP

University of Minnesota Medical School

Amanda Brummel, PharmD, BCACP

M Health Fairview

Kelly Schechter, RN

University of Minnesota Physicians

Nicole Beauvais, PA-C, MMS, MPH

M Physicians

Holly Boyer, MD

M Health Fairview

M Health Fairview

Background. The Centers for Disease Control and Prevention estimates that more than 34 million people in the United States have diabetes.1 Clinical guidelines from the American College of Physicians suggest an hemoglobin A1c (HbA1c) between 7% and 8%,2 and multiple mandatory public reports for quality outcomes include a metric centered on HbA1c control. M Health Fairview chose to embark on a project to reduce the percentage of diabetic patients with an HbA1c greater than 8%. Through strong collaboration between primary/specialty care disciplines, the organization used Lean methodology, person/family engagement, and leader standard work to improve diabetes care across the care continuum. Person-family engagement was a key to success. Two diabetes patients, with established care in the clinics, were invited to participate in a 2-day Rapid Process Improvement Workshop (RPIW). Patient advisors helped develop goals and scope and contributed to interventions. This project represented the first time patients had been asked to participate in an improvement project and it was unanimously felt that their voice was critical and necessary to guiding the work. The executive medical director for ambulatory care and the vice president of operations were appointed executive champions. Leaders approved the project goal to reduce the percentage of patients with uncontrolled diabetes in 2 primary care/family medicine pilot sites and identified a broad multidisciplinary clinic team. We brought together primary and specialty care disciplines to work on interventions. In partnership with quality, project teams ultimately narrowed the project scope to 4 areas using cause and effect analysis: (1) improving access to endocrinology; (2) providing effective education in diabetes; (3) ensuring medication adherence, affordability, and adjusting treatment plans; and (4) identifying depression in patients receiving specialty care. The Vizient Transforming Clinical Practice Initiative was funded by the Centers for Medicare & Medicaid Services and supported by Vizient Advisory Solutions.

Intervention Detail. As part of the Lean process, specific tools were used, including Cascading Problem Solving A3s, a 2-day RPIW, and structured management systems to support implementation and sustainment. Weekly huddle calls were established with executive champions to report progress and escalate barriers.


  • Access to specialty clinics: to drive improved access to specialty care, providers established compact agreements between primary care and endocrinology for graduation of stable patients back to primary care. This process allowed timely access for unstable and poorly controlled diabetes patients.
  • Education needs assessment: in family medicine, a provider alert and educational needs assessment process were developed to identify patient self-management needs and goals.
  • Medication adherence: clinic pharmacists performed phone outreach following visits to verify understanding of the diabetes treatment plan and to ensure diabetic medications were obtained, taken correctly, and adjusted when needed.
  • Depression screening and follow-up: specialty clinic staff were trained on depression screening standard work and a clear algorithm for follow-up was supported by the electronic medical record.
  • Quantitative baseline measures: includes the percentage of patients with an HbA1c > 8.0; more than 25% of the patients (n = 419) in family medicine and primary care clinics had an HbA1c over 8% in 2018, illustrating opportunity to improve control and outcomes.
  • Access to specialty clinics: only 8% of all appointments were for new patients in the endocrine clinic, demonstrating suboptimal access for patients with poor diabetes control.
  • Depression screening and follow-up measure: baseline data demonstrated 16% compliance, which is well below the 50th percentile when compared with the overall Merit-based Incentive Payment System population.
  • Quantitative process measures: includes the number of patients transitioned (“graduated”) from specialty to primary care, the percentage of patients receiving assessment and/or education plans, the percentage of calls completed to address medication concerns, and the percentage of depression screenings completed/total eligible.

Outcomes and Impact.

Outcome metrics:

  • Percentage of patients with an HbA1c > 8.0: family medicine and primary care clinics improved diabetes control in their populations to less than 25% of patients (n = 402) with an HbA1c > 8% in 2019.
  • Access: fifty-seven patients graduated from specialty to primary care, exceeding the goal of 41 patients.
  • Education: MD assessment and educational intervention resulted in 40% of patients reaching their goal of HbA1c < 8 in family medicine over 6 months of intervention.
  • Medication: PharmD interventions resulted in 80% of contacted patients reaching their goal of HbA1c < 8 over 6 months of intervention.
  • Depression: approximately 80% to 100% of patients received depression screening in the endocrine clinic by December 2019.

While the approach and concepts used to drive improvement were not novel in and of themselves, the cross-disciplinary collaboration, use of patients in the RPIW, and dedicated executive support for the work was innovative for our organization. These tools allowed us to better realize how to approach improvement work in the future. Collaboration between specialty and primary care clinicians opened a pathway to improve access to the endocrine clinic and resulted in the first primary/specialty care guideline (“compact”) for treating patients. Patient advisors participated in the entire process, from the design workshop through implementation. A primary goal of the Vizient Transforming Clinical Practice Initiative grant was the strategic deployment of quality improvement in ambulatory clinics, including engaged leadership. Leaders chose teams, successfully developed the infrastructure and commitment to sustain this work, devoted time/energy to Gemba walks, and ensured availability of resources for improvement projects. By the end of the project, executives noticed increased quality improvement capability, collaboration between specialty and primary care clinics, and multidisciplinary teamwork across the system. Momentum was gained to continue primary/specialty care collaboration as a method to identify and improve complex clinical health problems in our organization and our communities.

1.Centers for Disease Control and Prevention. Diabetes and Prediabetes: Fast Facts. 2020. Accessed November 3, 2020. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm.

2.Dellabella H. American College of Physicians Releases 4 Guidelines for HbA1c Targets in T2D. Endocrinology Advisor. 2018. Accessed November 3, 2020. https://www.endocrinologyadvisor.com/home/topics/diabetes/type-2-diabetes/american-college-of-physicians-releases-4-guidelines-for-hba1c-targets-in-t2d/.

Health Care Violence Prediction: Enhancing Safety Through Systematized Data Management


Bernard A. Theobald, M.A.N.

Mayo Clinic

Background. Seventy-five percent of all workplace assaults occur in health care, according to the World Health Organization.1 Twenty-five percent of nurses have been physically assaulted2 and health care workers have 4 to 16 times the risk of assault of other professions.3 In addition, only 20% of assaults are reported so the actual rates may be far higher.4 Nonetheless, the causes are complex and prediction of violence outside of narrowly prescribed clinical groups has not been successful. Vizient conducted a successful benchmarking study in 2019 to establish quality metrics for this issue, but the most effective interventions are multifaceted and involve improvements to facilities, staffing, training, and institutional culture. In response to a rapid rise in workplace injuries, Mayo Clinic Rochester opened a new inpatient medical unit in 2017 that is specifically designed for patient and staff safety and that accepts patients from all other units in the hospital, including the emergency department. It was an entirely novel concept, but to operate it required a tool to select suitable patients. No tool existed for this purpose so a new system was developed based on best practice.

Intervention Detail. The Mayo Healthcare Associated Violence Prediction Tool prompts the clinician-assessor to systematically examine criminal and other available records for history of prior violence. It then requires the grounds for current concern to be categorized, recognizing that there is a hierarchy of risk based on the nature of the actual behavior. It then asks the assessor to separately rate (numerically, 0 to 10) the behavior/aggression acuity, probability of benefit from transfer to the unit, and probability of illness worsening if transfer is delayed. There is then a “common sense” assessment to allow the clinician to record their evaluation without using the structure of the tool before they finally use all the above elements to make a decision about acceptance to the unit based on best estimate of risk for violence. A corresponding assessment is used for daily evaluations of patients currently occupying the unit. They are separately rated (numerically, 0 to 10) for behavior/aggression acuity, probability of behavior escalating if the patient is transferred out, and probability of illness worsening if the patient is transferred. In addition, the assessor records if they determine that a medication and behavior safety plan strategy to manage behaviors has been developed, and whether the patient has required an emergent/rapid behavioral response in the past 24 to 48 hours.

Outcomes and Impact. This tool has been successfully used for 2 years. Among other metrics, its application in the unit has led to a 96% decrease in staff lost/restricted days due to patient violence and a 43% reduction in behavioral health security calls across our institution. The tool is used to track individual patients’ progress, select patients to transfer out of the unit and, when applied across the whole unit, is able to guide staffing estimates and identify the need to enforce triage and lockdown measures. There are 4 common groups of conditions that prompt evaluation and subsequently lead to unit acceptance: schizophrenia, acute intoxication, delirium/dementia, and autism/intellectual disability/traumatic brain injury. It is evident that there are patterns to the trajectory of tool scores that correlate with medical knowledge of those conditions. The Mayo Healthcare Associated Violence Prediction Tool can identify and stratify patients with a high risk of violence who may be suitable for additional resources to promote patient and staff safety. It is applicable to undifferentiated clinical presentations and its use in the operation of a designated inpatient medical unit led to significant reductions in violent events and staff injuries.

1.Stephens W. Violence against healthcare workers: a rising epidemic. Am J Manag Care. May 12, 2019. Accessed November 3, 2020. https://www.ajmc.com/view/violence-against-healthcare-workers-a-rising-epidemic.

2.Almendrala A. Violence against nurses is a serious problem, but hospitals are basically policing themselves. HuffPost. September 14, 2017. Accessed November 3, 2020. https://www.huffpost.com/entry/violence-nurses-hospital-responsibility_n_59bad5a3e4b02da0e1404e47.

3.Arnetz, JE, Hamblin L, Ager J, et al. Underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents. Workplace Health Saf. 2015;63:200–210.

4.Hollister B, Scalora M, Hoff S, et al. Exposure to preincident behavior and reporting in college students. J Threat Assessment and Management. 2014;1:129–143.

Spreading the Secrets to Sustaining a Hospital Opioid Stewardship Program

Robbie Savely, PharmD, BCPS

McAlester Regional Health Center

Background. McAlester Regional Health Center is a 171-bed, not-for-profit acute care facility located in southeast Oklahoma, centered within a few hours of major cities such as Dallas, Oklahoma City, Tulsa, and Fort Smith. The swelling issues surrounding prescription drug abuse have been strongly felt in this area of the state. As a community leader in health care, we looked for ways to have a direct impact on limiting the supply and addiction in our community. The initial question we formulated was, “Is there a way to more safely prescribe opioids without having a negative impact on patient satisfaction?” The answer was a pharmacy-driven opioid stewardship program. Our committee began at the end of 2015 when antimicrobial stewardship was the talk. We came up with the idea of having a medication standards committee, which eventually developed into a joint committee of antimicrobial and opioid stewardship. Leadership felt these 2 high-risk classes had the most room for improvement and could have the largest impact in our hospital and community. As we began brainstorming on what exactly opioid stewardship would look like, we decided to structure the program on the same principles as antimicrobial stewardship: education, patient monitoring/interventions, reporting data/outcomes, and key leadership/administrative support toward pharmacy ownership of daily activities. All principles and measures were built on a foundation of improving patient safety and satisfaction. Proving most challenging were the limited time and resources of a community hospital. This forced us to focus on the most important interventions and measures of outcome. The opioid crisis continues, and health care facilities are still looking for effective ways to manage opioid use. We believe our unique experience in structuring and sustaining a pharmacy-driven opioid stewardship program is valuable for anyone wishing to dramatically improve inpatient opioid use.

Intervention Detail. Our committee was assembled with the typical stakeholders in place. Along with administrative support, we have a pharmacy champion and chair, a physician champion, and a nursing champion as key leaders. During the first year, we focused on pharmacy stewardship development, data measurement and reporting, and implementing housewide general interventions. We removed all opioids and benzodiazepines from hospitalist order sets. Also established was emergency department education and a policy against opioid refills, replacements, and nonemergent use. An education event regarding the newly released Centers for Disease Control and Prevention guidelines for chronic use was provided as continuing medical education. Meperidine was removed from the formulary. Over time, we also developed quarterly drug utilization evaluation reviews on fentanyl and naloxone use, 3-day auto-stops on intravenous (IV) therapy opioid orders, surgical order set standardization of all order sets containing opioids, and patient education. Daily pharmacy interventions are broken up into prospective and retrospective reviews. Prospective reviews occur as soon as an opioid is ordered. Pharmacy reconciles the home medication list with the Prescription Monitoring Program to ensure appropriateness of current orders; recommend available nonopioid options; ensure that PRN (“as needed”) indications are clear and not overlapping; and reduce concurrent central nervous system sedating medications, range orders, and multiple opioid orders when possible. Retrospective reviews include a review of the past 24 hours’ usage in high-risk patients to look for de-escalation opportunities, dangerous combinations that may have been added, or IV to oral (PO) conversions. Our clinical surveillance software identifies patients who meet each rule criteria in real time. The pharmacist can review what is prompted, and either speak to the physician on daily rounds or by a single phone call toward the end of shift by pushing the intervention to a follow-up list. Efficiency and efficacy of intervention work is evaluated quarterly by intervention data analysis. This process has received high praise from our physician staff.

Outcomes and Impact. For in-house evaluation, our measured outcomes are classified into 3 main categories: patient safety (varying measures of medication usage, falls, and adverse drug events [ADEs]), patient satisfaction (satisfaction or pain scores), and facility benefits (cost analysis, time, and length of stay). However, we have found the following to be most impactful for driving change:

  1. Primary data: ADEs related to opioids: –88.46%. Morphone milligram equivalents consumption: –68.39%. Opioid doses dispensed: –51.33%.
  2. Secondary data: nonopiate pain medication use: +273%. Hydromorphone use: –86.97%.
  3. Pharmacist time spent per day: 75 minutes (roughly 1.5 min/patient day).

Additional data to be discussed include: Hospital Consumer Assessment of Healthcare Providers and Systems pain scores, pain scale ratings, falls in opioid dispensed areas, cost savings (hard and soft), length of stay reduction, IV versus PO use, pharmacy interventions, and meperidine/fentanyl use. The impact and growth of utilizing clinical surveillance software by pharmacy created a perfect opportunity for becoming opioid stewards. Day-to-day physician hand-offs can result in a loss of initiative continuity. For locum physicians, initiatives are often unfamiliar. With pharmacy efficiently monitoring day to day, we can ensure our patients receive uniform medication management regardless of attending physician. Posting unblinded physician prescribing patterns has also been a cornerstone of our success. Physician groups are compared quarterly among their peers through “morphine milligram equivalents per patient day.” The impact of these 2 things has created a massive culture change. We noticed changes in areas of practice that we had not directly been involved with yet. We observed more prescribers voluntarily participating that may have been initially hesitant. We even began to hear patients buzz about our facility changes within the community, and facility representatives were invited to speak at several community events. Most important was what we saw with our patients. ADEs declined dramatically. Fewer patients were wanting/needing opioid medications—without a negative impact to satisfaction.

Airway Response Team: The Art of Patient Optimization

Sheila C. Blogg, MSN, BSN, BA

Medical College of Wisconsin

Paul A. Bergl, MD

Medical College of Wisconsin

Liz White, BSN

Froedtert Hospital

Staria Brickner, BSN, RN, CCRN

Froedtert Hospital

Kathryn Lauer, MD

Medical College of Wisconsin

David Saye, CSSBB

Froedtert Hospital

Brian Weyer, BS

Froedtert Hospital

Michael Fierro, MD

Medical College of Wisconsin

Jennifer Neubauer, BSN

Froedtert Hospital

Julie Roeske, RRT

Froedtert Hospital

Kristin Bialkowski, PharmD, BCCCP

Froedtert Hospital

Jennifer Vehring, RRT

Froedtert Hospital

Melissa Gregor, MSN, RN, NEA-BC

Froedtert Hospital

Medical College of Wisconsin

Background. Froedtert & the Medical College of Wisconsin (F&MCW) needed to improve care in patients needing emergent airway management. An interdisciplinary project team was assembled, including clinical and hospital leadership. Facilitated sessions were led by process improvement experts, who completed a map of current state processes. Improvement opportunities and future state were defined. The scope captured patients’ arrival to the inpatient units through hospital discharge or demise. Opportunities for improvement included appropriate response team members, delineation of roles and responsibilities, improved care coordination, medical optimization, and preparedness for intubation (if required). These focused changes led to transformation in the delivery of care, resulting in a more efficient use of health care resources and improved outcomes and patient experience. While designing the future state for the airway response team (ART) clinical pathway, all team members empathetically placed the patient at the core of all proposed changes, rather than around the current system’s design. This unique approach was successful in designing a process around patient-centered measures. Key components of the clinical pathway include early activation of the rapid response team and a specialized ART, recognition of airway deterioration, medical optimization, and standardized medical management and communication methods. The clinical pathway was launched in October 2019. Performance is monitored weekly in addition to bimonthly reviews by the multidisciplinary team and efforts are in place to continuously refine the process for long-term sustainability.

Intervention Detail. Data from F&MCW was compared with Association of American Medical Colleges teaching hospitals with >500 beds. Efficiency, patient centeredness and clinical effectiveness measures were analyzed using Resource Manager, a Vizient Clinical Data Base tool. This data was utilized in conjunction with the hospital’s electronic medical record (for specific process measures), and internal billing database for intensive care unit (ICU) days, deterioration to a medical emergency, and cost.

Actual code calls:

  • January 1, 2019 through October 13, 2019: 225 code calls
  • October 14, 2019 through December 31, 2019: 38 intubation/ART calls
  • January 1, 2019 through October 13, 2019: 73 intubation calls pre-ART so they were codes called for an intubation
  • January 1, 2020 through February 17, 2020: 30 ART calls

Approximately a 39% reduction in overall code calls cost:

  • Supplies: code carts—$370; savings per call = $25 143
  • Personnel: code team members—1 MD, pharmacy, 5 ICU nurses, anesthesia, 2 respiratory therapists, security, an administrative supervisor, and transport. Reduction in personnel needs code team versus the ART team = a 7-person reduction = $521 labor savings per call. Total savings since pathway was initiated = $35 428.

Total savings for the period October 14, 2019 through February 17, 2020 = $60 571.

Projected cost savings per year = $181 713.

When comparing pathway implementation data performance with Vizient Association of American Medical Colleges teaching hospitals, F&MCW mean ICU days was 5.46 while the Vizient mean was 10.35. The criteria used is not an exact match because F&MCW used total ICU days related to intubations only. Our analyst pulled Vizient criteria: ICU days > zero, emergent or urgent admission status, physician specialty related to pulmonary care or anesthesia, international classification of disease codes 0bh13ez, 0bh17ez, and 0bh18ez. Intubation deteriorating to medical emergency: our rate of deterioration decreased from 0.05% to 0.01%.

Outcomes and Impact. After initiation on October 14, 2019, 2 patient groups were compared to evaluate improvements: patients with airway emergencies cared for by the medical emergency team prior to launch of the clinical pathway (group 1) and patients who completed the pathway (implementation on October 14, 2019) (group 2). Following patient assessment by the rapid response team, the pathway is immediately triggered via electronic page to the entire ART if the patient will likely require airway management. The anesthesiology and medical intensive care physician teams are triaged to the patient’s room to begin medical optimization. The rapid response nurse, transplant ICU nurse, pharmacist, respiratory therapist, and patient flow coordinator also respond to ensure additional supplies, medications, and personnel are present. Patients may receive interventions such as intravenous fluids, vasopressors, breathing treatments to prepare for intubation, or adjunct breathing support. If patients are stabilized and do not require intubation, they may remain on the floor. If intubation is required, the patient is transferred to an ICU. Effective peri-intubation management reduced the incidence of patients medically deteriorating. Overall, code cart supply use, required medical personnel time, total ICU days, length of stay, and ICU admissions were reduced. The team reported less chaos and clearer communication. Predictably, this created a better experience for our patients. This specialized team has decreased patient ICU stays, intubations, and patient deterioration to a medical emergency, and saved the organization financially by only deploying a smaller team that provides more focused care to our patients, enabling caregivers to remain in their units, and most importantly, optimizing our patient care and improving outcomes.

5000-Day Reduction in Length of Stay by Improving Hospital Flow

Bela Patel, MD

Memorial Hermann Texas Medical Center/McGovern Medical School

Background. Improving hospital flow throughout hospitals and into and out of hospitals can improve patient outcomes by delivering the right care in the right place at the right time. Improving hospital flow will also improve value by reducing length of stay (LOS) and cost, as well as reducing staff burnout. Nearly all hospitals struggle with flow, and sharing innovative ideas will accelerate flow improvement.

Intervention Detail. Interventions to shape demand and improve emergency department to inpatient care included (1) streamlining communication; (2) using data to increase intermediate care unit acuity in certain populations; (3) implementing virtual hospice in emergency departments; (4) triaging patients to lower-acuity community hospitals; and (5) providing live data on pending patient admissions to inpatient units. Interventions to improve intensive care unit flow included (1) sepsis live dashboards; (2) innovative ventilator weaning; (3) Fast Healthcare Interoperability Resources application development; (4) an end-of-life discussion program; (5) a bedside tracheotomy program; and (6) finding health care waste in daily checklists. Interventions to improve flow on medical-surgical units included (1) redesigning intermediate care unit complexity to be “soft-intensive care unit”; (2) redesigning hospital medicine floors, frail elderly units, unit-based electronic flow awareness dashboards; and (3) decreasing short LOS admissions and seasonal unit populations to match demand. Finally, we created leadership LOS dashboards using Vizient data and an innovation team to support the needs of the campus.

Outcomes and Impact. Global impacts of these inventions include a reduction of more than 5000 Vizient risk-adjusted opportunity days and an efficiency and effectiveness ranking in the top 10 among the comprehensive academic medical centers, according to the Vizient Quality & Accountability Study. Individual project outcome examples include a $2.1 million cost reduction in 12 months with the bedside tracheotomy program, a 25% reduction in ventilator hours, and reductions in risk-adjusted mortality among many patient populations.

Four Clicks From Vizient Data to Actionable Information

Stephen W. Simington, MS, MPH

Memorial Hermann Texas Medical Center

Bela Patel, MD

Memorial Hermann Texas Medical Center/UT Health

Memorial Hermann Texas Medical Center

Background. Memorial Herman Texas Medical Center (MH-TMC) treats some of the most complex and diverse cases in the country, and with new residents rotating monthly, this consequently makes achieving length of stay (LOS) goals taxing. However, over the last 4 years, there has been a downward trend in the Vizient LOS index at MH-TMC. Although this has been a positive trend, the LOS index has plateaued in the past year with an observed-to-expected ratio near 0.95. The recent stall in the LOS index has had downstream effects for hospital throughput, as nursing units are at capacity and patient wait times for beds are increasing. There is a strong imperative to continue searching for innovative ways to monitor and improve LOS. Regular meetings are conducted with service line and medical school leaders to develop strategies and interventions to solve this complex issue. To capture the voice of frontline providers, executives and service line leaders attend daily multidisciplinary discharge rounds. Conducting these rounds requires an immense amount of coordination and time. While these activities are productive, they are too broad-based to yield targeted action plans for reducing LOS. Finding a way to identify data-driven opportunities that focus on maximizing resources in the greatest areas of opportunity is vital. Stakeholders at all levels of the organization, from unit clinical managers to the chief medical officer and medical school department heads, need this information to focus their efforts. With such a large Medicare population predicated on geometric LOS for reimbursements, it is important to manage and develop systems that are time-sensitive and allocate resources appropriately—which makes this topic relevant to this year’s conference because time and resources are the most important limiting factors at an academic medical center.

Intervention Detail. Using Vizient Clinical Data Base patient outcomes and patient-level data, a Tableau dashboard was created. LOS index is the primary measure used for the dashboard to identify gaps in performance and opportunities. A gradient color scheme is used to indicate the level of performance at each step of the drill down from the service line to both physician- and patient-level detail. Each click focuses on the greatest area of opportunity all the way down to the physician or patient level. The main premise of the first display in the dashboard is to give a high-level overview of how each service line is doing internally by the LOS index. With the first click on a service line, an Medicare Severity Diagnosis-Related Group (DRG) subsection by performance is given for the selected service line. The second click on a DRG produces 2 more visuals. The first visual is a benchmark comparison of MH-TMC against the top Vizient performers in 2019 and the second visual is a 12-month rolling control chart for the selected DRG in the service line. Clicking on the MH-TMC bar within the benchmark comparison activates a pop-up window where the physician-level LOS index can be selected. The last click gives a visual of the physician- or patient-level detail by LOS index for the selected DRG within a service line. The same steps can be repeated to drill down on discharge disposition, payer, and LOS cohort. The ability to drill down to a subset of patient groups in seconds allows for the implementation of multidisciplinary rounds and focus groups targeting key areas of opportunity, reprioritizing resources, and expending valuable time in the right areas.

Outcomes and Impact. We expect the use of this tool and the subsequent interventions that spawn from the utilization of the dashboard to show a reduction in the LOS index over time. The LOS domain is a dependency outcome, as multiple factors contribute to the success or failure of the domain. We expect this dashboard will affect other patient outcomes in the Vizient domains, such as efficiency, effectiveness, and safety, and vice versa. We also expect the dashboard to improve coordination of care between nurses, physicians, case managers, and other health care providers as they work together to improve overall care for complex LOS patients. The dashboard will impact resources as they are repurposed to the service lines, DRGs, or patient groups where there is a low performance in the LOS index. This will reduce the waste of resources on areas that are performing well. Service line leaders and health care providers are held accountable for their Vizient LOS index and are expected to take action to improve when necessary. Use of the tool allows them to invest time in the appropriate areas, optimizing decision-making, efficiency, and effectiveness. With strong backing from the executive team at MH-TMC, as well as medical school leaders, we expect the implementation of interventions from the dashboard to be coordinated and the subsequent gains in LOS improvement to be substantial.

Engaging Nurses in Sepsis Mortality Reduction: A High-Reliability Approach

Megan Cram, MHA, RN-BSN, CCRN-K

Sarah Hollenberg, RN-MSN, CNL

MU Health Care

Background. In March 2019, an interdisciplinary team at MU Health Care was charged with improving mortality at the 350-bed Midwest teaching hospital. The team was structured as a dyad, with nursing and physician leadership. Clinical members were further supported by quality and performance improvement staff who provided quality improvement methodology support. The team reported to an executive council that included the chief medical officer and chief nursing officer. Upon review of hospital mortality, sepsis was found to be the diagnosis with the highest mortality rate, as well as the most cases of mortality. The facility was in the Vizient Clinical Data Base 80th percentile for sepsis mortality and the 33rd for overall mortality. The goal was to utilize principles of a high-reliability organization to improve sepsis mortality and overall mortality. The team decided to focus on the principle of deference to frontline expertise, utilizing staff members spending the most time with patients—bedside nurses. One challenge was that approximately 35% of our bedside nursing staff have less than 2 years of experience. This challenge forced leaders to think about how to engage staff with markedly less clinical experience to become confident in requesting a physician’s presence to assess patients. An evidence-based tool, the National Early Warning Score (NEWS), was selected as an objective measure of patient likelihood of adverse outcomes. This objective, evidence-based tool allowed staff with any level of experience to confidently voice concerns in a shared language. The organization continues to see an increase in new clinical staff, making it important to learn how to support those with less clinical experience to ensure they are active, engaged, and confident members of the health care team. Pairing principles of high reliability with objective decision support tools should be the future trend of clinical improvements to support patient safety and staff engagement.

Intervention Detail. An interdisciplinary team determined NEWS would be utilized to specify risk for clinical decline. Review of NEWS indicated sensitivity to alert us of potentially septic patients, but more specific measures were necessary to rule out other causes of decline. To assist, a secondary differential diagnosis guide was created for frontline nurses. Initial methods required hand calculation of NEWS by the nursing supervisor for each set of patient vital signs collected in a 55-bed pilot unit. This calculation was completed every 4 hours to determine where each patient fell on a patient care flowchart. The flowchart, utilizing NEWS thresholds, guided nursing staff to more closely monitor a patient through increased vital sign frequency, physician notification and bedside evaluation, implementation of a nurse-driven diagnostic protocol, and/or notification of a rapid response team. Each nursing intervention was tied to a specific NEWS value, providing objective intervention guidelines. Deference to the expertise of nurses, combined with objective decision support, allowed engagement of frontline staff. As data indicated that overall mortality, sepsis mortality, and lengths of stay were decreasing in the pilot area, the information technology team was engaged to create a technology solution. To evaluate effectiveness, daily dashboards were provided to show compliance with each tier of intervention. Dashboards were reviewed by bedside leadership every 4 hours, with immediate follow-up for misses. Any patient with an elevated NEWS and no intervention was assumed to be a “failed” process that could indicate a patient in jeopardy, utilizing the principle of a preoccupation with failure. Bedside leadership went to the patient’s bedside and reviewed the clinical picture with staff for further guidance and reinforcement of protocol utilization. Weekly reports of electronic charting of interventions and outcomes were reviewed by each leader and misses were reviewed to determine if failure was related to protocol utilization or inaccurate charting.

Outcomes and Impact. Engaging the frontline staff using a high-reliability framework has allowed us to not only realize objective, quantitative outcomes, but also the qualitative outcomes of improved communication between interdisciplinary teams. A deference to frontline expertise requires the bedside nurse to request a physician or rapid response assessment after certain parameters are met. In the time that the intervention has been live, we have provided 490 bedside physician assessments and 198 rapid responses to the patient bedside. This situational awareness has allowed a reduction in code blues on the general floor by 58% from prior calendar year and an 50% reduction of unplanned transfers to intensive care units. To date, we have moved from the Vizient Clinical Data Base 80th percentile rank for sepsis mortality to the 17th percentile rank. We moved from a mortality index of 0.93 in calendar year 2018 to an overall mortality index of 0.8 for the intervention period. The true impact can be seen by extrapolating simple numbers and rates for our population; we have saved 15 lives, 11 of those related to sepsis. One unexpected outcome was the reduction of our 30-day unplanned readmissions. In the time since intervention, we improved 30-day unplanned sepsis readmissions from the Vizient 63rd percentile rank to the 18th percentile rank. Implementing NEWS scores at our facility is helping to ensure our patients get timely and predictable care and has engaged a workforce of over 1400 registered nurses. This intervention is changing our culture to one of responsiveness and high reliability.

Cloudy With a Chance of Sepsis: Using a Predictive Model to Forecast Sepsis and Implement Nurse Protocols

Micah Beachy, DO, FACP, SFHM

Tammy Winterboer, PharmD, BCPS, CPHQ

Charlotte Brewer, BSN, RN

Nebraska Medicine

Background. Despite significant strides made in early identification and treatment, sepsis remains the No. 1 cause of mortality at Nebraska Medicine. The changing and discordant definitions between national guidelines and payers, along with evolving best practices, has created confusion around how to define the best care for patients with sepsis. The recent Surviving Sepsis Campaign guidelines strongly support implementing a sepsis screening process, establishing a sepsis performance improvement program, and treating sepsis and septic shock as medical emergencies requiring immediate treatment and resuscitation. Since 2014, a multidisciplinary group has spearheaded Nebraska Medicine’s efforts around improving the care of patients with sepsis. Patients were previously evaluated through an electronic screening for systemic inflammatory response syndrome criteria, followed by a manual nurse infection screen to determine the presence or absence of sepsis, severe sepsis, or septic shock as per the original Surviving Sepsis Campaign guidelines. Despite some successes, the need for more specific screening tools and reliable treatment protocols was identified. After careful consideration, the team determined a transition to the Sepsis-3 definitions was needed to assist with standardizing clinical communication, simplifying nurse screening processes, and standardizing treatment across the organization. To incorporate additional scientific evidence, the group elected to slightly adapt the definition offered by the Sepsis-3 authors. The team implemented a sepsis predictive model (SPM) within the electronic health record, utilized in conjunction with a nurse-driven sepsis protocol and end-user education, to further aid in early identification and treatment of sepsis.

Intervention Detail. In November 2018, Nebraska Medicine incorporated Epic’s SPM into inpatient and emergency room workflows, creating a sepsis forecast. This sepsis forecast utilized the SPM score plus an infection screening question to prompt a nurse-driven protocol that aligned with the new organization-adapted Sepsis-3 definitions. Required e-learnings and targeted email communications were used to help educate clinicians regarding the changing sepsis definitions, nursing protocol, and SPM implementation. Additional marketing tools, including a sepsis forecast weather report video, were also used to ensure understanding of the goals and output of the SPM. The SPM score was utilized as the foundation of the Sepsis-3 forecast, which stratified patients into 4 levels of risk: elevated risk, rule-out Sepsis-3, risk for Sepsis-3, and risk for septic shock 3. The associated nurse-driven protocol was developed to empower nurses to escalate orders per protocol for each level of risk. These orders helped ensure appropriate lab results were available for providers to diagnose or rule out sepsis, while additionally ensuring initiation of emergent fluid orders for higher risk levels. Electronic health record tools such as best practice advisories (BPAs), icons on patient lists, a sepsis report, and a dynamic sepsis protocol order set were developed to present clinicians with the actions and orders appropriate for the current risk level. This innovative, dynamic order set was utilized to automatically hide duplicate orders instead of forcing the end user to manually assess what had and had not already been completed. Additionally, this order set displayed specific orders appropriate to the individual ordering user (eg, nurses saw orders specific to the nurse protocol and providers saw a broader range of orders). Protocol checklists at the top of the order set, in the sepsis report, and in nurse BPAs helped clinicians understand which orders had already been placed and which were still needed.

Outcomes and Impact. Initial outcomes demonstrated improved specificity of Sepsis-3 alerts compared with prior systemic inflammatory response syndrome alerts with fewer alerts on inpatients (33% versus 8%). However, the total number of alerts per patient remained high (10 versus 4), indicating poor compliance with the intended workflow. After additional collaboration with nurse leaders and unit-based nursing councils, as well as peer discussions with providers, the team determined additional barriers needed to be addressed. These included continued poor understanding of the adapted Sepsis-3 definitions, lack of clarity around the intended Sepsis-3 workflow, and misconceptions that the SPM alert was diagnostic for sepsis. Nursing leadership and unit-based nurse educators were utilized to reinforce the Sepsis-3 definitions, nurse-driven protocol, and intended workflow. These individuals received weekly reports identifying individual nurses and their responses to alerts. This allowed for 1-on-1 education, including why alerts fired and how their responses directed future alert firing. This resulted in a 30% reduction in the number of alerts per patient. Additional clarification of the intended provider workflow was sent via weekly email to all providers who had seen the BPA that week. Emails included information on how to add sepsis to the problem list or document “not Sepsis-3.” A 42% increase in providers placing orders from the BPA was seen. In the immediate 6 months after implementation, improvements were noted in time to first lactate (14%), antibiotics (17%), and fluid bolus (15%). Sepsis mortality observed/expected saw a 15% improvement post-implementation. Understanding that SPM alerts do not equate to a diagnosis of sepsis is an ongoing educational challenge. As more predictive models become the norm in patient care, clinicians will need to view predictive models as an aid to help forecast an event, acknowledging that additional testing may be required to further support whether a diagnosis can be made.

High-Value Care: A Practical Approach From Ideas to Implementation and Savings

Roxana Lazarescu, MD, MBA, FACP

Amir K. Jaffer, MD, MBA

NewYork-Presbyterian Queens

Background. The American College of Physicians defines high-value care as health care that balances clinical benefit with costs and harms with the goal of improving patient outcomes.1 The Institute of Medicine defines it as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.” At NewYork-Presbyterian Queens, we made a commitment to provide the best patient care and increase value to the patient by augmenting the quality of care and reducing the cost for all our patients. The chief medical officer challenged clinical leaders to eliminate low-value care through unnecessary testing and expensive tests that did not add value and to standardize the management of common inpatient diagnoses through order sets. After careful baseline data review, our multidisciplinary team noted that many tests and procedures ordered on the inpatient service were unnecessary (eg, patients receiving daily blood testing, patients with recent echocardiograms getting repeat echos, and nuclear stress testing in low-risk cardiac patients). There was variability between physicians who provided care for inpatients with common diagnoses. We felt strongly that we needed to focus our efforts on these opportunities. Our presentation outlines a very pragmatic approach to how other academic medical centers and community teaching hospitals can replicate this work at their own medical centers and deliver high-value care (ie, decrease cost without compromising quality of care).

Intervention Detail. We took a 6-step approach to this work, starting with identifying the high-value care opportunities. Second, we put multidisciplinary teams together. Third, we designed a sustainable solution for every intervention whenever possible. Fourth, we engaged all our providers (attendings, residents, and advanced practice providers). Fifth, we evaluated the impact by setting goals. Sixth, we worked to sustain improvements. Our interventions included (1) standardizing care for common inpatient diagnoses like congestive heart failure, chronic obstructive pulmonary disease, gastrointestinal bleeding, pneumonia, stroke, and venous thromboembolism; (2) decreasing unnecessary high-volume, daily labs in inpatients; (3) decreasing unnecessary inpatient echocardiograms and nuclear stress tests; (4) decreasing percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) in hospitalized dementia patients; and (5) decreasing unnecessary MRIs and magnetic resonance angiograms of the brain and neck in diagnoses like syncope, vertigo, and transient ischemic attack.

Outcomes and Impact. The NewYork-Presbyterian Queens High-Value Care initiative is a multistep process that started in 2018 with the standardization of care for patients admitted with a diagnosis of heart failure, pneumonia, chronic obstructive pulmonary disease, venous thromboembolism, gastrointestinal bleeding, or stroke by designing clinical pathways and drafting order sets, pocket cards, and flowcharts. This initiative had a positive impact on length of stay, readmission rates, mortality, and resource utilization, with a cost savings of $1.2 million in 2018. In 2019, we focused on identifying areas to improve the value for our patient care by optimizing test utilization, including (1) decreasing unnecessary, high-volume, daily labs (complete blood count, chemistry panels, coagulation testing), as well as specialized tests such as respiratory polymerase chain reaction panels; (2) decreasing unnecessary echocardiogram and nuclear stress tests utilization; (3) decreasing PEG and PEJ utilization rates in dementia patients; and (4) decreasing unnecessary MRI/magnetic resonance angiogram utilization rates in the inpatient service targeting diagnoses like syncope, vertigo, and transient ischemic attack. In collaboration with different departments (medicine, surgery, radiology, emergency department, neurology) and divisions (cardiology, palliative, infectious diseases, hospital medicine), standard, evidence-based recommendations were created and publicized through a pocket card. Multiple educational activities were initiated, including a kickoff medicine grand round, noon conferences for internal medicine and surgery residents, monthly physician assistant meetings, and a hospitalist division meeting to capture 300+ providers involved in direct patient care who are responsible for ordering these tests and procedures. While monitoring the impact of these educational activities on utilization rates, hospital policies were created to target some of the difficult areas such as palliative team evaluation for patients considered for PEG/PEJ insertion, limiting ordering abilities for respiratory polymerase chain reaction, and an echocardiogram lab cancelation policy for tests reordered within 6 months. Our team was able to reduce utilization rates for these tests and procedures by approximately 20% in 2019. In collaboration with the finance department, the total cost savings validated to date was $800 000 for that year.

1.Moriates C. Delivering High-Value Care: Why Should Residents Care? NEJM Resident 360. September 14, 2016. Accessed November 3, 2020. https://resident360.nejm.org/content_items/1847#:~:text=The%20American%20College%20of%20Physicians,goal%20of%20improving%20patient%20outcomes.

Our Supply Chain Transformation Journey: How We Did It!

Henry Seybold, CPA, MBA

North Kansas City Hospital, and Denise Hester, APPSC, Vizient

North Kansas City Hospital

Background. The North Kansas City Hospital (NKCH) supply chain team knew there were areas that needed attention. Team members were so focused on day-to-day problems that they were not able to address the process challenges or develop a strategic vision for supply chain. Core questions were identified, including: (1) were all technologies being used the same by each team member? (2) what was driving price indexes? (3) did team members understand the impact of their actions versus knowing what needed to get done? and (4) was supply chain viewed as a partner with the departments? Our plan was a 3-step approach: stabilize and redesign operations, elevate the knowledge of the team, and measure and sustain operations moving forward. We knew that this was not a project that would happen overnight, and it did take more than a year to complete. A supply chain steering committee and team charters were established, C-suite dashboards and departmental key performance indicators were created, and a new value analysis process was rolled out. Education was also a key driver, as we needed every team member to understand the impact of all actions taken throughout their daily work. Standard work was designed to help eliminate variation in how tasks were being performed. A rebranding was needed to take the operations from being just purchasing (the people who placed orders) to a fully integrated supply chain team respected by physicians, nursing, and customers and valued for the expertise they brought to the table.

Intervention Detail. An assessment was completed that provided a detailed description of people, processes, and technology observations. Included in the assessment were all of supply chain and accounts payable departments and their interactions with key stakeholders, including nursing, administration, and physicians. The assessment provided recommendations to bring the department to leading practice and a road map of activities required in the next 12 to 15 months. Based on the scope of the transformation, NKCH realized that the project would require additional resources and expertise to see efficiencies and process improvements in a timely fashion. We engaged the Vizient supply chain operations team to develop a detailed work plan to transform the operations. The work plan outlined not only the departments affected but also the key findings from the assessment work. An additional aspect of the project was the recently signed agreement to participate in an aggregation group. NKCH needed to ensure compliance standards were met and savings were captured. As part of the transformation, the team developed a process to review all new initiatives and refresh current spend, estimate savings based on that spend, and track the initiative through execution with the value analysis teams. The transformation plan was fluid, so as new training and education opportunities arose for the staff, the transformation team redirected its efforts to ensure sustainability once the transformation was complete. The 12-month project took some unexpected turns with staff departures and additional unplanned projects, but it also resulted in the ability to educate the organization on how supply chain is a strategic partner in the overall process.

Outcomes and Impact. NKCH partnered with the Vizient team to transform the hospital’s internal operations. Process improvements were achieved in all functional areas, including data quality, electronic data interchange utilization, exception handling, and periodic automatic replenishment usage reporting. They also created both C-suite dashboards and departmental key performance indicators. The on-site supply chain team was instrumental in supporting and driving change throughout the organization. Highlights of successes included creating a steering committee charter to highlight team efforts and project successes, developing procedures within value analysis for new product appeals, redesigned shelving to shift inventory fill rate, and shifting the management of nonstock items from clinical departments back to supply chain, where the inventory expertise existed. Our goal of rebranding the team from a purchasing organization to a trusted partner known as supply chain evolved over 12 months. Our presentation covers the hurdles we encountered, what drove the team to become a successful supply chain partner, and what we learned throughout this process.

Operationalizing the Vizient Quality & Accountability Study to Unify a Health System’s Performance

Anne Bobb, BS Pharm, CPHQ

Northwestern Memorial Hospital

Abram Beyer, MBA, MS

Northwestern Medicine

Northwestern Memorial Hospital

Background. As part of our system journey, Northwestern Medicine (NM) has focused on building a coordinated system quality plan with a standard quality dashboard, while also focusing quality improvement efforts on priorities identified locally. Our system, which includes 8 acute care hospitals, has set annual quality goals around a hospital-specific quality composite grounded in the Centers for Medicare & Medicaid Services (CMS) Star methodology. By leveraging the Vizient Clinical Data Base, we produced monthly scorecards with timely all-payer data and shared the results broadly, from local leadership to the board of directors. After 3 years of this approach, we recognized that performance on our CMS Star proxy did not predict CMS Star performance due to old data and continued challenges with the CMS Star Ratings methodology that changed with each release. We were also concerned that the CMS Star Ratings measures were not evenly weighted, and those weights changed in each release. After careful consideration, we agreed to change our inpatient quality composite to the Vizient Quality & Accountability (Q&A) methodology, which covers many of the same quality domains but is more comprehensive in covering all service lines and includes some novel domains and measures. We also appreciate the cohort benchmarking available in the Vizient Q&A methodology. This presentation covers the steps taken to arrive at the decision, including composite comparison and the pros and cons of making the change, to operationalizing the Vizient Q&A-based quality composite in our enterprise data warehouse (EDW). We will share how we are using the Vizient Clinical Data Base, as well as tools such as the Quality & Accountability calculator to track progress monthly.

Intervention Detail. Leveraging content expertise and cross-department collaboration between NM quality and analytics, an automated pipeline was developed between the Vizient Clinical Data Base and NM’s EDW using Python. Each Vizient report template supplied by the Q&A calculator is automatically run and results are stored in a relational database in NM’s EDW. The data is updated monthly in the EDW and a new, overall quality composite score is calculated for the current period. Data is fed to a control chart Tableau dashboard and validated and monitored by quality experts within the system. The monthly Tableau dashboard provides NM quality directors with a timely way to monitor the impact of quality initiatives. Using the period 3 calculator performance as a baseline, quality directors can compare fiscal year-to-date performance against baseline. Furthermore, by capturing all measure values and scores for all Vizient member hospitals, quality leaders can drill down into each measure to investigate special cause variations and create performance improvement initiatives around those specific measures. Quality leaders are also able to directly compare NM’s performance with similar Vizient cohort hospitals on a monthly schedule rather than quarterly. The result is a more current and transparent inpatient quality composite score to guide quality improvement throughout the health system.

Outcomes and Impact. Measuring and improving quality is a goal for every health care system in the United States, and probably the world. While there are numerous external ranking systems, these systems are challenged by limited and old data (up to 5 y old) and a lack of comprehensive measures. They may also be limited to certain patient populations. Tracking timely quality measures and identifying any opportunities is key to continuous quality improvement. The monthly dashboard gives quality directors many tools to drill down and explore the data themselves, rather than asking analytics for a separate analysis. Building the analysis capability into the tool has also drastically reduced the amount of time analytics spends producing the monthly dashboard. The dashboard displays current performance on the 100+ metrics in the Vizient Quality & Accountability Study, including current value, change from baseline, and measure numerator and denominator. Each measure can be viewed using 3 different chart types (Z score plot, metric value bar chart, or metric value trend), and includes a link directly to the Vizient Clinical Data Base report. The measures are easily sorted to identify the largest areas of opportunity and the tools needed to create monthly leadership reports are at our fingertips. The Vizient Quality & Accountability Calculator is also generated monthly, allowing us to model projected metric changes. In conclusion, our inpatient quality composite, modeled from the Vizient Quality & Accountability methodology, is a comprehensive and timely tool for measuring quality at each hospital. The Vizient cohorts enabled us to set a systemwide composite goal, as well as individual hospital goals, appropriately benchmarked with peer hospitals. It also enables us to realize the full value of using the Vizient Clinical Data Base. Our hope is that year-over-year improvements in metrics will also drive improvements in other external ranking systems.

Implementing the Intangible: Harnessing the Power of a Systemwide Collaborative Palliative Care Model in Oncology

Damanjeet Chaubey, MD, MPH, FACP, SFHM

Karen Mulvihill, DNP, APRN, FNP-C, ACHPN

Nuvance Health (formerly Western Connecticut Health Network)

Background. The disease burden of cancer on patients, families, and health systems is substantial. Traditional cancer care may not target all aspects of the disease as presented by the patient. The impacts of untreated or poorly managed symptoms can affect many facets of life, including physical functioning, psychological well-being, and social interactions. For many patients, including palliative care as a component of comprehensive cancer care may provide more options of disease management, thereby optimizing patient outcomes. Thus, the integration of interprofessional, team-based palliative intervention with usual oncology care should prove invaluable in establishing palliative care as a resource for improved patient outcomes within the cancer population. Additionally, the realization of reduced health care costs is another advantage for patients and health systems. The Whittingham Cancer Center at Norwalk Hospital (part of Nuvance Health) created the Comprehensive Cancer Care and Symptom Management program in which palliative care services are utilized. This innovative model created patient- and family-centered, comprehensive cancer care that is delivered by interprofessional teams comprised of oncologists, nurse practitioners, nurse navigators, and social workers. All patients who receive palliative care incorporated into their usual oncology care will benefit from holistic, person-centered treatment. Services include a whole person assessment and management of symptoms, psychosocial well-being, and social and spiritual support, as well as caregiver education and counseling. Social determinants of health are also assessed to identify relevant factors that influence health status and access to health care services. Timely, effective treatment and supportive interventions, coupled with coordination of care across all other disciplines, is the basis for this model. We present this design to drive transformational change through the joint efforts of traditional oncology care with palliative practice. Additionally, these tools provide a framework for delivering value-based, high-quality care while managing and reducing health system costs.

Intervention Detail. The key building components of establishing a comprehensive cancer care model include: co-creating plans for models that provide collaborative, interprofessional outpatient care for seriously ill populations; engaging stakeholders inclusive of entire clinical teams, patients, and families; and implementing measurable assessments addressing the needs and concerns of those involved. First, we identified the need for symptom management in our target population: patients with advanced cancers and high disease burden. Studies have indicated that the most common reason for patient hospital visits in this population is pain related. These visits are burdensome for patients and costly for health care systems. Next is the development of a collaborative palliative care team that works to coordinate patient-centered care inclusive of an advanced practice provider, clinical social worker, and a nurse navigator. Additional support services such as nutritional or spiritual care will also be referred as needed. Appropriate palliative interventions and end-of-life care specific to the patient are provided. Encouraging participation of patients and their families with clinicians in shared decision-making and addressing patients’ wishes regarding goals of care fosters open empathetic communication among all parties involved. This involvement of family caregivers is essential for optimal treatment of cancer patients to ensure treatment compliance, continuity of care, and social support. Measurable, self-reported data assessing burden is collected from patients and caregivers in the form of the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire and the Zarit Burden Interview (ZBI), respectively. These assessments will be conducted at various points throughout the course of a patient’s palliative treatment to track any changes. Patient scores are monitored and areas of high burden are addressed accordingly. Caregivers found to have high burden scores will receive social worker intervention, counseling, and education. Patient and provider satisfaction surveys are also collected to determine the overall success of the program.

Outcomes and Impact. Outcome measures used to evaluate the services demonstrated from this initiative have shown tangible data indicating positive health impacts for the palliative population. Current data shows 52% of patients have improvement in FACT-G scores within an average of 2.8 visits, or 5 weeks. Comparison of average FACT-G scores between first and last visit showed just over a 4% increase. Results of the ZBI show at least 48% of caregivers had some degree of burden for which they received education and counseling. Patient and family experience with palliative care services reflected a 99% satisfaction rate. Common social determinants of health were identified in our patient population that likely impact disease, as well as individual patient care. Following patients across the continuum of care included emergency department visits, hospital stays, and home telehealth. Further analysis found that palliative interventions led to timely hospice referrals for 29% of patients. Eleven patients with advanced illness were hospitalized within 30 days of an outpatient visit and only 6 were Medicare beneficiaries. Ongoing collection of data should continue to show reduced symptom burden of disease among patients; improved ZBI scores owing to relief of caregiver burden with appropriate support; sustained patient and family satisfaction with palliative services; and additional identification and evaluation of social determinants of health. Expected future program outcomes include increased early or timely hospice referral rates and reduced emergency department visits, hospital readmissions, and chemotherapy use in the last 14 days of life. Outcomes will also take into account payer strategy by utilizing improved hierarchical condition category scores to measure patient expenditure risk. Ultimately, this data will be used to purport that interdisciplinary palliative care integrated with usual oncology care will improve patient outcomes. It is anticipated that outcomes identified through the research conducted in conjunction with this program will yield findings that will contribute significantly to current literature.

Pitch Perfect: NYU Langone Health’s Road Map to Developing an Operational Innovation Structure

Sarah Szollar, MHSA

Beining Niu, MHA

Amy Horrocks, MHA, FACHE

NYU Langone Health

Background. In 2018, NYU Langone Health (NYULH) hosted a Shark Tank-themed contest for support services to highlight innovative ideas from frontline staff. An interdisciplinary team from the Manhattan campus proposed a project to prioritize bed cleaning through collaboration between patient placement and building services staff, which led to a 15-minute reduction in stat bed cleans. A group from food and nutrition at NYU Langone Orthopedic Hospital presented their idea to replace adhesive-backed date labels with washable labels for food storage. This simple change resulted in a labor savings of 0.5 full-time equivalents due to the decrease in time required to remove the labels from the reusable plastic storage bins. Another team from housekeeping at the Brooklyn campus previously developed an initiative to create an automated alert for in-between operating room (OR) case cleaning to expedite OR turnover. Time from wheels out to room clean improved by 33% at the Brooklyn campus. They shared this idea during the contest and it subsequently was replicated at the Manhattan campus, where it contributed to a 6% reduction in overall turnover time in the main ORs. The experience with the support services Shark Tank-themed contest reinforced the importance of promoting and recognizing innovation, as well as staff’s desire to share their ideas and put them into practice. To scale up from this initial success and drive innovation throughout hospital operations systemwide, the operational innovation team was established, drawing from existing resources. The team created the “Innovation Pitch” contest to solicit innovative ideas from all operational groups, to celebrate staff for innovative thinking, and to scale valuable ideas across campuses.

Intervention Detail. The operational innovation team identified an opportunity to build structure around operational innovation and create a mechanism for staff members to propose creative ways in which they can make their work more efficient and effective. A call for submissions to a contest dubbed the Innovation Pitch was distributed throughout the health system. The goals are to foster positive, disruptive change and growth; improve patient care, patient experience, and staff engagement; and leverage the expertise of the entire NYULH community to address the operational challenges we face as a health system. At the Innovation Pitch, staff members present their ideas to senior leadership and then implement their projects with mentorship from interdisciplinary leaders throughout the system. The Innovation Pitch has evolved into a quarterly production hosting nearly 400 people, judged by NYULH executives and members of the board of trustees. Presentations feature creative solutions, cost-savings potential, and proposed returns on investment. Any NYULH staff member can submit an idea. Submissions are evaluated using the following criteria: (1) degree of innovation; (2) return on investment; (3) degree of improvement in performance; and (4) scalability and ease of implementation. Submissions are accepted on a rolling basis and are reviewed by an interdisciplinary committee that includes leaders from hospital operations and subject matter experts in information technology, supply chain, and relevant departments, depending on the submission. All teams receive coaching prior to their presentation at the Innovation Pitch. Ideas selected to present are required to address the following areas: (1) challenge/opportunity; (2) innovative solution; (3) potential impact; (4) key stakeholders; (5) measurements of success; and (6) return on investment. All presenting teams are encouraged to implement their ideas, whether or not they win the event. Implementation progress and results are monitored and shared at future events, in a “Where Are They Now?” feature.

Outcomes and Impact. Out of 28 total pitches in 2019, 15 project teams were given the opportunity to implement their ideas. Several successfully launched projects include (1) Clamping Down on Closed Clamps—using tray liners to prevent closed clamps in the ORs, resulting in an annualized savings of $173 406; (2) Op Watch—creating a stop clock and dashboard for OR teams and support services to track OR turnover time (contributing to a decrease in main campus OR turnover time); and (3) Taxi, Please—collaborating with the Curb app to order taxis for patients leaving the emergency department. A key benefit of the Innovation Pitch is staff engagement. The process provides staff members the opportunity to collaborate with interdisciplinary colleagues and be recognized at the leadership level for innovative thinking. Additionally, many submissions are related to staff engagement, highlighting this as one of NYULH’s institutional priorities. Such launched projects include: (1) Guest Chef Showdown—a competition featuring employee recipes recreated by our catering team; (2) Employee Talent Show—featuring performances from employees throughout the health system; and (3) Employee Exchange Program—allowing employees in corporate services to shadow clinical employees and vice versa. The operations innovation team collaborates with our finance team to track return on investment on implemented projects, which can include cost and time savings. We also feature “Just Do It” spotlights at the Innovation Pitch by highlighting staff members who implement projects immediately without requiring major resourcing. Building on the success of the Innovation Pitch events, the operations innovation team is focusing on strategic innovation in 2020. Submissions are prompted by an operational goal for the institution, such as patient throughput. Submitters are encouraged to implement their ideas at the unit or department level to measure success prior to presentation at the Innovation Pitch. We anticipate this will instill cross-campus engagement and enterprisewide improvements.

Building a Centralized Transfer Center to Support Health System Expansion

Lisa Kesting, MPA

Meghan Wyman, RN, MSN

Jennifer Kessler, BS

NYU Langone Health

Background. Prior to the launch of the NYU Langone Health (NYULH) Comprehensive Transfer Center (CTC), transfers into and within NYULH were facilitated by both clinical and nonclinical staff. These transfers were often completed on paper, either through a centralized department or at the unit level. There was no standardized process for transferring a patient into NYULH, and the department typically facilitating transfers was not staffed 24/7. The lack of standardized processes led to delays in transfers, referring and accepting provider dissatisfaction, reduced reimbursement due to lack of insurance authorization, and potential safety risks due to inadequate clinical information. In May 2017, NYULH identified the need for a CTC with standard transfer processes across the health system. In order to facilitate the creation of the CTC within a short 9-month period, NYULH established a core leadership committee that addressed the identified opportunities and threats, including supporting the CTC medical directors. Together, the leadership team and medical directors conducted market research to identify best practices and potential software solutions to support clinical documentation in the patient’s electronic health record (EHR). The team also developed standard operating procedures (SOPs) and clinical workflows to ensure all transfers occurred safely and efficiently. Following a systemwide communication strategy, the CTC was launched in January 2018 with the goal of providing a single point of contact to transfer all patients into and within NYULH hospitals.

Intervention Detail. The launch of the CTC was achieved with a steering committee that provided comprehensive oversight and commissioned various subcommittees to implement targeted strategies that addressed specific problems. The transfers subcommittee developed clear clinical workflows and SOPs, while the technology subcommittee evaluated and implemented innovative supportive technology solutions. Because the CTC was founded due to the lack of standardized processes and clinical workflows for transfers throughout the health system, developing these tools was paramount. The transfers subcommittee developed prioritization levels for transfers that were designed to drive how each transfer is processed and what is clinically and financially required for transfer. Specifically, differing standards based on transfer priority were developed indicating whether medical director approval is needed, if insurance authorization is required, the expected transfer time, and how frequently clinical updates should be obtained. Additionally, it was determined that all transfers would be managed by a centralized group of nurses, removing the function from administrative staff and individual hospital units. The transfer registered nurses would manage clinical workflows, including facilitating an attending-to-attending conference call, presenting the transfer for medical director approval, coordinating nurse hand-off, and arranging transport. With these SOPs and workflows in mind, the technology subcommittee identified and implemented unique clinical documentation tools within the EHR, as well as a call center solution to assist in managing expected call volume and quality control. Following a January 2018 go-live, the CTC continues to grow with the expansion of NYULH. The framework built by the steering committee was deliberately created to be adaptive, and as new campuses join the health system, the CTC scope is expanded to care for new patient volumes. The CTC now manages all transfers and direct admissions into and across NYULH’s 4 hospitals.

Outcomes and Impact. The use of technology and integration within the EHR allows the CTC to track volume and various metrics. In the first month, the department safely facilitated 102 transfers. This volume showed consistent growth as the CTC expanded to new services and campuses:

  • In April 2018, the CTC launched at NYU Langone Hospital—Brooklyn, resulting in an increase of 25 transfers per month.
  • In June 2018, direct admissions were integrated, resulting in an increase of 120 admissions per month.
  • In April 2019, the team began facilitating overnight emergency department referrals, resulting in an increase of 21 referrals per month.
  • In February 2020, the CTC integrated with NYU Winthrop Hospital, resulting in an increase of 39 transfers per month.

By January 2020, the CTC was averaging a monthly volume of 347, including 190 transfers, 128 direct admissions, and 29 emergency department referrals. The volume of transfers facilitated by the CTC increased 350% over a 2-year period. An important quality metric and clinical best practice monitored by the CTC is the facilitation of conference calls between sending and accepting attending physicians. Previously, completion of these calls was inconsistent and lacked documentation. Since CTC go-live, initiation of MD-to-MD conference calls has become the standard. Prior to utilizing the patient’s EHR to document transfers, many requests were received by fax, email, or in-person. Less than 70% of transfers were initiated by phone, which is considered best practice. To standardize the transfer request process, 1 phone number was established for referring physicians to initiate a request into or within NYULH. With the evolution of the CTC, nearly 95% of transfers are initiated by phone.

A Different Way of Thinking About Reducing Your Mortality Index

Richard D. Guthrie, MD

Ochsner Health

Background. Improving risk-adjusted mortality is challenging and usually involves improvement in both preventable mortality and documentation excellence. To reduce preventable mortality, organizations commonly review mortality cases to identify clinical opportunity or conduct service-line drill downs to identify focus areas. These activities are important but can be augmented. Importantly, performance improvement focused on drivers that cross specialties can be as, or more, effective than mortality reviews or service-line drill down analyses. Examples of such drivers include identifying patient deterioration and providing early resuscitation, providing clinical triage of transferred patients, reducing primary sepsis mortality, and providing robust palliative care.

Intervention Detail. We explored our 5 major drivers of risk-adjusted mortality and as a result, have tangible, specific examples of our approach to performance improvement in these areas—which resulted in improvement in overall risk-adjusted mortality. The 5 major drivers include resuscitation, sepsis, transfer center operations, palliative care, and documentation excellence. Some of our specific tactics included using artificial intelligence alerts for patient deterioration, initiating proactive nurse rounding on patients with high Modified Early Warning Scores, and reducing the barriers for nurses to activate rapid response teams. We also augmented our advanced cardiovascular life support training to include team-based simulation lab exercises. In addition, we focused on more complete documentation for codes and rapid response calls to empower analytics to be used for improvement. Related to sepsis, we initiated code sepsis in our emergency department and focused on reducing time to antibiotics. New order sets were created to help reduce variation in sepsis treatment. Our transfers into Ochsner Medical Center (OMC) continued to increase in 2018 and 2019 and we now transfer in about 1000 patients a month. We committed a hospital medicine physician (24/7) to evaluate and triage these patients, establishing time goals for each level of acuity. Risk-adjusted mortality index (RAMI) was measured for each acuity level for patients in which we met the goals, as well as for those where we did not. We augmented our palliative care team and began an educational program through the Respecting Choices model. Once our RAMI core team program was underway at OMC, we scaled this program to our community hospitals—each of which developed a RAMI team, with similar subgroups based on the common drivers. We feel that this was one of our more successful spread and scale efforts to date.

Outcomes and Impact. Nearly all process measures improved related to these activities. Out-of-intensive care unit codes dropped more than 60% and sepsis raw mortality improved (although our primary sepsis RAMI is still higher than we would like and we believe we have more work to do in this area). Time to antibiotics improved significantly. We discovered that for transferred patients, time matters a great deal. When time targets were met for transfers, our RAMI was consistently below 1. When not met, RAMI was significantly higher. Palliative care consults rose significantly. Our documentation excellence program resulted in improved complication or comorbidity/major complication or comorbidity capture, as well as capturing of conditions known to reflect patient acuity. In looking at RAMI as our primary outcome measure, OMC’s RAMI did not improve as we would have liked. However, our system is dedicated to the concept of the right bed, right plan, right time and we’ve been successful at bringing the sickest of our patients to our comprehensive academic medical center, which can make improving RAMI difficult (since risk adjustment is not perfect). Our overall system risk-adjusted mortality improved from 0.98 to 0.90 to 0.87 from 2017 to 2019, which we believe is related to these efforts.

Prescribing Strategies to Achieve High Value, Low Cost

Michelle George, MHA, PMP

Jeffrey W. Miller, PharmD

Joy S. Trout, PharmD, BCPS

Lisa A. Ciccocioppo, BSBA, PMP, LSSBB

Penn State Health

Background. Our health system is increasingly entering into risk-based contracts in which over 45% of the quality metrics are tied to some type of medication use or adherence. Additionally, these contracts require that we control costs for both the patient and the plan. We had a goal to improve patient adherence in alignment with evidence-based medicine and recommendations. A multidisciplinary team was convened and tasked with driving iterative improvements, working to learn from available data, identifying prescribing patterns, and developing proactive solutions, as well as benchmarking to compare our performance to comparable entities in an effort to highlight opportunities for improvement. Our first step was defining the list of high-cost, low-value drugs to determine which drugs should be the focus of our initiative. The long-term goal was to proactively hinder the ability to prescribe these from an information technology perspective. A deeper dive into the current state of our prescribing practices revealed significant variation in how our providers approached ordering of medications and their barriers to achieving stated goals. We discovered that patients receiving certain formulations of metformin extended release (ER) incurred an expense 143 times greater than patients receiving the low-cost metformin ER formulation. With 40 patients receiving the high-cost metformin ER and 510 patients receiving the low-cost metformin ER, we found that 8% of the patients receiving metformin ER accounted for 92% of metformin ER drug spend. We determined that switching these patients from high-cost metformin ER to a lower-cost metformin ER would have a potential savings up to $265 056 for the 40 initial 1-month fills in this 1 drug category alone. The foundation for developing our high-value, low-cost prescribing initiative is built upon innovating a standardized, easy, patient-centric approach from a systems perspective to equip clinicians with the information necessary for informed prescribing.

Intervention Detail. Working with a partner insurance, we identified 12 high-cost/low-value medications: mupirocin cream, metformin ER, venlafaxine ER tablets, tretinoin microsphere gel, prednisone delayed-release tablets, acyclovir cream, epinephrine auto-injector, penciclovir cream, sodium bicarbonate-omeprazole combination, famotidine-ibuprofen combination, cyclobenzaprine ER capsules, and esomeprazole-naproxen combination. Each medication met 3 criteria points: (1) therapeutic alternatives existed that boasted similar anticipated clinical outcomes; (2) therapeutic alternatives were significantly less costly than the high-cost product; and (3) There would be no negative impact on patient care. This list of medications was presented to the pharmacy and therapeutics committee for review and consideration. A final decision was made to present a pop-up alert within the electronic medical record anytime a provider attempted to prescribe one of the identified medications. Within the pop-up alert, the provider is given the recommended lower-cost alternative to prescribe. The provider is able to cancel the prescribing action and prescribe the lower-cost alternative. The provider is also able to continue with the high-cost product, overriding the alert if it is deemed clinically appropriate. Education was sent out to providers via an email blast. An on-demand report was developed to track the number of times an alert fired and what action the provider chose. The report provides details on the date, patient, medical record number, the high-cost medication, the ordered medication, user, and position. From this data, we are able to determine the conversion rate from a possible high-cost medication to a low-cost medication. For those alerts that were overridden, we reviewed the patient chart and tracked the dispensing process of the identified medication. We reviewed to see if the medication was dispensed as originally written or changed to a lower-cost medication. We also reviewed to see if the medication required prior authorization. If prior authorization was required, a targeted outreach was made to the provider to educate about the benefits of the pop-up alert, as well as recommend the prescribing of the lower-cost alternative.

Outcomes and Impact. Data for the first 6 months of reporting was available at the time of this writing. The pop-up alert affected all areas of e-prescribing, including primary care, specialty, emergency department, and hospital discharge. Over the course of 6 months, the pop-up alert fired for 11 of the 12 targeted medications. A total of 581 prescriber-facing alerts were triggered. Nonprescriber alerts (eg, orders being queued for the prescriber) were excluded from data analysis. As a direct result of the alert, 260 prescriptions were changed to the lower-cost alternative, representing a 45% overall positive response rate for the pop-up alert. The most common positive responses were changes in high-cost, low-value mupirocin cream to ointment (91/124 positive responses) and metformin ER release mechanism change (62/140 positive responses).

Using average wholesale prices, we calculated the cost difference for each change to identify those that provided the most cost savings and assess the overall financial impact of our interventions. Metformin demonstrated the most savings, with 62 accepted changes and a difference in average wholesale price (AWP) of $2075 per month. Considering this is a maintenance medication that will be filled month after month, the annualized savings was estimated to be around $1.5 million. The next-highest dollar savings was for prednisone delayed-release tablets. Only 13 pop-ups triggered and all were accepted, and each 30-day supply changed represented a $3294 difference in AWP. Although mupirocin cream had the largest overall number of accepted changes, the magnitude of cost savings for this change was much smaller and represented a savings of $44 044 for the 91 accepted pop-up warnings (immediate savings for 1 tube, not including any refills). Overall, the total 260 positive responses represented a large magnitude of cost savings at just over $2.4 million annualized (based on a monthly cost savings ×12 for oral dosage forms and a monthly cost savings ×2 for topical products/injections).

Education and prescriber acceptance was an obstacle addressed with 1-on-1 provider education. In the first month alone, 10 prescribers were contacted directly by pharmacists to discuss the patient case and rationale for the alert, and efforts to outreach and educate are ongoing. Another barrier to overcome was directly related to a “no-cost to the patient” program affiliated with one of the epinephrine medication manufacturers. We are still assessing the impact of this program to our health system’s overall medication costs; however, this product represents the largest amount of negative switch responses, but each prescription may not represent a true cost savings opportunity (the difference in AWP for epinephrine products was $2673). Clinical pharmacists who resolved pop-up overrides noted that many of the high-cost, low-value target medications required prior authorization from insurances, and that there was an associated reduction in staff time needed for avoiding prior authorization when changing to the lower-cost alternative. This savings was not quantified for this project, but provider and staff satisfaction was noted.

Hospital Disaster Risk Assessment for Access and Functional Needs


Kevin G. Muszynski, BSc

Pomona Valley Hospital Medical Center

Background. Concept and Inception: During a chance meeting in 2016 between Steve Storbakken, director of emergency preparedness and environmental safety at Pomona Valley Hospital Medical Center, and L. Vance Taylor, chief, AFN Division of the California Governor’s Office of Emergency Services, Storbakken shared his vision of expanding hospital disaster preparedness for vulnerable populations. A partnership began with a mutual commitment toward developing a task force and ongoing program. Authority and Regulatory Requirements: In late 2016 the Centers for Medicare & Medicaid Services posted its Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule, an extensive set of regulations and recommendations to which all participating health care providers and suppliers were required to comply as of November 2017. Centers for Medicare & Medicaid Services also issued several sets of interpretations and guidance; the most recent required that the “unique vulnerabilities…of persons at risk,” including all those “with access and functional needs,” be addressed in detail. These rulings far exceeded the standards previously issued by The Joint Commission. Project Task Force: Joining Storbakken and Taylor on the task force was Kevin Muszynski, project manager in support services at Pomona Valley Hospital Medical Center. A team of health care and access and functional needs (AFNs) experts was assembled. The group met frequently, primarily thru GoToMeeting online meetings, and grew to include 2 MDs, a PhD, and several organization and agency leaders.

Intervention Detail. Goals and accomplishments include:

  • Recommendations for integration of AFN into emergency operations plans: created a comprehensive summary of recommendations to incorporate AFN planning into all 13 standards and 128 elements of performance in the emergency management chapter of The Joint Commission’s Comprehensive Accreditation Manual for Hospitals.
  • AFN Disaster Vulnerability Analysis Matrix: developed a data-driven worksheet that hospitals can use to assess their levels of preparedness for over 60 different AFN communities and to allocate their resources accordingly.
  • AFN Community Guidelines: compiled a list of AFN communities, their relative size, and distinctive needs using data from numerous AFN organizations and government agencies—notably California Governor’s Office of Emergency Services and the Federal Emergency Management Agency).
  • Integration of AFN into the hospital incident command system: hospital incident command system is utilized by hospitals nationwide and now internationally; revisions that will add AFN are being added to the 6th edition, including an AFN liaison officer position.
  • Hospital AFN Emergency Preparedness Resource Guidebook: the guidebook, currently in development, will serve as a compilation of AFN resources for emergency managers to use in their planning efforts and as a reference list of immediate contacts in all AFN communities for use in disaster response.

Presentations and Awards:

  • Accepted “IAEM-USA 2017 Partners in Preparedness Award” from the International Association of Emergency Managers at its annual conference, Long Beach, California, November 2017.
  • Presented at the California Hospital Association’s Annual Disaster Preparedness Conferences in Sacramento, California (September 2017) and Pasadena, California (September 2019).
  • Presented in 2019 at Southern California Association for Healthcare Risk Management in May, at the Association for Health Care Resource & Materials Management in July, and at the San Diego Association for Healthcare Risk Management in August.
  • Presented at The Joint Commission’s Annual Emergency Preparedness Conferences in Orlando, Florida in (April 2018), Washington, DC (April 2019), and Orlando, Florida (April 2020).
  • Published in The Joint Commission Resources’ Emergency Management in Health Care, 4th edition, June 21, 2019.

Outcomes and Impact. The AFN Task Force created a unique risk assessment matrix, similar to a hazard vulnerability analysis, using the Los Angeles County Emergency Medical Services’ Health Hazard Assessment and Prioritization format as its basis. The AFN Disaster Risk Assessment rates the level of risk to each of the AFN communities served by the hospital, from highest level of risk to lowest. Risk is calculated as: probability × (impact–resources). Probability is defined as the likelihood of need for assistance by each AFN community. It considers the relative size of each AFN community, its respective susceptibility to the effects of a disaster, and the historical need for assistance in disasters. Impact is defined as the potential for disproportionate harm to the health and well-being of AFN community members. It considers the potential level of harm in short-term emergencies of 24 hours or less, longer-term emergencies of 25 to 95 hours, and disasters of 96 hours or greater. Resources evaluates 10 specific areas:

  • Are each community’s needs addressed in the emergency operations plan and emergency management policies?
  • Are AFN service providers participants in the planning process?
  • Are AFN evacuation and transportation needs met?
  • Does staff receive training specific to each AFN community?
  • Are emergency medications available for each AFN community?
  • Are medical supplies available for each AFN community?
  • Is durable medical equipment available for each AFN community?
  • What is the patient surge capacity for each AFN community?
  • Has communication been established with AFN agencies and organizations?
  • Do drills and exercises include AFN communities? Do after-action reports include an AFN review?

Crossing the Intersection of Quality and Cost

Saria Saccocio, MD, FAAFP, MHA

Scott Hultstrand, JD, PCMH CCE

Prisma Health

Background. As value-based ambulatory care contracts have matured over the last 5 years, high performance in quality of care has transitioned from the main key to unlocking success to one among many challenging and complicating factors that must be addressed. The cost of care conundrum—often reflected in terms of overall payer spend per patient and impacted by ambulatory admissions/readmissions, emergency department (ED) utilization, imaging, specialist procedures, and medication—is now critical to success in Medicare, Medicaid, and commercial, value-based arrangements. Prisma Health’s ambulatory team, working through its Primary Care Council of physician leaders, leveraged its ambulatory chief medical officer and nursing, operations, and data/analytics leaders to develop a multilevel and faceted approach using physician practice accountability, transparency in performance assessment, and pathways to success with in-practice support. The goal was to implement a digestible plan of action that would allow physician practices in the ambulatory setting to lower costs of care and manage a larger patient population by opening additional access portals—while not sacrificing a continued commitment to the highest level of patient care quality. Along the way, patient perspective was considered by incorporating local patients as voting members of the council and hosting patient focus group panels from diverse age, gender, and racial backgrounds. As our region progresses rapidly toward full capitation, the future of health care in our area will only be as secure as our commitment to understanding how best to help physician practices and patients navigate the challenges of cost, quality, and access. Most of the country is facing similar challenges around ambulatory practices while simultaneously under the same time crunch; we have to learn how to do this together quickly if we are to maintain our market share in the midst of significant outside competition.

Intervention Detail. The approach we used included performance improvement and operational processes cascaded via a curriculum calendar using leadership structures created for scale and physician contractual alignment, with transparent data reporting on the progress. This multifaceted approach included:

  • Clinical quality: introduction of the Plan-Do-Study-Act cycle to improve patient care on quality measures that also impact cost of care (especially controlling high blood pressure, cancer screenings, and the flu vaccine), with goals in the entire organization (up to the CEO) contingent our performance.
  • Medicare annual wellness visits (AWVs), transitional care management (TCM), and chronic care management (CCM): utilizing additional Medicare payment for providing additional wellness, chronic, and after-hospital care, we built a process to track encounters, developed a user-friendly electronic medical record pathway to success, and motivated physicians and staff with this support and transparent data sharing.
  • Cost of care: Led by our Primary Care Council, we are reporting ambulatory-sensitive admissions and ED utilization in 2020, as well as working with 2 pilot practices to understand how best to hold practices accountable for these important cost and quality measures.

Reporting included the following to share progress and motivate improvement:

  • Clinical quality: a proprietary, web-based scorecard using electronic medical record data detailing clinical quality performance of individual physicians, including transparent comparisons with their practice colleagues, specialty peers, and the entire network of clinicians.
  • AWV, CCM, TCM: a monthly report collected from internal billing data, reported publicly to physician and practice leaders, and cascaded to all physicians with transparent, practice-level performance.
  • Cost of care: starting with 2 practices, ED and hospital utilization data is being shared, with an intent to scale to all practices in 2020, along with a plan to introduce a total cost of care metric at the physician level in 2020.

Outcomes and Impact. Clinical quality: Sixty-three percent of our hypertensive patients had their blood pressure controlled in 2018, with improvement to 72% of our hypertensive patients in control in 2019, reflective of significant standardization of processes across the clinical care continuum. Also, for the first time in our system’s recorded history, we improved in December instead of dropping in the last month of the year. Breast and colorectal cancer screening realized 6% and 4% (respectively) improvement in 2019 due to changes in practice workflow and access points. Finally, our influenza vaccination rates rose considerably in the first 3 months of the 2019–2020 flu season (14% higher than 2018–2019) due to an implemented Plan-Do-Study-Act cycle quality improvement project. AWV, TCM, CCM: for Medicare AWVs, we achieved a 17% rate of AWV for our Medicare population in our baseline year (2017). After changing our process, providing a pathway to success, and creating transparent and accountable reporting, 2018 AWVs hit 35%, and in 2019 topped 50% (>36 000 AWVs). For TCM, we moved from a few TCM visits in the first 9 months of 2019 to having all of our primary care practices achieving TCMs in the fourth quarter of 2019. Some are already at the 50% mark. We also looked into the impact of TCM on heart failure, and the readmission rates when compared with patients who do not use TCM (even those who visit primary care) are significantly lower. We are still implementing CCM as of this writing. Cost of care: Although we have just begun the journey of sharing cost-of-care data, we have positive feedback and have initiated action plans at our pilot practice. This is an ongoing learning process (as it is throughout the country).

A Comprehensive Program to Promote Biosimilar Acceptance in a Large Health Care System

Sophia Z. Humphreys, PharmD, MHA

Elie M. Bahou, PharmD, MBA

Providence St. Joseph Health

Background. U.S. health care spend reached $3.65 trillion in 2018. Of that, $344.5 billion was spent on prescription medications. According to the IQVIA Institute for Human Data Science, new specialty medications are among the primary drivers for the increase in overall drug costs.1 The majority of these high-cost specialty medications are large-molecule biologic medications. While there are generic alternatives for small-molecule chemical medications, there are no generics for large-molecule biologic medications. However, there are new, less costly medications called biosimilars that compete with high-cost biologic reference compounds. These new biosimilars are highly similar to the reference compounds in efficacy, safety, and immunogenicity. The emergence of biosimilars has introduced new challenges and opportunities. Biosimilars have been widely used in Europe. In the past 13 years, they have been used for 400 million patient days.2,3 Although the Food and Drug Administration (FDA) approved 26 biosimilars by the end of 2019, their uptake has not been as robust as in Europe. One reason is that the biosimilars often face patent litigation. Thus, many FDA-approved products have a delayed launch date. Reference compound manufacturers also offer significant financial incentives to third-party payers in the form of a rebate, which slows down payer uptake of biosimilars. Furthermore, health care systems often face volume-based tier prices, rebates, and other contracting methodologies utilized by reference compound manufacturers to maintain market share. In addition, physicians and patients have limited experience with biosimilars. Their slow acceptance can be another factor hindering biosimilar uptake. Providence St. Joseph Health (PSJH) system pharmacy established its medication utilization management (MUM) program to reduce costs without sacrificing the quality of patient care. PSJH achieved over $10 million in savings through effective utilization of biosimilars. The following discussion outlines the strategies used in our successful MUM programs for biosimilars.

Intervention Detail. This program required a multidisciplinary team. The system pharmacy clinical service team monitored the biologic medication pipeline closely, evaluated relevant clinical data, and developed an expedited formulary review process. The pharmacy and therapeutics committee reviewed relevant scientific data and approved formulary status of all 26 FDA-approved biosimilars before products were launched, which significantly enhanced our negotiation power for biosimilars and their respective reference compounds. The financial impact of biosimilars varied depending on account types. The group purchasing organization purchase prices were usually lower than the wholesale acquisition cost prices. The 340B drug pricing program accounts are particularly interesting. Pursuant to the new Centers for Medicare & Medicaid Services reimbursement methodology, biosimilar products within the pass-through period are reimbursed at the average sales price plus 6%, instead of average sales price minus 22.5% for the reference compound. Thus, PSJH consciously selected all newer biosimilar products (within the pass-through period) as system-preferred products. Pharmacoeconomic analysis was a crucial part of this program. Inpatient and outpatient billing and reimbursement methodologies were different; therefore, the financial impact of biosimilars varied. Inpatient reimbursement was usually based on diagnosis-related group, so the lowest-cost biosimilar was chosen as the preferred product. In contrast, outpatient reimbursement depended on payer preferences. We built Epic tools to guide all inpatient prescribing to the preferred biosimilars. The Epic-guided prescribing streamlined physician and pharmacist workflow, simplified the biosimilar ordering process, and improved efficiency. However, we used a different Epic build for outpatient infusion centers to allow outpatient physicians the freedom to prescribe a reference compound or a different biosimilar, if the patient’s payer preferred them. PSJH’s data scientists and financial analytic team were great partners for this MUM program. They tracked purchases, calculated savings, and evaluated our regional and local performance—all of which guided our focus for process improvements.

Outcomes and Impact. These programs required collaboration among pharmacists, physicians, data scientists, finance analysts, business office personnel, and health care informatics professionals. We simplified the approval process for biosimilars and enhanced physician involvement in the biosimilar MUM initiative development process. In 2019, PSJH’s biosimilar review and approval policies and procedures were updated and the review process was shortened to less than half of its historical length. By the end of 2019, all 26 FDA-approved biosimilars were reviewed and added to the PSJH system formulary. We continuously review and add new FDA-approved biosimilars to the current formulary. In 2019, 4 biosimilar-oriented MUM initiatives were implemented and total annual biosimilar-associated drug cost reduction exceeded $10.6 million. In 2020, PSJH added the biosimilars to Avastin, Herceptin, and Rituxan to MUM initiatives. By June 2020, these biosimilar MUM initiatives saved over $4.4 million on biologic drug spend and the average biosimilar adoption rate reached 49%. All biosimilar MUM initiatives were implemented via Epic build to guide prescribing from brand name reference compound to PSJH-preferred biosimilars. This method streamlined workflow for health care providers, increased efficiency, and improved patient access to care. The potential reduction of labor cost, risk of medication errors, and medication waste will be evaluated in the near future. Biosimilars and their reference compound spend and utilization patterns are monitored and reported to the system pharmacy and medical and finance leaders to guide future MUM efforts. In conclusion, this comprehensive, multidisciplinary MUM model can enhance systemwide acceptance of biosimilars, decrease biologic medication cost, simplify provider workflow, and improve overall system sustainability.

1.IQVIA Institute. Medicine Use and Spending in the U.S. A Review of 2018 and Outlook to 2023. The IQVIA Institute Report. 2019. Accessed July 3, 2020. https://www.iqvia.com/insights/the-iqvia-institute/reports/medicine-use-and-spending-in-the-us-a-review-of-2018-and-outlook-to-2023.

2.Maréchal-Jamil J. Comment From Biosimilar Medicines Group, a Medicines for Europe Sector Group. Regulations.gov website (posted by the Food and Drug Administration). June 26, 2017. Accessed August 3, 2020. https://beta.regulations.gov/document/FDA-2017-N-2732-0006.

3.IQVIA Institute. Advancing Biosimilar Sustainability in Europe: A Multi-Stakeholder Assessment. 2018. Accessed January 4, 2020. https://www.iqvia.com/insights/the-iqvia-institute/reports/advancing-biosimilar-sustainability-in-europe.

Choose the Environment: The Sustainable Practice of Anesthesia Gas Standardization


Brian Chesebro, MD

Providence St. Joseph Health

Background. There are currently 3 anesthesia gases commonly used for general anesthesia, of which 1 (desflurane) is about 20 times more potent as a greenhouse gas (GHG) and about twice the cost as another clinical equivalent, sevoflurane. The impact of these gases on the environment is not commonly measured but is significant, with 1 clinician in a typical practice emitting as high as 125 metric tons of carbon dioxide equivalents per year. By selecting a different gas, this could be reduced by over 95%. Despite these differences, there is no evidence of significant differences in clinical quality between desflurane and sevoflurane. With the goals of reducing the GHG effect while also reducing costs without compromising quality, we measured the variation in desflurane use within our 51 hospitals, implemented a plan to change practice, and measured the outcomes. This project required creative and innovative, collaborative efforts between clinicians and supply chain leaders.

Intervention Detail. Beginning with the 8 hospitals in the Oregon region, anesthesia agent choice, cost, efficiency index, and GHG effect were measured for each hospital and clinician. Practice variations between clinicians and between hospitals were also noted. For clinical quality, out-of-operating room (OR) time (from end of case to wheels out of the OR) and time in the post-anesthesia care unit were also measured. Index and observed periods were measured in 6-month increments for 3 years. Based on initial measurements, an education campaign using data and clinical evidence was launched at specific sites by the regional anesthesia champion. Education was also provided to the supply chain team around challenges with current contracts and vendor relations. This included contractual volume purchasing requirements tied to capital equipment that are specific to desflurane vaporization. Alignment of clinical and environmental outcomes with supply chain goals was critical to the intended outcome.

Outcomes and Impact. Within the Oregon region during the 3-year measurement period, desflurane use dropped from 43% to 7%, resulting in a GHG effect reduction of 79% (from 2500 to 525 metric tons of carbon dioxide equivalents/period) and a cost reduction of 57% (a $636 000 savings per year). There was no difference in the out-of-OR time or post-anesthesia care unit time. Improvements at individual hospitals and for individual clinicians were consistent. The total reduction of GHG effect is equivalent to approximately 4.5 million fewer miles driven by a Hummer. Using the Oregon region as a model, similar measurements and strategy were implemented systemwide. In 2019, desflurane use decreased from 16% to 8% across the system.

Machine Learning for High-Risk Readmission Identification

Patrick Hilden, MS

Ryan McCormick, MPA

Saint Barnabas Medical Center

Background. Addressing unplanned hospital readmissions presents a crucial opportunity to increase the quality of patient care and reduce costs. Understanding the effect of patient and treatment characteristics on readmission risk is critical to develop and tailor strategies to reduce unplanned readmissions. In order to assess risk factors for readmission, it is necessary to obtain patient-level data on demographic and treatment characteristics of admitted patients. However, compiling such data is often a difficult task when disparate systems are used to capture various aspects of patient care. Accurately compiling these sources can quickly become a resource-intensive task. The Vizient Clinical Data Base is a key resource for assessing readmission rates within an institutional population, allowing for readmission assessment to be aggregated in an endless number of ways. Further, the patient-level data provided within a Vizient case profile provides an extensive amount of information on individual patients and their diagnoses and treatment characteristics in a format that is ideal for the application of more advanced data analytic techniques. Machine learning techniques have become a go-to resource when the goal is to predict a binary patient outcome (eg, day 30 readmission yes/no), particularly when the number of potential features associated with that outcome is large. In the next section, using sepsis patients as an example, we highlight how a machine learning-driven analytic approach to assessing the risk of readmission can be used to gain additional insight into what factors are and are not associated with readmission by day 30.

Intervention Detail. Using the most recent available institutional data in the Vizient Clinical Data Base (2018 Q3 through 2019 Q2), we identified patients with any sepsis diagnosis (International Classification of Diseases, 10th Revision [ICD-10] R652, R6520, R6521) and subsequently identified whether or not each patient had an unplanned readmission within 30 days. We applied all standard exclusion criteria for index and readmission cases, per the default Vizient Clinical Data Base settings. For patients with multiple sepsis admissions during this time period, only the first readmit was included in the analysis. Demographic and treatment variables incorporated into our analysis included age, race, ethnicity, primary payer, severity of admission, and weekday/weekend admission timing—all of which are provided within the case profile. Using the ICD-10 diagnosis details provided, we also calculated individual comorbidities based on the Elixhauser approach, which allowed for 31 additional comorbidities to be identified based on the diagnosis codes, as well as an overall comorbidity burden given by the total number of a patient’s comorbid conditions. The Elixhauser comorbidities have been validated in numerous studies and cover comorbid conditions such as hypertension, congestive heart failure, diabetes, malignancy, and others. Using a set of over 40 demographic and treatment features, we applied a logistic regression machine learning approach to assess the impact of each feature on readmission risk, and to determine jointly which features were predictive of an unplanned readmission by day 30. In order to assess the accuracy of our model, we divided our data set into training and validation cohorts.

Outcomes and Impact. A total of 655 sepsis patients were identified from 2018 Q3 through 2019 Q2, 116 (17.7%) of which had an unplanned readmission within 30 days. The data was separated into 443 (2/3) and 222 (1/3) patients in the training and validation sets, respectively. When assessing the impact of patient features on the training data set, features that were jointly associated with readmission risk included the overall Elixhauser comorbidity burden, specific Elixhauser comorbidities of solid tumor and weight loss, and patient gender. When applying the previous model to the validation cohort, the average predicted odds of readmission among readmitted patients was 52% greater than that among nonreadmitted patients (0.19 versus 0.29), highlighting a significant increase in readmission discrimination when using the prediction model. Using a predicted likelihood threshold of 15% to delineate low- and high -risk patients, 11% of low-risk patients were readmitted within the validation cohort, while 26% were readmitted within the high-risk cohort. The previous information highlighted significant additional insight into factors associated with readmission when leveraging patient-level Vizient case reports and accompanying these with relevant comorbidities based on ICD-10 diagnosis codes. The ability to identify factors associated with changes in the readmission risk provides valuable information that future interventions can leverage to focus readmission reduction efforts on patients of particularly high risk. Additionally, new inpatient cases can be identified for the previous risk factors to tailor their post-discharge care to avoid unplanned readmission. While this work has focused on readmission in the sepsis population, our analysis is meant as an example of what additional analytic approaches are possible using the Vizient Clinical Data Base. Similar analyses could be done in an endless number of subpopulations, and with respect to other outcomes, including costs and length of stay.

Decreasing Inpatient, Cancer-Directed, Medication Expenditures Utilizing a Novel Formulary Pathway

David Leedahl, PharmD, BCPS, BCIDP, BCCCP

Sanford Health

Background. In 2017, our hospital observed a linear increase in cancer-directed medication inpatient expenditures month-over-month (averaging $27 965/mo). In the majority of hospitalizations, it was also discovered that the bundled payment for a hospitalization did not account for the cost of these medications. For the patient, we found continued opportunities to optimize timing of inpatient anticancer therapy, allowing for investigation of insurance coverage in the ambulatory setting, improved patient performance status, and adequate time to discuss goals of care. Our purpose was to decrease suboptimal use of inpatient anticancer therapy and decrease costs by establishing a streamlined formulary list, criteria for use, and mutually agreed upon workflow. Clear guidance to navigate these clinical, operational, and financial questions presents a critical need for health systems and pharmacy leadership who are tasked with the noble work of stewarding health care resources.

Intervention Detail. In January 2018, the oncology formulary and medical hematology/oncology groups established a clearly defined list of inpatient formulary, cancer-directed medications with clinical criteria for use. Requests for nonformulary, anticancer therapy were evaluated utilizing a standard request form that was circulated to hematology/oncology physician peers. The pathway created a mutually agreed upon process for requesting nonformulary, inpatient anticancer therapies and removed barriers to standard-of-care therapies for malignancies that are best managed in the hospital. The nonformulary request forms and approval/denial results were presented monthly at our oncology formulary and hematology/oncology provider meetings, providing transparency and a venue for discussion and feedback.

Outcomes and Impact. Despite an increase in monthly inpatient discharges year-over-year (2017: 2258; 2018: 2339; and 2019: 2424) and increase in case mix index (2017: 1.68; 2018: 1.79; and 2019: 1.82), the average monthly cost of nonformulary, inpatient, cancer-directed therapy decreased from $27 965 per month in 2017 (pre-intervention) to $10 217 from January 2018 to June 2019 (post-intervention)—a 63% reduction in monthly expenditures that was sustained for 18 months. Clear roles for team members, timely circulation of nonformulary forms, monthly review of nonformulary requests for evaluation/feedback, and a culture of open dialogue all were critical to program success.

Demonstrating Value to Support Growth of a Transitions of Care Pharmacy Program

Janjri Desai, PharmD, MBA

Michael Xu, PharmD, MBA

Jamie Kuo, PharmD, BCCCP

Stanford Health Care

Background. The average cost of an adverse drug event (ADE) was approximately $15 011 in 2018, using literature estimates and adjusting for inflation in health care costs.1 The Joint Commission identified the ineffective management of care transitions as a contributing factor to adverse events and readmissions. Similarly, the Centers for Medicare & Medicaid Services implemented the Hospital Readmissions Reduction Program in 2012 to lower the burden of health care costs due to preventable readmissions. The Transitions of Care (TOC) pharmacy program at Stanford Health Care (SHC) began as a direct result of this program. The goal of the TOC pharmacy program is to reduce medication-related errors as patients transition in and out of the inpatient setting to avoid preventable readmissions. In 2016, the program grew after internal audit data was presented demonstrating the impact of pharmacist intervention on admission and discharge medication list errors. Five pharmacist full-time equivalents (FTEs) now obtain admission medication histories, perform discharge medication list reviews, and provide discharge medication education to patients on medicine, general cardiology, heart failure, neurology, and hematology/oncology services. In addition, the TOC pharmacists participate in multidisciplinary team care rounds to proactively assist with discharge planning by identifying medication access issues. The 2016 program expansion proposal included a vision to provide such services to all inpatients at SHC with the intent of improving safety during care transitions and improving medication reconciliation completion rates for the institution. However, hospital administrators granted only 3.0 FTEs in addition to the existing 2.0 FTEs as proof of concept but also due to the cost burden of implementing such a large program. To strengthen the business case for further expansion, a pharmacy residency project in fall 2018 sought to quantify the impact of the program expansion—not just on the previously established error rate, but on overall cost avoidance to the institution.

Intervention Detail. Between October 2018 and March 2019, TOC pharmacist intervention documentation was tracked and analyzed. A workflow based on existing literature was developed to classify interventions based on their clinical severity as low, medium, high, or very high significance. Each clinical intervention was then assigned a probability of preventing an ADE based on previous studies classifying interventions made by clinical pharmacists. The study authors independently reviewed all clinical interventions and provided ongoing education to address any potential discrepancies and ensure standardized categorization of interventions among TOC pharmacists. Using literature estimates and adjusting for inflation in health care costs, we estimated our average ADE cost to be $15 011. Using Bureau of Labor statistics for the average wage of a pharmacist in California and adjusting for mean fringe benefits of 32.2%, the cost of 5 full-time pharmacists for the study period was estimated to be $461 675. The program return on investment (ROI) was calculated based on the cost avoidance of ADEs prevented by pharmacist interventions and TOC pharmacist total compensation.

Outcomes and Impact. During the 6-month period, 1349 interventions were analyzed. An estimated 215 ADEs were prevented, 25% of which had “high” or “very high” clinical significance and 54% of which had “medium” clinical significance. The annualized cost avoidance of pharmacist interventions was estimated to be $3.2 million. After accounting for pharmacist compensation, an ROI of 597% was calculated for the TOC program. This data was then presented to SHC pharmacy and quality department executives to reexplore expansion of the TOC program to enhance patient safety, avoid preventable readmissions, and improve the overall patient experience. Furthermore, the methodology employed to calculate the ROI of pharmacist intervention is now being applied to propose new inpatient clinical pharmacy services at SHC. While the initial study was time- and resource-intensive, it has become a model that can easily be applied and adapted to various pharmacy care settings to demonstrate pharmacist value in a manner that resonates with clinical and nonclinical administrators alike.

1.Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307–311.

2.Bureau of Labor Statistics Beta Labs. Inpatient Hospital Services in U.S. City Average, All Urban Consumers, Not Seasonally Adjusted. BLS Data Viewer. 2019. Accessed April 10, 2019. https://beta.bls.gov/dataViewer/view/timeseries/CUUR0000SS5702.

Transforming Diabetes Care: A Journey Toward Top-Decile Performance

Paul F. Murphy, BS, CSSBB

Joshua D. Miller, MD, MPH

Danielle Kelly, MS, AGNP-C, RN, CDCES

Stony Brook University Hospital

Background. The diabetes epidemic presents an alarming trend across the United States, with over 30.3 million people having the disease, according to 2017 Centers for Disease Control and Prevention statistics.1 This accounts for nearly 10% of the population—25% of whom are undiagnosed. The World Health Organization estimates that 1 in 3 people globally will have the disease by the year 2050. The cost of diabetes care has a tremendous impact on the U.S. health care system, totaling $327 billion spent—a figure that continues increasing annually.2 Over half of this is attributed to inpatient care. As a chronic secondary diagnosis, diabetes leads to longer lengths of inpatient stay and increased readmission risks. Patients with diabetes generally require more medications and procedures during admission, exhibit poor wound healing and greater infection risk, and experience higher in-hospital morbidity and mortality rates. Over the last 5 years, the incorporation and inclusion of a multidisciplinary diabetes advisory committee within the hospital quality strategy has provided the oversight and enthusiasm instrumental in enhancing care for over 7000 inpatient visits with diabetes each year at Stony Brook Medicine. The group began by defining the population with nationally recognized diagnosis codes, allowing for continued tracking of this defined population over time while ensuring adequate and ongoing review of clinical data associated with this population. Dashboard monitors were developed using Tableau software, identifying these same patient groups with a clinical flag-based criteria for diabetes indicators, or glucometrics. With a baseline population established and monitored, interventions were implemented over time and monitored through these real-time dashboards, including standardized insulin order entry, insulin pump safety, clinical nutrition interventions, standardized hypoglycemia protocols, and diabetes education.

Intervention Detail. The improvements in diabetes outcomes were based on 3 principles: (1) standardization of protocolized care for the management of patients with diabetes, aligning with American Diabetes Association standards of care; (2) novel development of a defined and automated tracking program to monitor and flag inpatients in real time; and (3) creating a culture of diabetes excellence institution-wide, founded on novel educational paradigms for clinician and trainee engagement. Standardization of care was largely based on the development of computerized physician order entry and a vetted educational initiative to relate these changes to all staff members in the hospital. Utilizing the electronic medical record, the team was able to minimize any rogue orders and monitor these instances over time. These standardized order sets are delineated by the amount of insulin a patient may require: low, medium, or high dosing based on insulin sensitivity with hypoglycemia safety nets. Additional subphases include perioperative and insulin pump care paths for appropriate recognition, documentation, and management. The Tableau tracking development was driven by teamwork between clinical, analytic, and information technology staff to test, develop, and review each iteration of the dashboard monitors through Plan-Do-Study-Act cycles. A second historic dashboard was designed to monitor these same flags on a trended basis over time. The institution has thus developed the ability to determine all inpatients with a history or new risk of diabetes while simultaneously tracking their outcomes each hour, month, and year of their care. Our multidisciplinary team of champions ensured that excellence in diabetes care impacted all levels of the institution, driven by daily review of these dashboards by various services for clinical opportunities, including carbohydrate-consistent meals, certified diabetes education, and/or endocrine consultation. Further implementations of insulin infusion order sets for critically ill patients and enteral/parenteral feed policies followed a similar cycle of process improvement.

Outcomes and Impact. Current data analyses report significant and sustained improvements from a 2014 baseline period. A1C availability within 90 days of admission increased from 50% at baseline to nearly 90% for the last 2-year period. Thirty-day readmission rates decreased from 16.82 at baseline to 12.24 in 2019 while maintaining a defined population case mix index of 2.0. Using the Vizient Clinical Data Base, Stony Brook was able to compare against institutions of similar size and establish appropriate goals regarding readmission rates. In accordance with American Diabetes Association standards of care, Stony Brook has worked with our laboratory department to define thresholds of hypoglycemia and critical value reporting, with rates of severe hypoglycemia near 0.05% for the inpatient population with a history of diabetes. This includes alignment with the Vizient insulin-related hypoglycemia metric, newly introduced on the Vizient Quality & Accountability Performance Scorecard. These hypoglycemic events are now included within a diabetes “never-event” review and reported at each committee meeting, along with opportunities for improvement. The development of the Tableau dashboard reporting includes these metrics, as well as utilization of insulin power plans, compliance with appropriate carbohydrate-consistent diets, and rates of hyperglycemia and hypoglycemia. Further, reductions in length of stay and 30-day readmissions have resulted in over $7 million in annual savings to the institution.

1.U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Estimates of Diabetes and Its Burden in the United States. https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed December 2019.

2.American Diabetes Association. Economic costs of diabetes in the US in 2017. Diabetes Care. 2018;41:917–928.

Start Small Then GO BIG: Sustaining a High-Reliability Management System

Sridevi Donepudi, MD, MMM, FAAFP

Chad Yeager, RN, MSN

Stormont Vail Health

Background. Stormont Vail Health’s vision is to be a national leader in providing compassionate, high-quality, and efficient integrated care. To enable and accelerate our progress toward that vision, leaders at Stormont Vail Health (SVH) knew that it was going to take everyone’s effort, as well as new methods and capabilities, to help the organization achieve these goals and continue to thrive into the future. Similar to other organizations, SVH was facing pressure to optimize value for patients and the community and remain viable in the future, despite tightening financial conditions and capacity challenges. SVH began the journey by deploying a continuous improvement strategy in 2013. The initial approach was oriented toward small focal improvement projects utilizing Lean Six Sigma methods. With the success and momentum from these early wins, the continuous improvement strategy evolved and grew larger in scope over the years to eventually become part of the cultural fiber of the organization.

Intervention Detail. Changing a culture to one based on continuous improvement and high reliability is not something that happens overnight, and it requires dedicated leaders focused on a long-term vision. Building on the successes and momentum related to the initial improvement projects, SVH launched a comprehensive and robust management system in 2015 with the assistance of Vizient consulting services. Our management system includes 3 components: strategy deployment, strategic improvement/execution, and a daily management system. Ensuring that improvement work aligns strategically is an essential part of any management system. Once the improvement priorities were established, we deployed the use of cross-functional teams to execute on those improvement plans using improvement tools appropriate to the type of innovation needed. Value stream mapping events, rapid improvement events, and 5S and 3P (Lean) innovation workshops are a few tools used to achieve breakthrough performance in areas that are of higher strategic importance and typically cross multiple departments. The daily management system is the foundation of SVH’s management system. Since 2015, over 900 staff (from executives to frontline employees) have been trained in A3 problem solving and over 300 in Lean management systems. In 2017, we deployed daily management with an administrative system performance board and huddle that occurs every weekday and involves all leadership from the executive and director levels. Daily management drives transparency and a culture of quality, safety, and accountability toward our strategic areas of focus. We also deployed a system of departmental performance boards and huddles that enabled us to drive improvement throughout the organization. We also deployed over 100 departmental performance boards and huddles that facilitate daily continuous improvement and strategically align departmental improvement work.

Outcomes and Impact. Over the 7-year journey to deploy SVH’s management system, we conservatively recorded nearly $15 million in cost savings and/or revenue generation directly associated with improvements tied to the deployment of our management system. In addition, we have seen (1) a 10% reduction in our inpatient length of stay, resulting in an estimated 1400 additional patients we were able to accept while utilizing the same physical footprint; (2) a 72% reduction in our hospital-acquired Clostridium difficile standard infection ratio by deploying cross-functional teams to understand root causes and implement countermeasures; (3) a 56% reduction in inpatient medical necessity denials, resulting in an estimated $1.4 million in revenue capture through improvement in first pass quality, consistency of hand-offs and accuracy of initial patient status; and (4) more than 800 A3 projects initiated by staff from all around the organization. Apart from the objective results, there is also practical evidence that these methods have become a part of the fiber of our culture. We now have a common language to discuss problem-solving and it is common to be in a meeting and hear “we need to do an A3,” as opposed to jumping to solutions that existed previously. Over time, we have also had an increasing number of inquiries from other organizations requesting to benchmark and observe our management system in action. One of the more notable visitors was ZDoggMD, who observed both our departmental huddles and our administrative huddle and planned to highlight our organization as a “Bright Spot” in presentations nationally. All in all, we are proud of the progress that we have made thus far deploying our management system and are excited to see where our journey takes us.

Community Partnerships Reduce Opioid Overdose Deaths and Reduce Emergency Department Visit Costs

E. Sue Thompson, MSN, RN, CNML

SwedishAmerican Health System, A Division of UW Health

Background. Opioid overdose kills approximately 5 people every hour in the United States. In 2016, the Illinois county of Winnebago ranked 12th statewide for overdose deaths per 10 000 people. Winnebago County Health Department’s Drug Overdose Prevention Program initiated a naloxone distribution program in 2017 through a State Opioid Response grant (No. H79TI081699) that allows for free naloxone distribution and opioid education in Winnebago County. The Mobile Integrated Healthcare Team and SwedishAmerican Health System began joint projects in 2018 to address needs in the community related to the opioid overdose epidemic in conjunction with the Winnebago County Health Department program. In 2019 SwedishAmerican Hospital’s emergency department (ED) entered into a memorandum of understanding with Winnebago County Health Department to provide a naloxone kit and overdose education to each overdose patient transported to SwedishAmerican EDs. SwedishAmerican Hospital is one of the few hospitals in the state to have an memorandum of understanding to participate in this program. The geographic location of the Rockford SwedishAmerican ED lies in the city center. This is the closest ED for a majority of Rockford patients suffering from opioid overdose. Project goals include reduction in opioid overdose-related deaths and in associated costs in the ED.

Intervention Detail. Naloxone kits are provided free of charge to the hospital and subsequently, there is no charge to patients and families. Kits are funded by the State Opioid Response grant. Seventy-three percent of opioid overdose patients are between the ages of 30 and 59. Our process includes the following: (1) training and education is conducted for hospital and clinic nursing staff regarding naloxone administration, patient and family education, and community resources; (2) patient, family, and community members are provided naloxone kits and education; (3) overdose patients are provided naloxone kits and education prior to discharge as inpatients and from EDs; and (4) post-discharge, a community paramedic visits the patient’s home within 48 hours to provide naloxone education. We provided over 150 hours of training to more than 1900 participants in 2019.

Outcomes and Impact. In 2018, opioid-related overdose deaths peaked at 159 in Winnebago County. In 2019, opioid-related overdose deaths dropped to 130—a 19% decrease in opioid-related deaths due to overdose from 2018 to 2019. Winnebago County coroner Bill Hintz attributed the decrease of opioid-related overdose deaths to community outreach and naloxone training and education. We achieve a cost avoidance of $168 750 in ED-associated costs for the treatment of opioid-related overdoses, including associated training costs. Partnerships with community substance abuse treatment centers have also positively impacted patient recidivism and long-term recovery.

Clinical Command Centers: Automating Care Delivery

Peter T. Chang, MD

Tampa General Hospital

Background. Efficiency is a cornerstone of the Vizient domains. At Tampa General Hospital, we approached our capacity issues by leveraging use of a clinical command center (CareComm) to advance care progression, mitigate discharge barriers, fortify patient safety, and create a process-based approach to patient flow. The idea of centralizing hospital operations to leverage real-time insights, employ predictive analytics, and predict events using artificial intelligence serves as a driving force for improvement and change. We are constantly using data from our command center to create a results management system for our process improvement projects. Once issues or problems are identified, frontline team members and leaders assemble to identify process improvement opportunities and select the analytics that will support and sustain the improvement. In essence, the team, our analytics, and our organization are able to continually evolve as improvements are made. In the last year, Tampa General Hospital added 30 beds of additional capacity from improved efficiency without constructing a single new bed.

Intervention Detail. The design of Tampa General Hospital’s new clinical command center is based on collaboration and innovation. Frontline team members, leaders, and executives assembled at the start of the project to identify the issues CareComm would solve. Two years ago, our observed-to-expected length of stay (LOS) was ~1.6 (using the Centers for Medicare & Medicaid Services-defined geometric mean LOS as the expected LOS). We designed a system that relies on colocated, process-driven, team-based collaboration instead of individuals and single point of failure processes. The heart of CareComm is based on the team and analytics. We strive to base our entire effort on reacting to real-time insights, using predictive analytics to proactively manage quality and outcomes and deploying artificial intelligence algorithms to prevent delays in care and avoid harm. We also wanted to convey a sense of urgency across the organization to embrace patient flow. CareComm closely follows the outcome metrics of LOS, hospital volumes, discharge times, and utilization. Behind each of these outcome metrics is a variety of process measures that serve as the basis for interaction between CareComm and the care that occurs at the bedside. For example, we are using multidisciplinary rounds to identify care progression delays and discharge barriers, which we then escalate from the bedside to the CareComm team. Our CareComm analytic tiles allow team members both in the center and on our units to react to trends as they happen. We are decreasing our reliance on historical reports to manage change. This allows the organization to be significantly more agile in our approach to process improvement.

Outcomes and Impact. Since the inception of the project in 2018, 12 000 excess days were eliminated and our observed-to-expected LOS is now 1.3-1.4, down from an average of 1.6 (compared with the Centers for Medicare & Medicaid Services’ geometric mean LOS). The value of our efforts can be quantified by the estimated addition of 30 beds without constructing any new beds. For the last few years, Tampa General Hospital was operating at capacity. During the last year, we’ve seen emergency department volume increase by 8%, inpatient admissions by 7.5%, and observation admission by 17%. The only way the hospital sustained these growth numbers the last fiscal year was through the organization and collaboration of CareComm and the entire Tampa General Hospital team. Last year we broke the Vizient observed-to-expected LOS benchmark of 1 and are currently ranked 19th in the efficiency domain. From a patient perspective, we’re eliminating time between events (eg, shorter order to complete times for diagnostic testing, faster identification of symptoms/diagnosis, and accelerated treatment delivery) to safely expedite care.

Implementing Electronic Care Pathways to Improve Patient Care and Reduce Length of Stay

Tatyan M. Clarke, MD, FACS, FASMBS

Joseph J. McComb, DO, MBA

Kathleen Needham, RN, MS, CPHQ, LSSBBC

Temple University Health System

Background. Temple University Hospital (TUH), an academic, level I trauma center with more than 700 beds, performs over 12 000 inpatient operations and nearly 17 000 outpatient operations annually. TUH is also a safety net hospital, supporting the most underserved patients in Philadelphia and the surrounding region. The hospital was struggling financially due to, at least in part, a challenging payer mix and system inefficiencies. We determined that implementing electronic clinical pathways could be a significant part of the solution. The goals of electronic care pathways are to reduce system inefficiencies and reduce variation in patient care, thus resulting in shorter hospital length of stay (LOS) for specific surgical populations. The pathways are grounded in the most current evidence-based literature. Each pathway defines the sequence and timing of interventions, optimal patient progression and patient outcomes, and provides the structure for data collection and analysis. TUH started with a relatively small patient population (ie, colorectal surgeries) where there was an existing pathway framework (ie, enhanced recovery after surgery). This was intentional to test the pathways and provide an initial win. From there, we expanded to elective orthopedic hip and knee surgeries. This patient population had a larger volume and some existing structure. The team was able to formalize the structure and improve system inefficiencies. The third pathway was created for all coronary artery bypass graft (CABG) and valve surgeries. This surgical population had no existing framework or standardization. This was the most challenging of the pathways to execute, but also resulted in the most significant reductions in LOS and system inefficiencies. The reports created via the pathways provide real-time and retrospective audits of specific patient outcomes. These allow TUH to address issues in real time while aggregate data assists in identifying opportunities for improvement. TUH is now spreading the pathways to another hospital in our system and considering which pathway to implement next.

Intervention Detail. As with any successful initiative, a multidisciplinary team was assembled with stakeholders from each relevant area for each pathway. Our teams consisted of information systems (ISs) analysts of varied expertise, clinical office staff, inpatient nursing, critical care nursing, perioperative services and staff, anesthesiologists, physical therapists, pharmacists, and the respective advanced practice providers and faculty physicians from each surgical specialty. The teams were facilitated by a clinical project manager, directed by a medical informaticist, and supported by an executive sponsor.

Additionally, TUH appointed a medical director to oversee pathway implementation and monitoring. Initially, clinical team members met several times to review current order sets and evidence-based practice from the literature. This group ultimately created the care pathway for each surgical population and outlined the sequence of the interventions and the optimal progression of postoperative patient care. The IS team members were then engaged to actually build the framework of the electronic pathway and guide the clinical team to identify appropriate, measurable patient outcomes that would be used later for data analysis and to identify additional opportunities for improvement. When the pathway framework was established, the team addressed existing operational inefficiencies that would impede achievement of the pathway outcomes. Once completed, IS conducted training for all team members across the continuum. When the pathway was live in the electronic health record, the IS team provided “at elbow” and telephonic support to all areas for the first 1 to 2 weeks. Once the pathway was live, outcomes were monitored and results were shared with team members and senior leadership. The ability to electronically audit interventions has increased compliance and allows TUH to provide real-time feedback to staff. Additionally, during the post-implementation phase of the pathway, the team used data collected from the pathway to further improve operational inefficiencies.

Outcomes and Impact. Since our initial pathway go-live, more than 100 patients have successfully completed a colorectal pathway, eliminating more than 150 excess patient days. More than 325 patients have successfully completed an orthopedic hip or knee pathway, eliminating more than 110 excess patient days. CABG and valve are our newest pathways and have been live for less than 1 year at the time of this submission. In that time, more than 150 patients have completed a CABG or valve pathway, eliminating more than 445 excess patient days. The CABG pathway has significantly reduced overall LOS, as well as intensive care unit LOS. We have also seen a decrease in complications and readmissions for pathway patients. The pathway reports have also provided opportunities for TUH to further improve organizational inefficiencies by leveraging compliance with pathway outcomes. The electronic reports have effectively eliminated the need to conduct retrospective chart reviews to determine compliance with interventions. Lastly, as an organization, TUH has learned a great deal about how to effectively implement electronic care pathways and we are eager to share the lessons learned with other Vizient members.

Supply Chain Best Practices: How One Industry Leader Drove Environmentally Preferred Purchasing Strategies for Safer Procurement Decisions

Aparna Dial, MS, MBA, LEED AP

The Ohio State University and Wexner Medical Center

Cristina Indiveri, MS


The Ohio State University Wexner Medical Center

Background. There is significant confusion in the marketplace regarding what makes a product environmentally preferred or “green.” There is no standardization or alignment when it comes to environmentally preferred purchasing (EPP) for health care organizations or suppliers. Members are often overwhelmed when beginning their sustainability journey about whether to focus on reducing toxic chemicals in health care supply chains, reducing waste, or conserving resources for climate mitigation strategies. How to make informed and transparent product conversions is often confusing and daunting. In addition, various companies are guilty of greenwashing to paint a picture of healthier, more environmentally friendly products. Members often struggle with focusing on clinical acceptability, quality, reduced cost, and choosing products that will create a healthier future for the next generations. EPP programs are often synonymous with choosing products that are helpful for the environment, but the true mission of these products is often overlooked: safety. Products that are not made with toxic chemicals contribute less to America’s waste problem. Additionally, products that utilize fewer resources may not be prioritized if organizations do not employ a value analysis process. “First, do no harm” is one of the first steps medical students take when treating patients and that can be applied throughout other areas of health care, including the supply chain. This project demonstrates sustainability and how to apply environmentally preferred practices and utilize them in procurement decisions. You will be able to apply the industry’s standardized attributes, implement best practices in product safety, and ensure human and environmental health within your institution and community.

Intervention Detail. Members have the opportunity to collaborate with Vizient to leverage purchasing power to institute safer products for patients, family members, and staff. The Ohio State Wexner Medical Center has adopted 23 standardized environmentally preferred attributes from Vizient that differentiate environmentally preferred products from conventional materials. Together with other leading organizations such as Kaiser Permanente and the Mayo Clinic, The Ohio State Wexner Medical Center is working to standardize these attributes across the industry to eradicate confusion and demonstrate transparent purchasing practices. This institution experienced various successes in conjunction with its new EPP policy. The development and adoption of an EPP policy was pivotal to the foundation of the program. A framework to establish baselines, track progress, and identify growth opportunities is essential for a sustainable program. Incorporating environmentally preferred attributes as a factor in purchasing decisions is another win that was celebrated by the team. To achieve success, leadership support and championship is required. Fostering buy-in and ownership within the supply chain department is integral to success. Educating commodity managers is essential for program continuity. Health systems should leverage existing expertise, resources, and best practices achieved by other organizations.

Outcomes and Impact. Members across the country are working to elevate their EPP percentage because research has demonstrated an overwhelming impact on human health. The Ohio State Wexner Medical Center is at the forefront by removing harmful chemicals of concern and excess waste from its supply chain through a variety of strategies. We increased the EPP percentage from 2% to 72% in 1 year. This happened through a number of scaling strategies, many of which came from being a member of the Vizient Environmental Advisory Council. First, the sustainability leader created a sustainable procurement working group. That group then created sustainable procurement guidelines for the medical center, adopting Kaiser Permanente’s environmentally preferred attributes. This highlighted the need for a new position within supply chain to manage this work. An individual was hired to manage both supplier diversity and social responsibility and has provided education to all commodity managers and others about the importance of EPP to patients and staff. A critical piece of our success has been the ability to use data to drive this transformation. The EPP dashboard that Vizient provides to understand which categories or departments are driving this implementation is extremely useful, and conversely, also highlights where there are opportunities to do more. The Vizient sustainable procurement guidelines have been incorporated into everyday practice through deliberations on commonly used products and prioritized where sustainable alternatives are available. While there are additional factors used to determine product selection, the addition of EPP criteria in the request for proposal scorecard for products, services, and processes has elevated key issues. Staff members are now considering how the product or service can conserve energy or water, reduce packaging, be recycled, be reused, and protect employees and patients from harm.

Evolution of a Transfer Center: 15 Years of Programmatic Progress

Elizabeth Carlton, MSN, RN, CCRN-K, CPHQ, CPPS

David Wild, MD, MBA

The University of Kansas Health System

Background. For many years, The University of Kansas Health System contracted with an outside call center to manage physician queries for patient transfer to our tertiary referral center. Call center staff were nonclinical and unable to provide any level of triage or assessment. Case mix index for transfer patients is appropriately higher than the general population, affirming the need for a higher level of care in a timely fashion. Our transfer center is a subspecialty model, meaning most patients are direct-admitted to the needed service. This placed the burden of identifying the correct level of care or service needed on the referring provider to know which team or intensive care unit to be called—and how to essentially attempt to navigate our complex system. This resulted in too many calls, turfing of the referral from service to service, long wait times, delays in definitive treatment, and overall discontent from our referring and internal providers. Additionally, there was no linkage to real-time bed availability, leading to access and capacity issues. Further gaps existed in the lack of review for medical necessity and/or financial clearance, placing a potential fiscal burden on patients who may be out of network. Rural geography and emergency medical services (EMS) availability further complicated the transfer process. We identified a need for the transfer center to be more than an “answering service” relaying calls. We needed a programmatic approach with defined leadership, strategy, metrics, and reportable outcomes linked to key strategic initiatives, service lines, and financial outcomes that also promoted our culture and focus on patient experience and safety. This work is important to the 2020 Vizient Connections Education Summit as it supports managing patients across the continuum of care, effective use of a transfer center to coordinate care, and improvement in the cost and quality of care.

Intervention Detail. The initial step to develop the transfer center program included development of the Transfer Center Oversite Committee (TCOC). This interprofessional team consists of our chief of staff, physician leaders/liaisons from nearly every service line, hospital leadership, EMS, quality and safety, risk management, operations, financial services, and marketing/communications. This team is responsible for advancing the function of the transfer center, improving patient outcomes, and supporting growth and strategic development. The TCOC developed standing metrics and case reviews, including overall growth, transfers by service, transfers by facility, disposition, denials, and delays. As a component of our risk management plan the TCOC reviews all transfer early deaths and any patient moved to a higher level of care within 4 to 6 hours of arrival. Risk mitigation strategies include a review of all denials for appropriateness. Through review of data metrics, the TCOC identified the need to change the overall structure, resulting in the exit of the outsourced answering service and implementation of an in-house nurse triage system to navigate transfers. As our capacity issues escalated, the team implemented a physician advisor team to ensure medical necessity of any non-Emergency Medical Treatment and Labor Act transfer requests. To assure fiscal responsibility we also implemented a frontline financial clearance review. The in-house team partnered with the medical staff office, patient placement, EMS, telehealth, switchboard, and other teams to strengthen and promote improved outcomes based on data from the transfer center. Positive technology levers included integration into the electronic health record and implementation of telehealth consultations, a robust telephonic system that prioritizes time-critical diagnosis calls, and secure instant messaging to decrease and streamline communication.

Outcomes and Impact. As a result of these improvements, requests for transfer have increased from 300 calls per month to well over 900 per month. Through utilization of the electronic medical record by skilled triage nurses, critical information needed to promote the care of the patient is available for the entire care team. Call abandonment rates decreased from over 15% to less than 1% from March 2018 to March 2019. Due to a robust and timely medical necessity and financial clearance process, out-of-network patient charges at 1 time exceeded millions of dollars per month and now are virtually nonexistent. Implementation of round-the-clock physician advisors resulted in point-of-entry status and medical necessity reviews, ensuring that nonemergent transfer patients received the correct level of care at the right location. The review of transfer early deaths promoted the investigation and eventual implementation of a general inpatient care hospice to support patients who presented for a final chance for definitive care but ended up transitioning to palliative interventions quickly. Case reviews also resulted in statewide improvements, including an ability to “cloud” images and improve EMS access. The review of calls deemed “consultative only” led to implementation of a transfer center-linked telehealth system. Internal and external physician satisfaction dramatically improved as triage nurses provided robust and accurate information to the correct teams in a timely manner, assuring patients were placed with the right service in the correct level of care.

Reimagining Rural: Driving Value-Based Care Across the Continuum

Jodi A. Schmidt, MBA

Robert Moser, MD

The University of Kansas Health System Care Collaborative

Background. Launched in 2014 under a Centers for Medicare & Medicaid Services Health Care Innovation Award, the University of Kansas Health System (UKHS) Care Collaborative is a Rural Clinically Integrated Network (RCIN) established to measurably improve quality and reduce total cost of care. With less than 3% of rural Kansas patients receiving thrombolytics, historically, and zero rural ST-elevation myocardial infarction (STEMI) patients meeting door-to-intervention best practice guidelines, the collaborative developed a unique, rural-specific model for implementation of treatment protocols and evidence-based practices. Developed by academic medical center subject matter experts and rural providers, the protocols were supplemented by telehealth tools, checklists, and boots-on-the-ground training and support. One chief nursing officer commented that as an RCIN, UKHS Collaborative Care wants to practice according to the latest research-based guidelines, and the care collaborative just makes it easier to do that. Governed by a rural board of managers, the RCIN expanded its work to include sepsis and heart failure, stemming from data indicating that only 65% of rural emergency room patients were accurately diagnosed with sepsis. The data also indicated that heart failure combined with any other chronic condition demonstrated twice the total cost of care. We are currently piloting trauma performance improvement, opioid prescribing best practices, and palliative care programs. Enrolling as an accountable care organization (ACO) in the Medicare Shared Savings Program and generating $2.3 million its first year, the rural network established regionalized chronic care management services. A year-over-year analysis of the benefits of this care coordination program demonstrated a 21.3% reduction in total cost of care for Medicare patients benefitting from this service. Perhaps most importantly, as a governing body, the rural physicians and administrators serving on the ACO board have broadened their skills in claims analytics and population health management—skills growing in importance as the health care delivery system continues to evolve.

Intervention Detail. Care collaborative interventions are purposeful and straightforward: (1) rather than assume rural providers have the experience and resources to adapt nationally recognized guidelines, the clinical team modifies them to the realities of rural resources and capabilities; (2) rather than sponsor regional/statewide workshops to which 1 or 2 attendees must travel, the collaborative brings the training to each community, allowing the majority of physicians, advanced practice providers, nurses, therapists, and emergency medical services personnel to learn the same best practice guidelines at the same time and tailor implementation to their unique circumstances; (3) rather than expect overextended rural staff to compile and report on performance measures, collaborative staff abstract data quarterly, generate comparative reports, and highlight performance improvement and case review opportunities as an Agency for Healthcare Research and Quality-recognized Patient Safety Organization; and (4) rather than creating a tool kit for care management and remote patient monitoring, the ACO trains and oversees health coaches and provides supporting technology, both to enhance efficiency and provide specialized training (eg, medication reconciliation and motivational interviewing). Together, this hands-on, boots-on-the-ground approach to best practice implementation is the secret sauce to the care collaborative’s performance improvement results. Recognizing rural primary care providers are often spread thin as hospitalists, emergency room providers, and long-term care and emergency medical services medical directors, continual updating of care collaborative evidence-based protocols is supported by subject matter experts at UKHS. As the only academic medical center in the state, the faculty regularly participate in national research studies and contribute to development of national guidelines. As a result, timely updating of stroke and sepsis protocols was achievable, allowing the latest in evidence-based, research-driven care to reach rural communities within months of release.

Outcomes and Impact. Through the care collaborative approach, rural use of thrombolytics for stroke now outpaces the national benchmark of 22%, rising 3% to 33% in 2019. Likewise, door-to-intervention for STEMI treatment was successfully reduced from 78 minutes to 33 minutes, against a national goal of 30 minutes. Accurate identification of sepsis in rural emergency departments has improved from 65% to 95%, and 1-, 3-, and 6-hour best practice bundle compliance is strong. In a comparison of total cost of care, acute myocardial infarction/STEMI costs were reduced by 17%, stroke was reduced by 1.9%, and sepsis increased by a modest 0.6%, compared with an increase of 3.3% in comparable Nebraska rural hospitals. Note: abstraction of 2019 annual results are unavailable as of the time of this submission. As an ACO, the collaborative also reports annually to Centers for Medicare & Medicaid Services on ambulatory measures of quality, reporting baseline data in 2017 and receiving a 93.15% in 2018—above the national ACO average. Additionally, Mathematica evaluators conducted a satisfaction survey demonstrating success. The collaborative had a positive impact on:

  • Quality of care and services: 97%
  • Ability to respond in a timely way: 100%
  • Ability to provide care or services that are responsive to participant preferences, needs, and values: 94%
  • Access to care or services for all: 84%
  • Achievement of participants’ health goals: 94%
  • Participant satisfaction: 91%
  • Participant quality of life: 100%
  • Care coordination: 97%
  • Member retention rate: 100% over 5 years

Rapid Improvement Supported by Incident Command Structure and Vizient Clinical Data Base Data

Imran Andrabi, MD

Lisa Harton, MBA, MPH, RN, FACHE, NEA-BC

Amy Ryan, BS


Background. Near the end of 2017, ThedaCare embarked on a 3-year journey to move the organization’s hospital-acquired infection and mortality quality metrics from bottom decile to top decile. The organization had a flagship hospital that was positioned to receive a 2-star safety and quality rating from the Centers for Medicare & Medicaid Services (CMS). The organization was also subject to repeated quality payment program penalties.

Intervention Detail. The Agency for Healthcare Research and Quality published a framework to drive high-reliability principles within organizations that first requires changing mindsets.1 Under the leadership of a new CEO, a vision of zero harm was instilled throughout the organization to change mindsets. A 3-year vision and strategy to achieve world-class quality by moving from bottom decile to top quartile, and ultimately to top decile, was communicated. The second step is to change processes and environments that affect patient safety. ThedaCare developed a CEO-led incident command structure to set the tone for weekly rapid cycle change. The CEO-led incident command structure allowed a deep dive into safety and quality opportunities to create a shared mental model and clear next steps between operational leaders and executive leaders. Processes were designed to support the weekly incident command deep dives to instill high-reliability thinking in leaders and challenge assumptions by using data to define key levers needing improvement, and Plan-Do-Study-Act methodology was implemented to support thought processes and accountability. Deep dives challenged hypotheses that weren’t supported by data to ensure that efficient and effective improvement interventions were launched. ThedaCare also implemented the Vizient Clinical Data Base to serve as a guide for external benchmarking and provide exposure to improvement communities across the country. Changes in the environment were supported by introducing and empowering staff to stop the line when they feel an action could result in patient harm or poor quality. Safety huddles at the unit, facility, and system levels were implemented to support high-reliability thinking, create a daily intense focus on safety and quality, and share system learnings. The final step is improved outcomes. ThedaCare experienced significant improvements in quality and safety.

Outcomes and Impact. The structure and process supported the achievement of a 32% reduction in inpatient mortalities, a 73% reduction in catheter-associated urinary tract infections, a 63% decrease in central line-associated bloodstream infections, and a 76% decrease in surgical site infections between January 1, 2017, and December 31, 2019. More than 340 lives were positively impacted. Our mortality ranking moved from the bottom 10th percentile to the top 10th to 15th percentile in the Vizient Clinical Data Base. The time between hospital-acquired infections moved from days to years. Top quartile has been surpassed and getting to zero is at our fingertips. ThedaCare realized over a $4 million dollar impact through reduction in costs related to poor quality, as measured by the Agency for Healthcare Research and Quality cost of hospital-acquired harm, reduced CMS penalties, and increased quality payment program returns. Two flagship hospitals improved CMS safety and quality star ratings from 2 to 4 stars and 3 to 4 stars.

1.Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Agency for Healthcare Research and Quality. April 9, 2008. Accessed October 16, 2020. https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-operational-advice-hospital-leaders.

Next-Generation Patient Flow: Restructuring Operations to Achieve Your Goals

Shane Flickinger, MHA, FACHE, CLSSBB

Thomas Jefferson University Hospitals, Inc.

Brian Sweeney, RN, MBA, FACHE

Jefferson Health New Jersey

Thomas Jefferson University Hospitals, Inc.

Background. In response to the rapid closure of Hahnemann University Hospital, Thomas Jefferson University Hospitals (TJUH), Inc. hospital leadership established an emergency department (ED) boarding task force with accountability for rapid improvement identification, implementation, and results monitoring. Sponsored by the chief operating officer and chief nursing officer and facilitated by the vice president of clinical operations in collaboration with the Jefferson Health performance excellence team, the task force included leaders from medical staff and nursing leadership (ED and labor and delivery), ambulatory practice operations, and hospital operations. The task force identified 13 key initiatives and key performance indicators. Work groups were assigned to each initiative to solicit voice of the customer feedback and develop an implementation plan. Weekly progress meetings with key performance indicator reviews allowed for timely barrier identification and resolution, resource allocation, and intervention modification. Supplementing ED care model redesign, hospital leadership identified an opportunity to recapture approximately 70 inpatient beds daily through inpatient length of stay (LOS) reduction, program reallocation, extended recovery redesign, and patient admission from the TJUH Division Center City Campus ED to the Methodist Campus. Promoting systems thinking and results sustainability, the work of the ED Task Force and voice of the customer was integrated with the TJUH, Inc. Division Center for Operational Resource Efficiency and the 1-Year Operating Plan. Center for Operational Resource Efficiency is a colocation of decision-makers armed with real-time, predictive analytics enabling better, faster, and more accurate decisions. Today’s volatile political and economic health care climate requires leaders to quickly respond to local and national public health emergencies, while balancing and modifying strategic focus as needed to reflect a changing environment. This presentation provides health care leaders with the following tools: (1) accountability structure for rapid improvement identification, implementation, and results monitoring; (2) innovative solutions to optimizing inpatient capacity without adding beds; and (3) an operational excellence framework to align strategy and operations.

Intervention Detail.

  • ED care model redesign: (1) redesigned intake model to include pivot registered nurse and teletriage, as well as intake waiting room model; (2) established fast track as a vertical treatment area and added temporary 5-bed, low-acuity treatment area; (3) implemented hallway staging for patients admitted to clinical observation unit; and (4) redesigned admission process to include transfers to another TJUH, Inc. campus.
  • Real-time capacity alerts: (1) developed departmental surge plans; (2) designed ED, post-anesthesia care unit and procedural area surge calculations to predict and respond to patient volumes; and (3) implemented real-time census alerts at predefined intervals and thresholds for rapid identification and response to inpatient census demands using secure text messaging.
  • Plan-of-care rounds, patient progression alerts and escalation huddle: (1) identified 14 677 inpatient opportunity days, translating to approximately 40 inpatient beds daily; (2) reengineered plan-of-care round optimization and real-time patient progression delays with escalation pathways; and (3) instituted 12:30 PM care progression planning and escalation huddle for patient progression delay resolution and proactive next-day planning.
  • Bed reallocation: (1) relocated 2 specialty programs to other TJUH, Inc. campuses and (2) generated an additional 10 to 15 inpatient bed capacity.
  • Extended recovery: (1) identified 10 to 20 extended recovery patients placed in inpatient beds for 24 to 36 hours, Monday through Friday; (2) colocated designated populations on an observation unit; and (3) developed clinical pathways in collaboration with clinical teams from cardiology, gastroenterology, interventional radiology, and nursing.
  • One-year operating plan and operational excellence: (1) established TJUH Division Operational Excellence framework to align strategic initiatives (quality and safety, finance and operations, service, people, and growth) with key learnings from task forces and (2) facilitated systematic project management and monthly review process to ensure deployment and integration of strategic initiatives across the TJUH, Inc. Division.

Outcomes and Impact. Through the second quarter of fiscal year 2019, the TJUH, Inc. Division accommodated the increased volume associated with the Hahnemann University Hospital closure while improving patient flow metrics and meeting established quality and patient safety, finance and operations, service, and growth targets:

  • Inpatient LOS: through December 2019, year-to-date LOS and opportunity days were reduced by 30% compared with the same time period in the prior fiscal year. This was achieved with a 7.5% increase in inpatient volume through the same time period compared with the prior year.
  • ED boarding: through January 2020, the total number of admissions increased by 16.3%, while total ED boarding hours for admitted patients decreased by 4.3%. Additionally, the percentage of ED patients assigned a bed within 1 hour increased 7.9%, while the average number of minutes to a bed assignment decreased by 10%.
  • TJUH Center City Campus ED to Methodist Campus transfers: through January 2020, 352 patients were admitted to Methodist compared with 57 in fiscal year 2019. This translates to a 40% increase in inpatient census at Methodist and an average 50 transfers per month compared with 5 patients per month in the prior fiscal year.
  • Extended recovery: through January 2020, an average of 21 patients per week were sent to the extended recovery unit. The average LOS was 22 hours, which is half the average LOS of an observation patient. The average discharge order time was 11:11 AM and discharge time was 12:53 PM, approximately 2 hours prior to the overall average discharge order and discharge time at TJUH Center City Campus. The reduced inpatient bed utilization for extended recovery patients has improved operating room bed assignment metrics. Through January 2020, the percentage of operating room patients assigned a bed within 1 hour increased by 17.6%, while the average number of minutes to a bed assignment decreased by 17.5%.

Driving Results Through Leadership and Management Systems Alignment and Accountability

Dennis Delisle, ScD, FACHE

The Ohio State University Wexner Medical Center (formerly employed at Thomas Jefferson University Hospitals, Inc.)

Ricardo Perez, DO, JD

Thomas Jefferson University Hospitals, Inc.

Thomas Jefferson University Hospitals, Inc.

Background. Jefferson Methodist Hospital (JMH) is an urban community hospital located in South Philadelphia. It serves as the sister hospital to Thomas Jefferson University Hospital, Jefferson Health’s academic medical center. As Jefferson Health continues to expand through mergers, the role of JMH has evolved over time. Under new leadership, JMH became a core component of a broader South Philadelphia clinical strategy, connecting the dots across the care continuum. To that end, the leadership team developed a matrix model of oversight that aligned decision-making, resource allocation, and clinical program growth within the market. Central to achieving quality, operational, financial, and service goals was the transformation of key work groups and committees. JMH leadership took the challenge head on by redesigning work utilizing the balanced scorecard framework: quality and safety, service, people, finance and operations, and growth. Each area serves as the foundation for determining key performance indicators (KPIs) and targets, aligning work groups and committees, and driving leadership accountability. Details are reviewed in the next section. The JMH leadership team actively engaged frontline staff, physicians, and board members to solicit input and feedback throughout the development and redesign of systems and processes. This was achieved through employee forums, voice of customer interviews, feedback sessions, surveys, and informal discussions. The pressure to achieve quality and financial goals is high. Hospitals continue to feel the pressure of reducing reimbursements; shifts from inpatient to outpatient procedures; and increases in equipment, pharmaceuticals, and staffing costs. It is necessary to be efficient, effective, and reliable to ensure longer-term success and viability. This can be achieved through the use of operational excellence methodologies and concepts, engaged and aligned leaders, and an emphasis on supporting employees on the front line.

Intervention Detail. The balanced scorecard framework is the foundation of the alignment strategy for the leadership and management systems. JMH leadership utilized key operational excellence concepts and tools like Lean, change management, and project management to design quality and efficiency into the model. The major changes that led to significant results (which are detailed in the Outcomes and Impact section) include:

  • Quality and safety: under the leadership of the associate chief medical officer, the team developed the Quality Improvement and Patient Safety Committee. This committee was an evolution of the existing performance improvement committee, which lacked key stakeholder representation, consistent data reporting, and strategic projects to drive outcomes. The Quality Improvement and Patient Safety Committee identified 3 key areas for improvement based on Vizient data analysis and organizational priorities: clinical documentation improvement, care progression, and readmissions.
  • Service/People: the team reinvigorated a weekly leadership rounding model that expanded participation from 8 to 25 rounders. Rounders interview patients and employees throughout the hospital campus, soliciting feedback on service delivery and process improvement. Over 800 staff members completed service excellence training to reset standards and expectations. Employee forums held every 4 months provide updates and bidirectional communication with staff on issues, challenges, and opportunities. Additionally, 40 leaders were selected to complete a robust leadership development program emphasizing engagement, transformation, and execution.
  • Finance/Operations: an operations team was created with representation from all clinical and nonclinical areas. Managers provide monthly standard updates, including KPIs (volume, staffing, and budgets), along with communication and recognition updates. This forum provides broader awareness and engagement, breaking down functional silos and building an interprofessional team.
  • Growth: in collaboration with service line leaders, JMH was able to develop and initiate key clinical services meeting community needs (eg, pulmonary) and broader regional/national programs to enhance the hospital’s reputation (eg, transgender surgery, headache, and orthopedics).

Outcomes and Impact. At the onset of this effort, JMH leadership agreed that the Vizient Quality & Accountability Dashboard would serve as the barometer for progress and success. Through engagement with our Vizient-designated representative and the performance improvement department, JMH leaders evaluated opportunities and created a narrow focus for strategic improvements. From 2019 to the first quarter of 2020, the following outlines our Vizient Quality & Accountability Dashboard score improvements: (1) overall rank: 34th to 6th; (2) effectiveness: 62nd to 11th; (3) safety: 36th to 8th; (4) Hospital Consumer Assessment of Healthcare Providers and Systems: 65th to 12th; (5) efficiency: 97th to 64th; and (6) mortality: 20th to 17th. Observed-to-expected mortality is at top decile performance at 0.55. Case mix index improved from a fiscal year 2019 baseline of 1.459 to a fiscal year-to-date of 1.502. Despite significant increases in emergency department visits, transfers, and admissions, length of stay was reduced from a fiscal year 2019 baseline of 4.75 to a fiscal year-to-date of 4.50. It has been imperative to use data to inform and direct improvements. Transformation of leadership and management systems requires clarity around performance expectations (KPIs and targets) and accountability. Use of proven operational excellence methodologies can accelerate results as shown through this case study. Early signs suggest sustainable outcomes, and the leadership team will continue to modify and refine approaches to simplify.

Constructive Self-Cannibalism: A Survival Guide for Academic Medical Centers

David Lubarsky, MD, MBA

UC Davis Health

Background. As part of a leadership transition in 2018, UC Davis Health was plagued by low margins and intense competition common to the modern academic medical center (AMC). We knew our financial bottom line mattered, but none of the old strategies met a persistent demand from our community to serve more at-risk patients; and, frankly, we didn’t believe that patients’ less-complex needs were best met at our hospital—especially as surrounding lower-acuity hospitals sat mostly empty. Leadership and staff were frustrated with negative community perceptions about pricing and access to care. Overall, the time was right for a shakeup. This case study will be valuable to Vizient members, many of whom face threats like the lost promise of brick-and-mortar expansion models and the increase of care choices for consumers. We set out to build true partnerships with existing institutions where consumers already sought care, specifically rural hospitals in northern California with workforce shortages and Federally Qualified Health Centers (FQHCs) in our surrounding community. We believed that upleveling the skills offered would ensure that all existing institutions, including our own AMC, were used fully and to their best advantage with financial sustainability to ensure appropriate, streamlined, better care for patients. For each partnership, a relevant academic department was placed in the lead (eg, pediatrics, internal medicine, hematology-oncology) as the starting specialty to ensure patients’ needs were met, build relationships and trust, and achieve results. To lead this effort, we began with what may seem like a novel concept—talking things out. As we discussed common goals from a place of good faith and solving problems for patients with potential partners, it became clear that none of us could make an impact alone, and we built relationships that would lead to accountable progress. We believe that this hybrid model of care must become a future trend.

Intervention Detail. We planned our intervention on the assumption that UC Davis Health is an anchor institution in northern California. First, we performed a thorough assessment of care across our region, including a deep dive into how many Medicaid and uninsured patients actually received care across UC Davis Health’s assets. We looked for gaps in the safety net, reached out to community organizations, and asked how technology could be used in an innovative and efficient way to solve problems in a manner that is convenient and appealing to patients. Our faculty physicians, staff, and community members were eager to have their voices heard and shared ample data proving the needs of the constituencies they cared about. This needs analysis allowed us to frame the idea for a rural-urban hybrid model of care expansion. Next, we created formal partnerships with 3 rural health care systems that we believed had the leadership will and patient mix to implement. The partnerships formed virtual connections between our main medical center emergency department and neonatal intensive care unit and the rural hospitals where UC Davis Health specialists provided consults over video visits. We developed clear guidelines for when to use telehealth and how to best transfer patients. We offered webinars about diagnosing and treating pediatric conditions such as asthma, bronchiolitis, and sepsis. We also sent our specialists and students to train and learn in these communities, increasing the level of care immediately available in these more rural areas. Simultaneously, we invested in bolstering contracts with FQHCs, including a major expansion at a county clinic located just a block from the main medical center. To grow this clinic, we applied (with Sacramento County) to the federal government to deliver subspecialty care using the full cost reconciliation available to FQHCs. The clinic is now one of only a few locations in America where patients receive subspecialty care at an FQHC.

Outcomes and Impact. Adventist Health Lodi Memorial serves as an excellent example of the success of our initiative. Our partnership with this not-for-profit, 194-bed hospital was launched in 2018 to expand pediatric and neonatal care services. The hospital is about 40 miles from the UC Davis Medical Center, so UC Davis Health physicians and nurses were able to practice on-site. The partnership built a level II neonatal intensive care unit facility to treat premature infants with both on-site and 24/7 virtual care from UC Davis Health specialists. In the first year of the partnership, hospital admissions at Lodi Memorial increased by more than 50% (1314 to 1966), and daily census was up by 35%, even as length of stay declined from 2 days to 1.7 days. At UC Davis Health, the number of pediatric patients transferred to receive care closer to home has increased by 7%, while the percentage of patients transferred from Lodi Memorial declined by 28%. Patient mix index increased by 42%, and there was even an uptick in transfers of commercially insured patients back to Lodi. We believe this work has proven the cost-effectiveness and patient safety of a model where AMCs are set up for the most serious, high-touch cases and community hospitals only need to transfer patients who absolutely have to be at an AMC. It’s a win for patients, with care closer to home and shorter stays, a win for the community hospital partner that needs more patients, and a win for UC Davis Health, as we get more acute patients.

SUIT: Tailoring Acute Care Treatment of Substance Use Disorders

James Chenoweth, MD, MAS

Daniel K. Colby, MD

Aimee Moulin, MD

UC Davis Health

Background. Substance use disorders (SUDs) are an increasing burden on health care systems. It is estimated that 1 in 7 inpatients has a SUD, a burden that has nearly quadrupled in the last decade.1 Opioid use disorder (OUD) alone costs the health care system $15 billion each year.2 These patients have longer lengths of stay, higher readmission rates, and increased mortality post-discharge. Additionally, patients with OUD are more likely to be discharged against medical advice before completing inpatient care. While the data may appear grim, there are interventions that can improve the care of these patients. Screening, brief intervention, and referral to treatment can increase outpatient treatment utilization and decrease readmission rates, while medications for opioid use disorder (MOUD), such as buprenorphine and methadone, can increase the number of patients in treatment 30 days after discharge while decreasing 1-year mortality. Additionally, initiating treatment while the person is a hospital inpatient can decrease the risk of discharge against medical advice. Despite the data supporting emergency department and inpatient-based treatment for OUD, this care is lacking in most health systems. Survey respondents also expressed a desire for a consultation service that could aid in the care of these patients through brief interventions, MOUD initiation, and referral to treatment.

Intervention Detail. We designed our substance use intervention team (SUIT) using a model developed by the Bridge program, and we utilized the existing infrastructure of our medical toxicology consult service. This is a multidisciplinary team made up of pharmacists, substance use navigators (SUNs), and physicians who are board certified or board eligible in addiction medicine or medical toxicology. When a patient is identified as having a SUD, a SUN referral is placed by the care team. This referral can be initiated by any member of the care team, including nursing, physicians, social work, registration, or support staff. SUNs are specially trained in motivational interviewing and identification of barriers to receiving SUD treatment. They also maintain a close relationship with community resources that can be utilized post-discharge. If a patient is identified as potentially needing MOUD or other pharmaceutical therapies, a SUIT physician consultation is performed. This consultation involves an in-person evaluation of the patient; in-depth discussion of the risks and benefits of MOUD; and a careful chart review to evaluate for proper timing of medication initiation, dosing, and discharge medication plans. All patients receiving MOUD are reviewed by a pharmacist who can also initiate consultation with the SUIT physician. At the time of discharge, the SUN performs a warm hand off with outpatient providers to ensure that each patient has appropriate follow-up. Patients are then contacted at 1 week and 1 month post-discharge to determine if they are still in treatment and to assist with any gaps in care that may have arisen after they left the hospital. In addition to the patient care activities performed by the SUIT team, health care provider educational activities are also performed. This includes bedside teaching and departmental presentations discussing care of patients with SUD and the benefits of SUIT team consultation.

Outcomes and Impact. The formal SUIT service launched at our hospital on March 1, 2020. Prior to launch there was a partial rollout of the physician consult service and SUN evaluation with referral to treatment. The SUNs have evaluated and referred a total of 667 patients. In the 3 months following launch, the SUNS assisted in the care of 442 patients. During the initial phase, most evaluations were performed in the emergency department. Following the official launch, the SUNS were made available to all treatment teams throughout UC Davis Medical Center. In addition to the evaluations and referrals to treatment performed by the SUNs, there have been 73 physician consults, of which 24 were initiated on MOUD during their hospital stay. Only 2 patients who were not started on MOUD left against medical advice prior to evaluation by the physician. Given that all of these patients had SUDs, the fact that only 2 out of 73 left against medical advice is viewed as a huge success and proof that this model can greatly improve the care of patients with OUD and other SUDs in the acute care setting. Our team has also begun an education process throughout our health system aimed at improving care of SUD patients. SUIT team members have given more than 10 presentations to a variety of groups, including nurses, nurse practitioners, physicians, and hospital executives. As the full service matures, we will formally collect follow-up data, including evaluations on the ease of follow-up, continuation in treatment, and barriers to receiving continued treatment.

1.Walley AY, Paasche-Orlow M, Lee EC, et al. Acute care hospital utilization among medical inpatients discharged with a substance use disorder diagnosis. J Addict Med. 2012;6:50–56.

2.Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002-12. Health Aff (Millwood). 2016;35:832–837.

Innovative Advance Care Planning Across Three Patient-Centered Settings

Jacqueline Baron-Lee, PhD, CPHQ, PMP

Emily Mroz, MS, PhD(c)

UF Health

Background. Advance care planning has recently been considered a core component of value-aligned medical care.1 Optimization in advance care planning improves patient centeredness, cost-effectiveness, care standardization, and clinical outcomes. The impact of advance care planning is relevant to patients, caregivers, clinicians, health care staff, and community members because it affects care delivery in clinics and inpatient settings, as well as care and communication in community settings. Knowing and documenting a patient’s advance care plans, particularly their health care decision-maker and goals in care if incapacitated, promotes person- and family-engagement, patient experience, care transitions, and patient safety. Despite the well-established benefits of advance care planning, research demonstrates substantial and persistent barriers across clinic, inpatient, and community settings, including gaps in understanding, limited workforce, narrow scope of educational efforts focused on exclusively older and terminally ill persons, and societal stigmas. To address each of these advance care planning barriers using cost-effective strategies in our community, multiple interventions were designed for clinic, inpatient, and community settings in partnership with our Patient and Family Advisory Council, community hospice agencies, early health care learners, clinicians, and community partners. This work not only affects care delivery, but it also exemplifies innovative approaches to strategic alliances with the community, workforce innovations through learner integration, and above all, a strong emphasis on person and family engagement in care. Each intervention has been conducted, tested, and refined over 5 years using community, patient, and stakeholder feedback. Our explanation of these interventions helps to ensure continued progress toward normalizing and optimizing participation in advance care planning.

Intervention Detail. Prospective evidence-based interventions, utilizing standard rapid-cycling Plan-Do-Study-Act cycles, were employed in the clinic, inpatient, and community settings. Ongoing review of the literature on advance care planning education and interventional resources guided each new Plan-Do-Study-Act cycle. Within the clinic, a supportive care team was developed to support the existing workforce, providing trained volunteers to: (1) normalize advance care planning education for patients and caregivers in a specialty service line; (2) meet patients and caregivers “where they are at”2 related to discussions and completion of advance care plans; and (3) complete and scan advance care planning documents into our electronic health system. The inpatient setting intervention centered on evaluation of the use of the Care and Communication Bundle (CCB) developed by Nelson, Mulkerin, Adams, & Pronovost, 2006, which suggests specific advance care planning aspects across a patient’s length of stay.3 Following insight into providers’ limited understanding of palliative care and advance care planning in the neurology and neurosurgery service line, CCB protocol was disseminated.4 We assessed levels of adherence in documenting: (1) goals of care on day 1; (2) completion of an interdisciplinary team meeting on day 3; and (3) referral to palliative care on day 5. Additional closed-loop communication strategies with all care team members in the neuro-intensive care unit (neuro-ICU) were completed. Finally, within the community setting, we developed year-long educational programs, with an emphasis on booster education throughout April in recognition of National Healthcare Decisions Day. Community interventions were selected intentionally to target individuals with diverse attitudes toward health care and advance care planning (eg, the Massachusetts Coalition for Serious Illness 2019 Research Report) and across all adult life phases. Efforts include: (1) the creation of “Before I Die Walls” across the local community; (2) hosting community “Death Over Dinner” events; and (3) community-based film screening and discussion.

Outcomes and Impact. A tremendous number of outcomes improved as a result of this continuous work. Within the clinic setting, over 2000 patients and their families have interacted with the supportive care team. Of these encounters, 83.3% were successful in enhancing education about advance care planning. Of the unsuccessful encounters, 11.2% were due to clinician interruptions, as this program occurs within the typical flow of clinic-based care. Within the neuro-ICU setting, 130 expired patients’ medical records were assessed for adherence to the CCB evaluation while also demonstrating that the neuro-ICU was compliant with the CCB in 80% of cases. Data illuminated that the CCB, developed for use in the surgical-ICU, may not be fully applicable for patients in the neuro-ICU. Based on these initial findings, just-in-time discussions of the CCB in the neuro-ICU are now incorporated into regular interdisciplinary interactions, leading to increased adherence and referral to palliative care services. Outcomes and impact in the community setting have also been robust year after year. Our local county’s city commission declared the month of April National Healthcare Decision Month, which has increased our number of community partners from 3 to 13. The “Before I Die” walls’ impact also improved over time, with 13 locations across the county. Despite brief encounters with “Before I Die” Walls, 38% of community members who completed follow-up surveys reported that encounters with these walls left them encouraged to discuss completion of their advance care planning. “Death Over Dinner” events have inspired hundreds of community members, across several dinners, to more fully explore their perceptions of, and reservations about, advance care planning. Fifty percent of attendees, on average, complete advance directives after these events. Initiating community conversations across adult age groups, although relatively novel, has strengthened communitywide acceptance of advance care planning and reduced social stigma.

1.Sudore RL, Lum HD, You JJ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53:821–832.e1.

2.Sudore RL, Schickedanz AD, Landefeld CS, et al. Engagement in multiple steps of the advance care planning process: a descriptive study of diverse older adults. J Am Geriatr Soc. 2008;56:1006–1013.

3.Nelson JE, Mulkerin CM, Adams LL, et al. Improving comfort and communication in the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care. 2006;15:264–271.

4.Bluck S, Mroz EL, Baron-Lee J. Providers’ perspectives on palliative care in a neuromedicine-intensive care unit: end-of-life expertise and barriers to referral. J Palliat Med. 2019;22:364–369.

The Difference Is in the Details: Micro-Behavior Assessments to Improvements

Jacqueline Baron-Lee, PhD, CPHQ, PMP

Miis Akel, MS, BS

Andressa A. Sleiman, MS, BCBA

UF Health

Background. Research shows patients are affected by the small things during clinical interactions. There is truth in the idea that the difference is in the details! Aspects of clinical interventions—such as how information is delivered to patients and their caregivers and if and when clinicians introduce themselves, remain at eye level, and incorporate family members, as well as their empathic demeanor—all make a difference to patients. Micro-behavior details such as teach-back adherence score (TAS), micro-communication, and observed empathy all are documented as best practices in health care. Teach-back, the chunk-and-check of small idea units shared with patients, is considered the gold standard of communication because these details matter. In addition, micro-communication, or subtle communication behaviors, such as introduction of name and role as well as being at eye level with patients, all make a difference to patients. Observed empathy is another micro-behavior important to patients. Studies have shown that patient-reported clinician empathy, and subsequent empathy scores, can increase providers’ use of specific behaviors. However, there are infrequently micro-assessments on the known behaviors that shape clinician interactions with patients. Although teach-back, micro-communication, and observed empathy are included in professional training, it is not common among academic medical centers to utilize this infrastructure for regular quality assurance and feedback of these micro-behaviors. The current work, under guidance from our Patient and Family Advisory Council, developed interventions to assess and improve these 3 micro-behaviors. Continued integration into the infrastructure and engagement with clinicians fuels organization culture.

Intervention Detail. With guidance from our Patient and Family Advisory Council, the interdisciplinary clinical and academic program quality improvement team at UF Health developed interventions to assess 3 micro-behavior domains, including clinician TAS, micro-communication, and observed empathy. First, a teach-back protocol was developed. This protocol included 5 idea units known to affect patients including: (1) diagnosis and care plan; (2) medications; (3) activity needs; (4) pain; and (5) reaching the care team. Clinicians in neuromedicine were educated during regularly occurring grand rounds and faculty, divisional leadership, and unit staff meetings throughout the year. Videos, scenarios, and practice in dyads occurred at each education session. Clinicians were provided educational materials before, during, and after the sessions. Attendance reached 80% of clinicians with additional booster education reoccurring over time. Quality improvement interns, who serve as third-party observers, joined clinical encounters across the continuum of care. The 5 idea units, in addition to the introduction and utilization of patient-friendly materials, were assessed. Providers received raw data reports and eventually received a TAS as part of an ongoing dashboard. Second, micro-communication domains are also taught to clinicians using a similar method during the teach-back education. Aspects such as introducing oneself by name to patients and caregivers, explaining one’s role, and remaining at eye level to patients during communication were assessed. Finally, observed empathy was assessed during our patient shadowing infrastructure. In this paradigm, quality improvement interns joined the entire clinical encounter, which may be across settings and the continuum, to assess clinician empathy. Observed empathy includes reassurance for the patient, head- nodding, eye contact, engaging in follow-up questions, attentiveness, engagement, and communication without electronic device distraction. Quality improvement interns rated clinicians on a 5-point Likert scale after substantial training and demonstration of rater reliability.

Outcomes and Impact. Both process and outcome measures are assessed for all 3 micro-behavior interventions. Specifically, teach-back encounter number, clinician name and role, location, and TAS are assessed. To date, over 500 encounters occurred with approximately 50 clinicians across 3 discrete clinical settings throughout the continuum of care. Physicians currently demonstrate the highest TAS, whereas nurses have the lowest TAS. Other nonphysicians and nurse clinicians remain stable but lower than physicians in their TAS. All 5 teach-back domains improved over time, with medication and pain teach-back domains improving the most. Use of external, patient-friendly materials remains an opportunity for improvement. Micro-communication was assessed for 58 matched sample patients. A ceiling effect in communicating name and role to patients was observed with little room for improvement available. However, an opportunity was found in regard to remaining at patient eye level. Despite an 11% improvement in remaining at eye level, clinicians were not at eye level 84% of the time. Finally, clinician-observed empathy using a standard third-party assessment demonstrated a high level (4.00–4.67/5.00), regardless of clinician and clinical setting.

Conquering the Centers for Medicare & Medicaid Services Severe Sepsis Metric

Kelly Gray-Eurom, MD, MMM, FACEP

Joseph Furbeyre, MD

Rhemar A. Esma, MD

UF Health Jacksonville

Background. The Centers for Medicare & Medicaid Services (CMS) severe sepsis bundle metric (SEP-1) is a process metric that is difficult to achieve. It takes a complex, nonlinear clinical care condition and distills it into a series of linear steps. Abstraction of the metric is difficult to say the least. Data analysts must enter the results of over 40 questions—any of which can cause noncompliance with the metric. CMS has made updates to the metric over time to account for some of the complexities in sepsis care (the addition of emergency medical services intravenous fluid and ideal body weight), but the metric still does not include abstraction rules for important clinical confounders such as congestive heart failure or end-stage renal disease. For these reasons, noncompliance with the metric is frustrating for all involved in sepsis care. Many organizations use triage protocols or “clipboard administrators” in attempts to achieve bundle compliance. Many would argue these approaches have increased the cost of health care by promoting unnecessary testing and have also alienated bedside providers because the abstraction algorithm is extremely rigid. When not placed into the correct clinical context, metric fallout review programs can be perceived as second-guessing clinical staff. Another difficulty with this quality metric is the extreme delay in data results from CMS, which lags by at least a full quarter. It is nearly impossible to create improvement activities with data that is 3 or more months in arrears. UF Health Jacksonville elected to take a proactive approach to help our providers succeed with this metric.

Intervention Detail. Sepsis data flow was automated by our quality data engineers so that real-time chart review of 100% of severe sepsis cases was possible. Quality data abstraction was usually completed within 24 to 28 hours of patient care. Physicians, nurses, and ancillary staff received information while the patient care was still fresh in their memories. Processing, documentation, and other care gaps could be discussed as educational and process improvement activities rather than disciplinary actions. Rapid discovery teams made improvements in electronic health record (EHR) functionality, orders, and lab mapping based on information learned during these debrief sessions. Challenges with the EHR nursing activity screen made repeat lactic acid orders difficult to see. Once identified, this was easily corrected. An interesting nursing workflow discovery was made by the team. In septic shock patients, the resuscitation nurses drew the blood cultures, hung the antibiotics immediately, and then scanned the blood culture bottles because they knew timely antibiotics were key to patient survival. This excellent care process inadvertently created a timing fallout. Work had been completed correctly. The blood cultures were drawn before antibiotics. However, the time stamp in the EHR showed antibiotics before blood cultures because nurses scanned the blood cultures into the EHR after they scanned the antibiotics. Once this workflow abstraction oddity was identified and discussed, it became a rare event. Physician documentation of care plan rationale and critical thinking also improved because the process metric was approached as a team learning activity for improvement rather than a statement of wrongdoing. Correct patient care always took priority over the metric itself. If the correct care resulted in an abstraction metric fallout, that was acknowledged to the bedside team as the correct course of action for patient care.

Outcomes and Impact. From July 2019 through January 2020, compliance with the CMS severe sepsis metric increased from 38% to 65% across the entire campus. The national average for compliance is 50% to 55% based on the sample population. We anticipate our compliance will continue to rise due to bedside staff engagement, our decision to acknowledge and accept fallouts due to algorithm shortfalls, and putting systems into play that assist staff with compliance.

A Meeting of Minds: Multidisciplinary Collaboration for Medication Management and Optimization

Kerry M. Parrish, MHA

Lacey M. Lee, PharmD, BCPS

UNC Health

Background. The establishment of the University of North Carolina (UNC) Health Care System Pharmacy Analytics and Outcomes Team has driven the pharmacy department forward in creating and guiding data-focused operational and strategic decisions. The team currently uses a ticketing approach to analytics requests, similar to the traditional ticketing process of information technology analytics, and has successfully decreased the turnaround time of medication utilization-related requests from a minimum of 14 days to 1 day for most requests. As the team continues to demonstrate its capabilities—and was recently awarded the American Society of Health-System Pharmacists’ Best Practice Award—the desire to use data analytics to drive operational and strategic decisions continues to increase. The ever-changing landscape of new medication approvals, medication shortages, and payer structure, as well as the push to improve overall patient outcomes while decreasing overall costs of patient care, has driven the need to take a more in-depth look at how UNC Health Care compares to other academic medical centers with respect to topics such as medication utilization, patient outcomes, and length of stay. The medication management and optimization team was created in May 2019 by combining 2 existing teams, the medication optimization partnership and the medication use safety and policy team, as a way to streamline medication utilization initiatives, health system formulary management, drug information services, and policy and guideline development. Based on pharmacy’s recent success of embedding a pharmacy analytics division into the department, the following question was raised: would integrating a business intelligence analyst into the department of pharmacy’s Medication Management and Optimization Team enhance medication utilization data analysis, foster enhanced multidisciplinary partnerships and collaboration, and streamline medication utilization and optimization initiatives?

Intervention Detail. In August 2018, the Medication Optimization Partnership was created with the embedded analyst model in mind. The goal was to have a clinical specialist pharmacist and a business intelligence analyst solely focused on medication utilization and optimization initiatives throughout the UNC Health Care System. In May 2019, with the merger of the medication optimization partnership and the medication use safety and policy team, we expanded to 4 clinical specialist pharmacists and 1 business intelligence analyst—all dedicated to addressing data and analytics needs using internal reporting databases and Vizient reporting tools.

Outcomes and Impact. The integration of a business intelligence analyst into the Medication Management and Optimization Team has led to enhanced reporting capabilities and the development of successful multidisciplinary collaborations with anesthesia, cardiology, gastroenterology, and obstetrics and gynecology. Currently, several different medication optimization initiatives are being implemented:

  • A service-line driven pipeline was developed as a road map to determine where and how to prioritize system initiatives. Through use of Vizient resource utilization tools and internal data, a year of medication utilization within UNC Health Care was identified and benchmarked against selected comparative groups, and a ranking by service line and individual medication set the pace for where and who to partner with for the most streamlined, data-focused success.
  • A Vasopressin monitoring dashboard was developed in collaboration with an anesthesiologist champion to show anesthesia’s overall use of vasopressin over time. This successful partnership streamlined the education process regarding shifting vasopressin utilization to more cost-effective agents such as phenylephrine and/or epinephrine. This led to a decrease in vasopressin utilization, as well as decreased overall medication waste in the operating room setting. Using embedded analytics, the dashboard was created with physician and pharmacist input—bypassing the ticketing back-and-forth structure of the traditional analytics team.
  • Intravenous (IV) acetaminophen utilization in cardiothoracic surgery was successfully reduced as a result of collaboration between cardiothoracic surgeons, medication management and optimization pharmacists, and the business intelligence analyst. The analyst attended the meeting and was able to answer data-driven questions regarding IV acetaminophen utilization by pulling data on the fly. This successfully reduced the time it took to change practice and implement changes in cardiology order sets, reducing IV acetaminophen utilization from 4 consecutive doses per case to 1 dose per case.

Introducing a Peer-Mentored Care Model

Matthew Thompson, MBA

John F. Thomas, PhD

University of Colorado School of Medicine

Background. Traditional telehealth programs have been the prevailing approach to providing specialty care in primary care, patient-centered medical homes. Many patients who have chronic health issues that require the intervention of a specialist are required to travel to a medical center where the majority of specialist providers reside. Through traditional telehealth, patients get improved access to care and through e-consult mechanisms, primary care physicians (PCPs) can improve their practice knowledge to manage more on their own. However, each of these alone does not offer the concept of force multiplication. The University of Colorado School of Medicine’s Peer-Mentored Care Collaborative (PMCC) model is a new, breakthrough model of care. For patients, providers, and employers alike, individual components of the PMCC have shown to be effective at reducing hospitalizations, incurred costs related to travel and time away from work, and many other costly scenarios complicating the health care industry. The PMCC serves as a continuous and coordinated ecosystem connecting various medical homes as communities of practice with a broader range of tools that, when used concurrently and interchangeably, offer a range of options to manage acuity and chronicity of chronic diseases. This model has improved patient and provider satisfaction significantly. The PMCC is made up of 2 innovative programs, Project Coordinating Optimal Referral Experiences (CORE) and Extension for Community Health Outcomes (ECHO) Colorado. These programs offer PCPs tools to partner with one another through enhanced cooperation, coordination, and communication to build a patient-centered medical home that improves access to specialty care and reduces fragmented care. Most 2020 Vizient Connections Education Summit participants are aware of the increasing trend in the expansion of telehealth. By outlining our PMCC, participants can understand the rational health care spectrum and how telemedicine, e-consults, and ECHO fit into a peer-mentored care model that supports the Quadruple Aim.

Intervention Detail. The PMCC utilizes 2 models: Project CORE and ECHO. The CORE model uses tools embedded in the electronic medical record system, known as enhanced referrals and e-consults, that provide point-of-care decision support. These decision support tools enhance clinical workflows, improve communication and coordination of care at the interface of primary care and specialty care, and enhance quality and efficiency of care. ECHO Colorado offers a unique platform that provides health professionals and those whose work impacts health the opportunity to be part of a community where experts and peers share knowledge and experience using technology—not proximity—to connect. ECHO Colorado was established with a mission to leverage the knowledge and experience of geographically diverse communities for workforce development and improved health for all. ECHO Colorado achieved success by developing partnerships and removing barriers. It is where treatment, prevention, wellness, technology, and learning converge. ECHO leverages readily available, web-based technology (available in nearly every community) to disseminate curated medical knowledge to frontline providers, facilitate specialist/primary care comanagement of patient cases, and promote best practices to reduce disparities in health care, and, when appropriate, obviate the need for patients and families to travel long distances unnecessarily to receive specialty care. Typically, this is accomplished through regularly scheduled ECHO sessions during which specialists and primary care clinicians meet via videoconference in an “all teach, all learn” collaborative focused around a particular clinical or public health-related topic. The PMCC creates a truly collaborative care system that improves access, facilitates care management, and expands capacity through mentorship and workforce development. Further, we have shown that this is an iterative process where analysis of the questions asked through an e-consult can better inform the knowledge gaps and needs in participating communities, which can then be addressed via ECHO learning modules.

Outcomes and Impact. Between April 2018 and July 2020, 563 PCPs across 42 clinics in Colorado placed over 6500 e-consults and 55 500 enhanced referrals to the University of Colorado. This resulted in saving our adult health patient population over $65 000 in transportation costs by eliminating the need to travel from the patient’s primary ZIP code to Anschutz Medical Campus. Based on modeling, after evaluating direct and indirect opportunity costs, patients who can forego a specialty visit because of an e-consult will save an average of $102.92 (adult health). In 2019, ECHO trained nearly 1200 providers in over 60 separate health-related topics. While the PMCC is working to become fully operational by the end of 2020, we have seen several favorable outcomes to date. The impact of a PMCC-like approach was recently highlighted in an upper payment limit dollar-funded project designed to improve timely diagnosis and care for children with autism spectrum disorders. Limited access to specialty care services often compounds problems by delaying needed treatment. This is particularly relevant in underserved rural and frontier communities. Through the combined approach of ECHO training, communities of practice, and PCP access to e-consults, PCPs demonstrated a 70% increase in use of the screening tool for autism in toddlers and young children. Participants from trained practices had a mean wait time reduction from 18 months to 2 months (an 88% wait time reduction), with PCPs and community providers expressing satisfaction and higher confidence in identifying children who require further assessment. Another early outcome was around type 1 diabetes. In Colorado, access to a board-certified endocrinologist for rural patients is limited due to a small number of specialists mostly working at our academic medical center, UCHealth University of Colorado Hospital. Academic medical center-based endocrinologists completed over 780 e-consults with PCPs across the state during 2019, dramatically reducing wait time for care and increasing PCP capacity to manage care locally and more consistently.

Cross-Training Security Officers As Emergency Room Psychiatric Nursing Assistants to Decrease Violence and Improve Quality of Care

Lance Clemsen, MS, LISW

Douglas C. Vance, AA

Jeffery A. Vande Berg, MS

University of Iowa Hospitals and Clinics

Background. The health care industry leads all private industries in the incidence of nonfatal workplace assaults. Emergency departments (EDs) and behavioral health are exceptionally vulnerable. Diminished mental health and addiction resources had an unprecedented impact on our ED, hospital, community, and region. Demand outpaced capacity and ED beds were commonly congested due to lack of behavioral health throughput. Inpatient behavioral health units were routinely at 100% capacity. Our ED was reporting more disruptive and violent behaviors, including more confiscated weapons, a dramatic increase of gunshot wounds, and more victims of violence. Overall, patients presenting to the ED were sicker, their complexity was worsening, and overall ED length of stay significantly increased. Staff assaults and destruction of property became commonplace in the ED. Increasing fear and concern was reported among staff, patients, and visitors. Waiting in a hospital—especially in emergency circumstances—is inherently stressful. Coping skills are stressed and patients and visitors may be prone to more anxiety than in other situations. Stress is arguably worse for those seeking emergency care for mental health and substance misuse, given fewer resources and compromised coping abilities. Our hospital environment had changed, and not necessarily for the better. Our hospital is routinely at full capacity, the statewide system is constantly at maximum occupancy, and transfer options are not frequently available. In 2016, Iowa was ranked 49th of 50 states on per capita ratio of psychiatric beds. Staff assaults, destruction of property, and more weapons had become commonplace. Regulatory agencies are mandating remedies to solve violence against health care workers.

Intervention Detail. For several years, our disruptive patient and visitor program collected data and implemented various interventions toward the goal of reducing violence within the medical complex. For this project, we mapped the ED workflows and asked why. Senior leadership approved a 12-month pilot project to cross-train security officers as psychiatric nursing assistants and an operations improvement Lean engineer was assigned to provide expertise when 3 security officers were redefined as crisis stabilization officers (CSOs). The CSOs were charged with proactively engaging all behavioral health patients presenting to the ED. Special emphasis was focused on patients who were most impaired or most disruptive. CSOs would intervene with patients and significant others by providing education regarding the ED process. CSOs would also provide just-in-time crisis intervention, alerting ED staff to special needs and identifying early warning signs of escalating tension. CSOs underwent special training as psychiatric nursing assistants and completed crisis intervention training. Focused supervision and feedback were implemented.

Outcomes and Impact. The objective and subjective data confirm that our CSO intervention had a positive impact on patient care quality and staff safety. These results were achieved despite increased ED behavioral health volume, increased length-of-stay boarding minutes, and a budget crisis that did not allow for any new hires. The CSO effort had multiple measurable benefits, including enhanced quality of nursing care, a dramatic improvement in patient satisfaction, and a significant decline in violent events occurring in the ED. During the pilot phase, the ED behavioral emergency security watches decreased 18% compared with the previous 12 months, while the ED behavioral emergency security watch rate decreased 45%. This decrease occurred during a time when length of patient wait time increased. Restrictive actions decreased 40%. The rate of injuries related to the same events (staff and patient) decreased 50%. We initially intended for the CSOs to focus on ED behavioral health patients. This focus quickly evolved into using their unique skills with all ED patients. Disruptive events are not exclusive to behavioral health patients; anyone encountering the extraordinary stress of the ED setting may become disruptive. These benefits were achieved by augmenting an existing resource to positively influence the overall dynamic of the ED. Initially, our psychiatry leadership was skeptical regarding the benefits of CSOs focused on behavioral health patients. They have since become unequivocally supportive.

Advancing Care Coordination Through Community-Based Coalitions

Penny Gilbert, MBA, MSN, RN, NEA-BC, CPHQ

Jacqueline Owens, MHA

University of Kentucky HealthCare

Background. Economic disparities are known to influence collective health outcomes. At-risk populations are increasingly susceptible to getting lost within the care continuum. These economic barriers create a negative downstream effect for health care as a result of individuals being less likely to see a physician and have preventive screens and more likely to use emergent care services as safety nets. Although systemic root causes of disparities in the United States will take time to eliminate, health systems can begin promoting health equity by engaging executive leadership in strategic initiatives. The shared commitment between The University of Kentucky HealthCare (UKHC) and HealthFirst Bluegrass for health care access, value, and equity facilitated the robust membership of Bluegrass Community Care Continuum (BGC3) to include nonclinical and clinical partnerships alike. Members recognize that, while they often treat the same populations, they had no idea where or when additional treatment was being sought by vulnerable individuals, especially the homeless population. Communication was streamlined with formal documentation outlining workflows for each organization, direct points of contact, and evidence-based practice of Situation, Background, Assessment, Recommendation-formatted hand-offs. This allowed for real-time, cross-continuum communication among entities that adhere to compliance regulations such as the Health Insurance Portability and Accountability Act. This standardization of communication enabled members to realize there is much more to health care than what is simply within their individual arena, and the complexity of our community health care needs required a true integration of resources. BGC3 engages members through a shared mission and leverages transparency to improve coordination of care. Asset-based interventions are driven by the steering committee and implemented to build accountability and drive measurable outcomes for success. BGC3 has created a circle of care around our vulnerable patient populations by bridging the gaps in coordination and care.

Intervention Detail. According to the most recent U.S. Census, Lexington-Fayette accounts for the largest population of homelessness in the state and includes 26% of the total population in Kentucky. Over one-third are defined as low-income, 8.3% of households have no access to a vehicle, and 21.7% do not report having a regular doctor. As the second-fastest growing city in Kentucky, the immediate need for efficient use of existing resources is ever-pressing. In 2016, the American Hospital Association reported emergency department (ED) visits reaching an all-time high of 142.6 million. With census increasing by the day, UKHC was becoming a marker for avoidable illness that could have been prevented with primary care management, patient education, and/or improved public health initiatives. In 2018, multivisit patients (MVPs), defined as patients with 50 or more ED visits in a rolling calendar year, accounted for over 3000 encounters, often identifying as homeless and suffering from unmanaged physical, mental, and/or behavioral health. In an effort to address episodic care and establish a culture of health equity, our program leverages data analytics to develop targeted interventions that identify vulnerable patients and facilitate the appropriate resources to address both their individual health and social needs. Community health assessments identified areas of opportunity, while the communication document standardized interventions in real time. Data is collected and reviewed on a monthly basis to monitor outcomes and ensure accountability. Dashboard development identified metrics and established performance benchmarks indicating improvements in emergent utilization, continuity of care, transportation barriers, primary care physician coverage, medication reconciliation, temporary/permanent housing, and resolution of food insecurities. The steering committee helped to define future strategic goals, drive initiatives, promote engagement, and further develop our methods for continuous improvement. The accomplishments of our community to date represent a commitment to sustainable and achievable change.

Outcomes and Impact. Current outcomes show success in stabilizing health status for vulnerable populations in our community. Communication processes have reduced the use of emergent services among the top utilizers monitored. MVPs accounted for more than 2000 ED visits at UKHC in 2017. The top 2 MVPs accounted for more than 50% of the total visits. To date, we have reduced MVP ED utilization by more than the 50%. Seventy-eight percent of patients previously enrolled in homeless medical respite secured permanent housing, shelter, or appropriate placement in transitional support services. With a readmission rate of 5.6%, HealthFirst Bluegrass care navigators are an integral piece to providing appropriate continuity of care. Individuals must satisfy the bottom tier of Maslow’s hierarchy of needs if they are to achieve health stability. Fayette-Urban County Government Paramedics experienced a nonemergent 911 call reduction, creating a projected cost avoidance to date of $3.54 million for the city of Lexington. This success gained local and state recognition, allowing for program sustainability. To date, paramedicine has a 54% diversion rate with increasing volumes of 1% to 2% every year. HealthFirst Bluegrass has evaluated and established standards for patient scheduling, allowing greater opportunity for individuals to be established and treated. No-show rates for several indigent community clinics have decreased by 40%. The impact of our collective efforts has demonstrated success in stabilizing health status for vulnerable patients. There is still work to be done, and it is BGC3 members’ belief that we must stop expecting individuals to come to brick-and-mortar institutions to receive basic health care maintenance and/or services. As previously noted, our community lacks transportation and financial funding, and many individuals lack health care coverage. We as health care providers must begin the work necessary to take services to individuals rather than expecting individuals to come to us. Slated for summer 2020, with implementation delays due to COVID-19, the Wellness on Wheels Bus represents the next initiative toward improving access and quality of care for our vulnerable patient populations.

Diagnosing Sepsis: Early Warning Scores and Standardizing Clinical Decline

Mason Crawford, RN-BSN, MHA

Ben Wax, RN-BSN

Megan Cram, RN-BSN, MHA

Sarah Hollenberg, RN, MSN, CNL

University of Missouri Health Care

Background. In January 2019, the Centers for Medicare & Medicaid Services (CMS) released a new star rating that showed University of Missouri Health Care (MUHC) as having a significant deficiency in mortality rankings when compared with similar facilities. Due to this rating, groups of standardized performance improvement priorities were formed utilizing data from the Vizient Clinical Data Base to identify specific diagnosis groups that would have the greatest impact; the comparison group was Vizient academic medical centers. Vizient data identified sepsis diagnosis-related groups (DRGs) 870, 871, and 872 as making up over 50% of all mortalities at MUHC. In February 2019, 12 DRG-based groups were established by an executive oversight group that included a nurse manager, a medical director, an executive sponsor, a data analyst, an information technology professional, and 2 performance improvement professionals. Based on CMS reports, these groups are accountable for mortality, readmissions, direct cost, and length of stay. To maintain this accountability, all groups gave a weekly report to the oversight team. Through Vizient data, the sepsis team identified mortality as the primary priority and reviewed previous interventions, including the implementation of provider-facing sepsis alerting in the electronic health record (EHR) and a sepsis adviser. Despite these being live for 2 years, utilization continued to be low and sepsis bundle compliance was minimal. Three major sepsis patient populations were identified, including: (1) those who meet CMS criteria for SEP-1 and mostly entered the system through the emergency department; (2) direct admit transfer patients from outside facilities; and (3) non-present on admission (POA). The non-POA cases do not fall into the DRG definition but are considered sepsis based on International Classification of Diseases, 10th Revision coding. The sepsis team’s scope was expanded to include these patients based on their potential impact on overall mortality. Based on SEP-1 performance and patient outcomes this was not a priority area with room for vast improvement. The second-largest population with opportunity was direct transfers from outside facilities, followed by non-POA sepsis patients.

Intervention Detail. Two interventions were identified to decrease mortalities to the Vizient top 25th percentile for comprehensive academic medical centers. The first was a sepsis collaboration with the facilities that had the most opportunity for improvement in their sepsis patient outcomes. The second was an innovative utilization of National Early Warning Scores (NEWSs) in conjunction with algorithms that assisted with the diagnosis of causes including sepsis. The mechanism to reach out to select sending facilities was already in place through our existing emergency medical technician department and previous collaborations focused on stroke and myocardial infarctions. This intervention was delegated to the current director of emergency medical technician with sepsis team support as needed. NEWS had been a topic of conversation previously at MUHC and had been vetted for a trial 4 years prior to this sepsis project. Because of this, NEWS had been mapped to existing documentation and had been running in the background in the EHR. This allowed the team to identify average NEWS by patient location and level of care to assist in identifying thresholds for algorithm interventions. A pilot on a single general floor occurred for 3 months before it expanded to a second location. The established low, moderate, high, and very high thresholds, along with their interventions, were identified as effective in the identification of patient decline. Through a partnership with our EHR provider, NEWS alerting—paired with a nursing-based response algorithm—was implemented on all general care floors and the step-down unit in August 2019.

Outcomes and Impact. Since go-live on August 20, 2019, several different measures have been tracked, including adherence to the protocol, intermediate measures, and outcome measures. The goal for moderate or higher NEWS with vital signs every 4 hours was 75%, with a baseline of 72%. In July 2020, this occurred 86.4% of the time. The interventions for both high and very high scores were new processes with expectations of 25% adherence. High scores are responded to appropriately 27.5% of the time and very high 25.6% of the time. All of our adherence measures achieved our initial expectations within the first 6 months of electronic intervention. Intermediate measures included the expectation of a 25% increase in rapid response team calls on general floors and a 25% decrease in code blue calls on general floors. What we saw in the first 6 months was a 65% increase in rapid response team calls and a 41% decrease in code blues on general floors. Along with this, there was a 15% decrease in the mortality index, going from a baseline of 0.92 to 0.78. The mortality index of 0.78 has remained below our goal of 25th percentile (0.8 observed-to-expected) for 3 months. Driving these changes, sepsis mortality observed-to-expected went from the 80th percentile to the 2nd percentile based on Vizient data. Beyond data, the sepsis team has had exceptional frontline feedback regarding the ability to quantify nursing intuition into a language that other disciplines can understand and respond to in a timely manner. The goal of increasing and hardwiring protocol adherence is continuing, and in August 2020, a new electronic workflow was implemented based on frontline feedback to help ensure adherence and reduce dissonance with current practice.

From White Bag to White Glove: A Medication Access Story

Matthew D. Groth, PharmD, MS

Annie Coco, CPhT

Thai Nguyen, BS

University of Rochester

Background. The utilization of external specialty pharmacies for high-cost, clinic-administered medications is a challenge facing all health systems today. This process, known informally as white bagging, occurs for multiple reasons. In most cases, it is due to the restrictive payer policies brought about by increasing vertical integration among payers, pharmacy benefit managers, and national specialty pharmacies. This also may occur when a traditionally noninfusion site or newly acquired practice is unfamiliar with a buy-and-bill model. In these cases, white bagging offers access to medications with limited financial risk or responsibility for the clinic. The white bag process has negative consequences for health systems, including: (1) the introduction of a disruptive third party to the patient-provider relationship; (2) added administrative burden for inventory management, medication delivery logistics, appointment scheduling, and clinical documentation; (3) delayed initiation of treatment; (4) the admission of pharmaceuticals from unauthorized sources; and (5) unfavorable financial outcomes and lost opportunity. This topic is of high importance for institutions that provide high-cost medications in their clinic settings. Policies with permissible allowances for white bag processes present a lower quality of pharmaceutical care and a heightened risk for a sustainable business model.

Intervention Detail. In February 2018, University of Rochester established a new policy prohibiting the use of external specialty pharmacies for office-administered medications. This was done in recognition of increasingly restrictive payer policies that were threatening the patient-provider relationship and impacting the hospital’s ability to provide consistent care to all patients. Shortly after this policy was approved and disseminated, multiple treatment sites were identified in violation of the new policy because they had established a model that relied heavily on white bag processes for their high-cost medications. Approximately 200 patients across 2 departments were receiving regular biologic injections and all doses were being managed through a white bag process utilizing national specialty pharmacies external to the health system. These practices were directed to comply with policy, but concerns were raised about increased costs to patients as a result of the transition. The clinics explained that they did not have the administrative resources to manage copay and foundation assistance programs for the patients, as the specialty pharmacies had always done. Through careful business planning, a decision was made to hire a medication access specialist to work with each department and take responsibility for the financial outcomes associated with their program. Functioning first as a resource for the patient was the cornerstone of the medication access specialist role and limiting patient exposure to complex financials was a fundamental component of the program. Ensuring that patients knew they had a resource working on their behalf and could communicate directly with the specialist was an important feature as well. In addition to this primary responsibility, the specialists were tasked with accountability for the conversion process in their respective clinics while also developing a scalable and efficient workflow that could be adapted in future locations.

Outcomes and Impact. Teams consisting of pharmacy leadership, medication access specialists, nurses, physicians, information technology, and administrators were established to plan the project. Over approximately 9 months, almost all cases were transitioned to a buy-and-bill model, with medication access specialists managing assistance programs in their entirety. This program has shifted full responsibility for management of these biologic medications away from the clinic staff to the medication access specialists, yielded favorable financial outcomes for patients and the office, and eliminated the intrusion of third-party pharmacies from the patient- provider relationship. This program was created from the ground up with patient centeredness at its core. With sound business practices and a commitment to the strategic vision from the beginning, we believe we’ve developed a high-touch and sustainable patient access model for high-cost medications provided in our offices. Patients have expressed high praise for their medication access specialists (whom they know by name) and we have simplified the way they receive and pay for medications. Pharmacy technician staffing, and perhaps more important, retention, of skilled technicians is one of the biggest challenges health system pharmacies face today. The opportunity for advancement among this staffing group has become a focus for our pharmacy leadership to highlight in our departmental communications. We quickly learned that many high-performing technicians who are looking for new responsibilities show significant interest in this medication access role. Next steps include program expansion to larger, more complex environments such as oncology; neurology; and allergy, immunology, and rheumatology. We are also looking to further integrate with our pharmacy specialists in our specialty retail operation to co-evaluate our Medicare patients to determine their best option in terms of billing methodology (Part B versus Part D).

Don’t Stop Believing: Ambulatory Quality Preventive Care Transformation Is a Translational Journey

Tiercy Fortenberry, RN, MSN

Victor Legner, MD

Vanderbilt University Medical Center

Background. It will be easy, right? How hard can it be to implement a few ambulatory quality measures into a major, multispecialty academic clinic? Afterall, at Vanderbilt University Medical Center (VUMC), we perform these screenings and evaluations for patients all day every day—we can surely pull this off in 1 year. Ambulatory quality program performance scores were lower than expected and requirements worth approximately $10 million to $15 million annually were continuing to ramp up. While clinic performance was being reported, clinical teams were unaware of requirements, goals, or opportunities for improvement. Excellent patient care was buried within narrative notes, knowing who needed what was challenging, actionable data and tools to drive improvement were limited and often within the health information technology work queues, and formal quality improvement efforts were practically nonexistent in our primary care clinic settings. VUMC leaders imagined how ambulatory clinics might be more proactive in population health quality initiatives. The decision was made to focus on embedding and improving quality measures within approximately 30 primary care clinic locations. Key leaders came together to create the backbone of change through a governance and accountability model to support information-gathering, decision-making, and resource approval. The Population Health Executive Committee was responsible for the teams supporting the framework and the support engine. The Adult Clinical Performance Committee and the Pediatric Clinical Performance Committee were accountable for clinical practice standards, performance, and outcomes. Clinician and operational task forces were consulted to make recommendations about practice standards and workflow implications. These new groups were embedded into the existing organizational governance structure so that information flowed up through the highest levels. This transformation journey is critical to prepare a large, multispecialty practice for the evolving health care environment. Transformation does not happen overnight; it is a slow, steady process.

Intervention Detail. Strategically, VUMC leaders focused on implementing quality preventive care initiatives within primary care clinics (adult, women’s health, and pediatrics). Data analyses of all quality measures within various programs were completed and a Pareto chart of the most impactful measures across VUMC was created. Ambulatory quality metrics were added to the organization’s pillar goal plan and cascaded from the organizational level to focus areas within primary care. A road map was created to align pillar measures with resources and timelines. This road map included input from multiple VUMC stakeholders, the Vanderbilt Health Affiliated Network, and the local clinical areas. A program management office was established to help navigate the multiple teams and projects. While governance, accountability, and strategic planning are key components, frontline transformation occurs even closer to our patients. The quality department’s clinical effectiveness engine works with local-level leaders to create data that is meaningful, such as “which patients need an HPV (human papillomavirus) vaccination?” or “which patients need to come in for a wellness exam?” Additionally, tools such as a flu dashboard were created to help clinics understand how many patients are missed opportunities for flu shots or flags to indicate a patient needs a mammogram. Supported by the quality department, local-level leaders teach clinical teams improvement methodology concepts such as AIM statements, driver diagrams, run charts, and action plans. System-level project teams helped create system-level improvement efforts such as direct scheduling and bulk patient outreach processes. Overall, interventions are focused on elevating local operational leaders, translating information into actionable data for clinics, and empowering clinical teams to perform clinical improvement work. A major lesson learned is that analytical measurements such as regulatory measures show an organization where to improve but operational measurements show teams what they can do to improve today, tomorrow, and in the near future.

Outcomes and Impact. Over the past 4 years, VUMC created the capabilities to measure and improve approximately 35 ambulatory preventive care measures while implementing Epic as our electronic medical record. All measurement is payer agnostic and can be filtered by numerous views and attribution layers within Tableau. We anticipate more of this functionality within Epic in the future. VUMC is improving patient care experience and quality while also protecting penalty dollars within regulatory requirements. Improvements within commercial payer programs are also promising. VUMC has experienced year-over-year increases in cancer screenings and flu shot immunizations. Our pediatric clinics have increased their volumes for well-child care and immunizations. In 2019, VUMC added depression screening and intervention to its list of improvement initiatives and 82 000 patients were screened for depression. Additionally, approximately 15 nurses are doing quality improvement work in our primary care clinics. Our primary care clinics are seeking patient-centered medical home recognitions; in 1 payer contract, VUMC has gone from a 3-star rating to a 5-star rating in 2 years. VUMC is learning to transform reporting into meaningful improvement in patient care and is better prepared for value models than ever before. The journey continues—there is still much left to do with team-based care, proactive patient outreach, and robust patient engagement. Additionally, VUMC continues to grow its primary care footprint and is looking at ways to engage with patients in our specialty clinics on preventive health care.

Poster Presentations

Ready, Set, Learn: Employee-Driven Competency

Kendra Meany, BSN, RN-BC

Mandy Edmunds, MSN, RN-BC

Blessing Health System

Background. How do you best ensure that provided education is meaningful when addressing the many adult learning styles? Blessing Health System struggled with the concept of how to effectively deliver competencies to the variety of learning styles possessed by our staff. As many educators experience, our staff demonstrated a lack of motivation to attend mandatory training and grumbled about having another computer-based learning module to complete. Staff requested that education be on their time frames and in a style that fit their needs. After careful review of best practices for competency, we decided it was time to put competencies back into the hands of the true owners—the learners. After the topic of education was chosen, a variety of options that appealed to multiple learning styles were created. This allowed staff to choose the education in a format in which they learn best. Through this method, we were able to eliminate the need for 1-on-1 education makeup. This allowed our leadership team to hold staff accountable in real time for education. As education continues to push forward, employees are looking for the competency trend to follow. The purpose of our project focused on meeting the needs of staff, increasing employee engagement in learning, and increasing quality of patient care in a health system struggling with accountability for education. The inclusion of our abstract in the Vizient Connection Education Summit brings a fresh look to an outdated educational plan approach.

Intervention Detail. The lack of accountability for education was a serious issue within our organization. Staff members knew that if they did not attend the mandatory training, the only repercussion they would face would be scheduling a 1-on-1 makeup of the information with their unit-based educator. This education was a poor use of resources and time that did not provide the intended education. This lack of employee buy-in was eye- opening and demonstrated a need to change how education was delivered. After hearing Donna Wright present and further reviewing the information in her book, The Ultimate Guide to Competency Assessment in Health Care, we were certain that her methods were the guidance our organization needed to move forward. The significance of following Donna Wright’s alternative competencies was demonstrated when 5% of the organization’s staff chose not to attend mandatory education that was offered over 58 hours spanning 7 days to ensure that all shifts were covered. Through the development of an alternative competency, staff members who did not attend were instructed to complete the make-up education and demonstrate competence of their knowledge on the topics presented. A variety of options were given, including video creation, a PowerPoint demonstration, and completion of an orientation skills day to demonstrated knowledge. After successful utilization of the alternative competency make-up, the next education planned included multiple competency options. The educational opportunities were advertised and included webinars; puzzles; online, continuous-based learning; staff chart audits with presentation of findings; and even real-time demonstration of knowledge at the bedside.

Outcomes and Impact. Since the implementation of alternative competencies there have been 3 educational sessions delivered utilizing this method. All 3 resulted in 100% attendance. Staff members verbalized increased satisfaction with allowing them to choose their own learning method and they also reported increased knowledge of the education topics. After completion of alternative competency education, the organization’s catheter-associated urinary tract infection rate improved from a September 2019 score of 0.30% to a November 2019 score of zero across the organization that was maintained through January 2020. We continue to develop our new method for competency assessment and grow our options for competency. We are expanding our competency education to a housewide effort following successful implementation on a smaller scale. Our goals for the next year are to incorporate alternative methods for competency into each educational program offered throughout the hospital.

Reduce Catheter-Associated Urinary Tract Infections 30% With This One Weird Trick (Diagnostic Stewardship)

Marc Philip Pimentel, MD, MPH, CPPS

Casey McGrath, RN, MSN

Sinead Bolze, RN, MBA

Amy Bulger, RN, MPH

Brigham and Women’s Hospital

Background. Catheter-associated urinary tract infection (CAUTI) is the most common hospital-acquired infection and a major focus in improving the quality of inpatient care. However, contaminated urine culture specimens are all too common in patients with Foley catheters—the risk of contamination increases by 5% per day, whether or not the patient has an infection. In some settings, the contamination rate is near 50%, which leads to overdiagnosing CAUTI and subsequent unnecessary antibiotics and elevated measured rates of CAUTI. Furthermore, CAUTI is used in the Centers for Medicare & Medicaid Services’ pay-for-performance program, contributing to a major portion of $3.8 million at risk for poor performance. Brigham and Women’s Hospital formed an interdisciplinary, interprofessional team led by quality and safety leadership, physicians, nurses, and leaders in laboratory testing, information systems, and materials management. The project’s scope included the entire lab testing workflow, from the time a physician decides to order a urine culture to collection of the specimen to running the test in the laboratory. The project aimed to increase urine culture appropriateness to 90% (percentage of positive urine culture results in catheterized patients) and eliminate CAUTIs with false-positive urine cultures within 3 years.

Intervention Detail. To define the extent of our problem, we reviewed our historical cases and found that up to 30% of measured CAUTI cases lacked pyuria (white blood cells in the urine that are a sign of infection). Based on interviews with frontline staff, we found that many were ordering urine cultures without using a urinalysis to identify a potential infection. We created a process map of the current state for ordering urine culture specimens and identified several areas that required intervention to ensure appropriately ordered specimens and clean collection practices. We intervened using the following steps: (1) created a new hospital policy for prevention of unnecessary urine culture testing; (2) piloted a decision support change by hiring an infectious disease fellow to monitor pending urine cultures daily, educate our physician interns about appropriate urine culture ordering, and cancel a urine culture when there was no pyuria; (3) introduced new containers for both urinalysis and urine culture specimens containing a preservative to prevent bacterial overgrowth while waiting to run the urine culture in the laboratory; (4) created an automated process in the laboratory to run the urine culture specimen only after pyuria was found on the urinalysis; and (5) created an alert in the electronic medical record to redirect users to the new reflex urine culture test instead of the standalone culture.

Outcomes and Impact. During the pilot phase of the project, our observed CAUTI rate dropped by 30%. Following the rollout of the automated process, the number of calls made by the infectious disease fellows dropped to zero, while the appropriateness of urine culture testing increased from 50% to 96%. Moreover, 5500 potentially false-positive urine culture specimens were prevented from being run, decreasing labor costs in the laboratory and potentially reducing unnecessary antibiotic treatment. Since we implemented the automated urine culture reflex testing workflow on June 19, 2019, we have had zero CAUTIs with false-positive urine culture through November 2020.

Open for Business: Taking Command of Capacity Management

Adam Spartz, MBA, BS, RRT

Staci Glick, MSN, RN

Cindy Loyd, BSN, RN

Columbus Regional Hospital

Background. Manufacturing throughput, with its assembly line approach and rigorously measured cycle times, takt times, workspaces designed for optimal efficiency, and work areas that can be rearranged to accommodate different products, was the basis of our new vision. Attention to these details drives efficiency, quality, and productivity. There are many parallels when looking at hospital throughput; however, our assembly line encompasses people presenting from various areas (eg, direct admits, surgery, catheterization labs, and the emergency department). A fundamental question was asked in the Columbus Regional Hospital organization—how can we do this better for staff, patients, the community, and the health system? In tandem with evaluating the current state, a group undertook a concept design for a command center and what it would look like at our facility. Many places and things have command centers, with mission control at the National Aeronautics and Space Administration being perhaps the most famous. Today’s iPhones also have a command center that you can see with a simple swipe on your home screen. One might also draw parallels to the dashboard console of most new vehicles as a command center for your vehicle. What do these 3 examples have in common? All provide real-time information that allow for informed decision-making. During our internal assessment, we recognized that a lack of real-time information was leading to some uninformed decision-making. The house supervisor role was keeping track of bed placement/availability manually, which oftentimes led to confusion. Additionally, operational leaders struggled to see the shift-to-shift flow of patients through the hospital due to the lack of real-time information. There was a growing concern that because of the way capacity was being managed, we were losing 5 to 15 admissions a week—something the hospital wanted to avoid.

Intervention Detail. Our electronic medical record vendor was on-site in April 2018 and we learned of the capacity management functions that were going to be available to us in our new system. This led us to an off-site visioning workshop in August 2018 to determine the scope and begin concept design for a formal command center to run inpatient operations. Our initial focus was on bed placement. In January 2019, a space was identified within the hospital that would be repurposed as the command center. The space is roughly 1500 square feet and contains 2 private offices, 3 semiprivate cubicles, 7 open workstations that face a wall of monitors displaying real-time data, a small conference room, and a breakroom. For privacy and security concerns, access to the area is limited to certain individuals and is badge access only. The roles existing in the command center were also identified: a manager, house supervisor, and a command center specialist. The latter 2 were envisioned to be 24/7 roles. Other functions would also be operated via the command center, including nursing resources (float pool), patient transport, scheduling, and day-to-day staffing—the belief being that colocating these individuals and functions would have a significant return on investment to the organization with minimal cost. The go-live date for the command center was scheduled for July 21, 2019, which intentionally coincided with the go-live date of our new electronic medical record. Positions were filled in the lead-up to the go-live date to allow for ample training time in the applicable modules. The initial focus was bed placement, with plans to focus on staffing management during the first quarter of 2020. Organizationally, command center functionality is positioned in the long-term to move beyond the initial focus of bed management into other areas, like emergency preparedness and even communications.

Outcomes and Impact. Since the launch of the command center in July 2019, both the reception and the results have been overwhelmingly positive. The individual nursing units are no longer responsible for patient placement, with exceptions for our behavioral health, inpatient rehab, and birthing center due to their patient population and requirements for admission. Direct admits, which can prove challenging during periods of high census, have seen the unable-to-accommodate percentage drop from an August 2019 high of 6.1% to a low in January 2020 of zero. The emergency department has seen a similar decrease, from an August 2019 high of 4.9% to a January 2020 low of zero. Those numbers taken by themselves represent quite an achievement, but also of importance is our census, which has increased by 20.2%. Our data prior to launch is not as solid, but conservatively we were losing 5 admissions per week, with more aggressive estimates at 15 per week. In nursing alone, that is equivalent to $250 000 to $750 000 of lost net income in the first 6 months of 2019. Taking that lost admission number all the way to zero in 6 months has been a heavy lift and a huge accomplishment for the organization. We now have staff monitoring bed capacity boards to identify potential flow problems and when we see problems developing, they are addressed in real time. On-call leadership is also able to monitor capacity dashboards from mobile devices should their intervention be required. Moving forward the command center has been tasked with keeping our lost admission percentage as low as possible, while taking on scheduling and day-to-day staffing to ensure we have the proper number of staff present for the acuity and census at any given time. A long-term strategy for the command center is still being developed.

Improving Chronic Obstructive Pulmonary Disease Care Across the Care Continuum

Chris Stoelting, BS, RRT

Cathy Seuell, MSN, RN, CRRN

Deaconess Hospital

Background. Deaconess Hospital in southwestern Indiana serves patients from Indiana, Kentucky, and Illinois. This area has a high prevalence of chronic obstructive pulmonary disease (COPD), both as a principal diagnosis and as a secondary diagnosis. Deaconess Hospital was seeing an increase in COPD patient readmissions and was not meeting hospital goals. In addition, care was fragmented and nonstandardized, and COPD patients struggled with self-care to prevent exacerbations. In 2017, a COPD cohort leader was assigned to work on understanding the cause of 30-day readmissions. Through readmitted patient interviews, it became clear that patients lacked an understanding of the disease and how to self-manage their care to prevent exacerbations. With data review, the vice president of medical affairs determined there was an opportunity to improve the care of COPD patients by establishing a COPD medical director at Deaconess. A pulmonologist within the Deaconess Critical Care Group Practice who championed evidence-based practice ideas that could positively impact COPD care was appointed COPD medical director in early 2018. Under their leadership and in conjunction with the COPD cohort leader and a Lean Six Sigma black belt, a COPD steering team was established to begin designing the Deaconess COPD care program. The COPD steering team leadership reported monthly progress to the vice president of medical affairs and the chief nurse executive. These administrative leaders assisted in breaking down barriers for the team and served as liaisons to the rest of the Deaconess administrative team. Through this strong collaboration between the vice presidents, the COPD medical director and the COPD steering team, we were able to implement standardized COPD care within Deaconess inpatient and outpatient services. Deaconess has been successful in assisting patients with successfully self-manage their COPD.

Intervention Detail. The COPD steering team analyzed the hospital’s 30-day readmission rate. The Medicare COPD 30-day readmission rate pre- intervention was 18.66%, with an excess readmission cost of $138 000. The team identified and reviewed the COPD patient care process through staff and readmitted patient interviews. Chart reviews identified patient education and discharge planning issues. The team identified care variations and gaps in the transition of care from the hospital. The COPD steering team conducted literature reviews and benchmarked with hospitals who had implemented successful COPD care programs, identifying key interventions that improved care and reduced 30-day readmissions. The COPD medical director led the team in designing a COPD care program. Interprofessional care team members included respiratory therapists, pharmacists, nurses, case managers, social workers, a pulmonology/critical care physician, a hospitalist, a family practice physician, an advanced practice provider, a dietitian, and a Lean Six Sigma black belt. Utilizing evidenced-based care standards, a COPD care bundle and inpatient COPD navigators were introduced to the organization’s 2 acute care hospitals in January 2019. The COPD bundle within the hospital’s electronic medical record includes admission and discharge order panels. These include referrals to pharmacy, palliative care, smoking cessation, pulmonary rehabilitation, follow-up appointment within 3 to 7 days of discharge, remote patient monitoring, and a Prednisone Rescue Pack. Utilizing the COPD bundle, the COPD navigators coordinate COPD inpatient care with the interprofessional care team. Patients receive education on disease, proper inhaler technique, and exacerbation reduction strategies, as well as an action plan that gives clear direction on rescue pack implementation and when to seek medical assistance. In September 2019, the Deaconess pulmonary rehabilitation program launched with the goal of adding an outpatient component to the COPD program. The rehab program includes education, exercise, and functional quality assessments. The team worked to increase COPD patient referrals and active program participation by patients.

Outcomes and Impact. The COPD 30-day readmission rate post-COPD bundle and COPD navigator intervention was reduced to 15.1%. After pulmonary rehabilitation implementation the rate was further reduced to 14.3%. Pre- and post-intervention comparison had a P value of 0.022 (P < 0.05 is statistically significant). The reduction in 30-day readmissions resulted in a $324 000 savings with an overall gain of $461 000 from baseline. Feedback from COPD patients, staff caring for the COPD patients, and inpatient providers has been extremely positive. Through the work of the COPD navigators and the care team, transportation and financial issues—including the ability to afford medications—have been identified as major issues for the Deaconess COPD patient population that the team has begun to address. Patients who graduated from the pulmonary rehab program from January 2020 to March 2020 met functional improvement goals: 75%: 6-minute walk test; 66.7%: shortness of breath questionnaire; and 61.5%: COPD assessment test. Due to the COVID-19 pandemic, pulmonary rehab was closed for nearly 2 months. During that time the rehab staff called patients weekly to provide support and assistance to reduce exacerbation risk. When the program was reopened, 80% of patients returned to resume pulmonary rehab. An inhaler recommendation chart was developed by the COPD medical director to be distributed to hospitalists and primary care physicians. This chart provides evidence-based, standardized guidelines for the appropriate inhalers to prescribe for patients based on their condition. The COPD medical director and COPD steering team are working with other chronic disease teams, primary care providers, and specialists to more fully develop chronic disease management using lessons learned from the COPD program.

Creating and Utilizing an Opioid Continuum of Care Model

Dean McEwen, MBA

Denver Health

Background. In 2017, there were an estimated 6668 individuals in Denver, Colorado, suffering from opioid use disorder (OUD).1 Due to the chronic nature of opioid addiction and the association of OUD with mental health conditions and polysubstance use, effective treatment for OUD is complex and lifelong. Standard and effective treatment for OUD includes medication-assisted treatment (MAT) and behavioral counseling. Caring for persons with OUD requires a multidisciplinary approach, integration, and coordination. Denver Health (DH) established the Center for Addiction Medicine (CAM) to provide addiction services for persons living in the city and county of Denver. The CAM aims to optimize: access to care; identification of persons with OUD; timely and appropriate linkage to MAT; and supportive therapy, adherence to MAT, and retention in care. Efforts to quantify the number of patients with OUD and evaluate treatment success resulted in identifying a number of data sources. One of the primary sources was the electronic health record (EHR) system. Other information was recorded in paper logs, spreadsheets, and other unlinked databases. Besides the EHR, another key database system was the Substance Abuse and Medication Management System, which tracks MAT dosing. Evaluating these different data sources identified gaps in standardized definitions and methods of documentation across the enterprise. An in-depth evaluation conducted by the CAM Knowledge Management Team quantified the number of DH patients with OUD and identified a lack of standardization in clinical documentation and coding, incomplete or inconsistent definitions of key therapeutic milestones, and an inability to provide continuity of care across the DH network due to independent and unlinked data systems. Developing standardized definitions and integrating these disparate data sources together was a key task in developing a unified continuum of care model that would enhance operational, managerial, and evaluation activities to improve patient care and retention.

Intervention Detail. The CAM developed an opioid continuum of care model to evaluate the impact of our efforts. It is based upon the HIV Care Cascade developed by Ed Gardner, MD, from DH. Through an iterative process, the model evolved to become a continuum of care for patients with (OUD), opioid misuse (OM), or opioid poisoning (OP). The model, typically depicted using a bar chart, consists of the following metrics: (1) estimated OUD, OM, and OP in Denver; (2) identified OUD, OM, and OP at DH; (3) received MAT at DH; (4) retained in MAT > 90 days; and (5) retained in MAT > 1 year. The first metric, estimating opioid issues within Denver, is difficult to quantify because no data sources exist with that information. Instead, our estimation uses a national prevalence rate applied to the Denver population. The second metric required us to identify the number of patients with OUD, OM, or OP within our system. Initial attempts to quantify that number were performed using International Classification of Diseases, 10th Revision (ICD-10) codes. The statistics from diagnosis codes were immediately dismissed by providers as incomplete. Interviews were then conducted with providers from various service areas (inpatient, primary care clinics, emergency department, and outpatient behavioral health services) to determine how opioid documentation occurred. The providers’ input identified varying documentation and process practices. Definitions to identify patients with OUD expanded significantly and required detailed data examination. These definitions included ICD-10 codes, the Clinical Opiate Withdrawal Scale, MAT orders, self-reported opioid use, toxicological screening laboratory results, and key words within provider notes. Using 2017 inpatient data, the number of patients identified with opioid issues using the expanded definitions resulted in a 236% increase when compared with only using ICD-10 codes. The received MAT and retention metrics also required discussion but did not require significant effort in developing definitions.

Outcomes and Impact. The establishment of definitions for the opioid continuum of care model created the capability to examine changes to processes and outcomes for different time periods. This model is valuable because it depicts: (1) the potential number of DH patients that may need treatment; (2) the percentage of patients enrolled in treatment; (3) the number of patients successfully retained in care for varying durations; (4) where patients are most likely to drop out of care along the treatment continuum; and (5) a snapshot in time that can be evaluated in future time periods to assess changes in each aspect of the continuum of care. The opioid continuum of care model was populated using 2017 and 2018 data to compare the impact made by the CAM. The following information depicts the numerical changes for each stage within the continuum of care for 2017 and 2018.

No title available.

Compared with 2017, the 2018 results indicate a larger number of patients were identified with opioid issues and more patients received MAT. However, there was a significant decline in the percentage of patients retained in care for greater than 90 days (67% compared with 59%) and greater than 1 year (47% compared with 40%). Using this comparative information helps us study gaps in the continuum using qualitative and quantitative analyses to improve retention in care. Overall, this continuum of care model is extremely useful in evaluating patient treatment for OUD. Future work will examine other substance use disorders (eg, methamphetamine, alcohol).

1.Prieto JT, McEwen D, Davidson AJ, et al. Monitoring opioid addiction and treatment: do you know if your population is engaged? Drug Alcohol Depend. 2019;202:56–60.

Cost-Effective Methods for Care Partner Engagement in Primary Care

Carolyn Clevenger, RN, DNP, AGPCNP-BC, GNP-BC, FAANP, FGSA

Laura Medders, MSW

Emory Healthcare: Integrated Memory Care Clinic

Background. Emory Healthcare’s Integrated Memory Care Clinic (IMCC) is a unique clinic model developed in response to dementia care partners’ requests for all primary medical care to be managed by a dementia specialist. The IMCC is the nation’s first and only comprehensive primary and dementia care practice. One of the core values of the model is the coproduction of care with our patients and their care partners. Most people living with dementia receive their primary medical care in a setting absent of dementia specialists, while the IMCC is a unique model in a single location. However, innovative practices developed and tested in the IMCC model can be replicated into other primary care settings. Unlike many patients living with chronic conditions, people living with dementia do not have the cognitive capacity to manage their disease without a care partner. As a result, the bulk of treatment decisions, interventions, and services must be targeted to the care partner. The additional time required to care for both the patient and their partners must be built into the workflow of patient visits while optimizing reimbursement. The issue addressed in this presentation is the efficient and cost-effective incorporation of care partners into the primary care of people living with dementia.

Intervention Detail. For people living with dementia, a knowledgeable and effective care partner is a far better intervention than any pharmacological option. The IMCC engages the care partner before, during, and after office-based encounters with our patient. Brief interactions are documented for cumulative time spent in chronic care management; interactions greater than 30 minutes with practitioners are documented for prolonged non-face-to-face visits. Prior to office visits, care partners may opt to have a supplemental visit by phone or videoconference with the practitioner to report observed medical and psychiatric symptoms or results of any home monitoring, share information about other health care or community services used, and describe their goals for the upcoming visit. This allows the clinician to focus entirely on the patient with dementia during the office encounter. During the cognitive assessment visit, care partners report on function and behavioral symptoms and their caregiving confidence via electronic tablet. Answers to these sensitive questions upload directly to the medical record for the clinician to address appropriately while minimizing the requirement for people to describe sensitive topics in front of the person for which they are caring. Following visits, care partners may also have a supplemental visit to debrief the encounter. These are especially helpful in the case of appointments for which care partners could not be present. While not all visit information may be shared, a care partner is necessary to reliably implement the care plan. The clinical social worker dedicates time to care partners to build competency, confidence, and knowledge in their role as care partner. The IMCC offers individual psychotherapy appointments for care partners, family therapy appointments, psychoeducation group classes, and stage-based support groups.

Outcomes and Impact. When surveyed, IMCC care partners describe access to the clinical team as both the most meaningful part of their IMCC experience and the most desired service we could increase. The IMCC applies chronic care management billing and prolonged non-face-to-face encounters to support time spent outside the office visit by practitioners and other clinical staff. Cognitive assessment and care planning supports the dedicated input of care partners on physical and psychiatric symptoms. Family (psychotherapy) (without the patient present) billing supports care partner and family meetings with a clinical social worker. We expect 40% of patient visits to benefit from a pre- or post-visit appointment with care partners by phone or videoconference. The supplemental visits are currently being incorporated into the regular visit schedule. At this time, these visits are occurring at a rate of 2 to 5 visits per week. On average, 12% of the patient panel receives 20 minutes or more of chronic care management per month, while 4% receives more than 60 minutes per month. More than 20% of care partners have participated in the 6-week, face-to-face, psychoeducational program and 23% have participated in the clinic’s support group. Both the supplemental visits with care partners and the educational and support groups have improved the flow of the patient encounter. The providers find that the well-prepared care partner is better able to share in decision-making, the patient is able to express their own voice during the office encounter, and the visit length is adequate to provide excellent primary and dementia care.

Pancreatic Surgery Care Delivery Optimization Using a Focused, Interprofessional Team Approach

Kristi Opper, MS, RN, ACNS-BC

Froedtert & the Medical College of Wisconsin

Background. Health care organizations across the country are pursuing innovative ways to improve patient outcomes through care delivery redesign, population health management, and application of evidence-based quality and process improvement methods. This includes addressing chronic problems such as avoidable days in the hospital, costs associated with nonvalue-added treatments, and overall quality of care. At Froedtert & the Medical College of Wisconsin, the average length of stay (LOS) for pancreatic surgery patients was 11.60 days in fiscal year 2017. The direct costs attributed to caring for these patients were observed to be 70% higher than national benchmarks. The pancreatic surgery team includes 4 surgeons who provide advanced treatment options to our patients having pancreatic cancer and who would not be offered surgery at other institutions due to vascular involvement of the tumor. Patients are treated preoperatively using medication and radiation therapy to decrease the size of the tumor to allow for a complete resection and vascular reconstruction. The complex nature of the treatment and having individualized yet, different care pathways led to significant variation in LOS and added costs to the health system. Upon comparison with our Vizient cohort, clinical outcomes data indicated that our observed-to-expected mortality rates and readmission rates were similar; however, our patients had 30% longer lengths of stay. This created a heightened awareness of the issue at hand and propelled our surgery team to address every aspect of care for the patient, from the time the patient saw their surgeon through the postsurgery recovery period.

Intervention Detail. Between October 2017 and December 2018, we assembled a multidisciplinary team of physicians, advanced practice providers, a clinical nurse specialist, registered nurses, dietitians, pharmacists, physical therapists, diabetes care providers, anesthesia, and perioperative staff to charter the Pancreatic Surgery Enhanced Recovery After Surgery (ERAS) project. Using the Plan-Do-Study-Act method of process improvement and Lean and project management tools, care teams developed a detailed process and project plan for identified areas, from presurgery planning through postsurgery appointments. The interventions developed included: (1) patient education and engagement; (2) prehabilitation; (3) ERAS nutrition; (4) care pathway standardization; (5) diabetes management; (6) nonopioid pain management; and (7) postdischarge follow-up. A new standard of care was developed with approval for new treatments, workflows, and comprehensive education and training for physicians and staff. A pilot with 18 patients included prehabilitation, ERAS nutritional supplements, and bupivacaine liposome injectable suspension tap blocks. Through chart review and analytics, we collected additional data on patients before the intervention was fully implemented and after the 18-patient pilot. Data was collected on a total of 60 patients, including pain scores, opioid use, ambulation, return of bowel function, LOS, readmissions, and cost of care. This allowed the team to effectively evaluate the interventions that were most effective and provide greater benefit to the overall program beyond decreased costs. In addition to cost, we evaluated many outcomes, including narcotic use, pain, LOS, and readmission. The remaining patients were in 2 other groups; the first group included patients who had surgery before the interventions were put into place and the second group had the ERAS nutritional supplements and a standard tap block after the new care processes were put into place.

Outcomes and Impact. Patients who received all of the care enhancements had the most improved outcomes. LOS decreased from 11.6 days to 8.06 days. As a result, the cost-of-care index decreased 53% from baseline, which can be attributed to successful implementation of the ERAS bundle. Initial efforts while designing the interventions were met with resistance from a few key stakeholders; however, with the application of process improvement and change management techniques our team navigated through the challenges while never losing sight of the project objectives. Additional improvements were observed related to opioid use. Patients who received long-acting bupivacaine tap blocks used 8 mg of morphine equivalent less than patients who received a standard tap block. Pain assessment scores were similar for patients even though opioid use was decreased. All patients received a standard postoperative pain management plan, including a patient-controlled analgesia pump. The use of bupivacaine liposome injectable suspension tap blocks was expanded to clinically appropriate abdominal surgery patients. Most of the patients were admitted to the postsurgical floor, avoiding any intensive care unit stays, and most were also ambulating much quicker due the result of prehabilitation. Nurses and dietitians reported that increased patient and family awareness through proactive communication and education led to faster patient self-management. The pancreatic surgery interprofessional team continues to look for improvement. Additional work is now being done to review fluid management and resuscitation in the operative and immediate postoperative periods and the development of additional education for patients toward self-management using learning tools in the home environment is being evaluated. Several additional teams are being formed across the health system to adopt elements of the ERAS protocol. These efforts should continue to impact LOS, reduce unnecessary treatment costs, and help our health system provide exceptional care to our patients.

Putting Our Best Foot Forward: Improving Care in Diabetic Foot Ulcers

Laura Handa, MS, RN

Maralyssa Bann, MD

Anneliese Schleyer, MD, MHA

Harborview Medical Center

Background. Harborview Medical Center (HMC) is a 413-bed, academic, level I trauma center and urban safety net hospital in the greater Seattle area. HMC treats the most vulnerable populations, with approximately 15% of inpatients marginally housed and 30% on Medicaid. Many have multiple comorbidities and are at high risk for skin conditions, given numerous risk factors. Among HMC patients with diabetic foot ulcers, 29% had mental health diagnoses, 24% had substance use disorders, and 24% were marginally housed in fiscal year (FY) 2019. A study on the economic impact of chronic, nonhealing wounds for Medicare patients found that in 2014, 8.2 million (15%) suffered from at least 1 chronic wound or wound infection, and of those, 278 800 (3.4%) were diabetic infections.1 Caring for patients with diabetic foot ulcers is often complex, as multiple specialties are involved and the foot ulcer may not be the primary reason for admission. Several factors such as location of the wound (eg, heel versus forefoot), type of infection, and other comorbidities can compound confusion as to the most efficient and effective course of treatment, potentially contributing to extra hospital days. A patient outcomes report from the Vizient Clinical Data Base showed a 1.31 length of stay (LOS) index for patients with either a principal or secondary diagnosis of “diabetes mellitus with foot ulcer” discharged in FY 2019. We benchmarked our performance to 10 academic medical center hospitals (with 5 being America’s Essential Hospitals) with similar case volumes and expected lengths of stay as our population—with HMC falling close to the average on both. Case mix index and all-patient refined diagnosis-related group severity of illness demonstrated similarities in patient acuity for HMC and the comparison hospitals, demonstrating a comparable cohort to benchmark against. The cohort’s combined average LOS index was 0.94, compared with HMC’s LOS index of 1.31.

Intervention Detail. The process improvement team convened a clinical interdisciplinary group to identify variation and delays in care. The team mapped current state processes and identified areas to target for improvements. Resource Manager, a Vizient Clinical Data Base tool, was instrumental in defining the target patient population with International Classification of Diseases, 10th Revision diagnoses and allowing us to investigate the variables associated with a higher LOS index. Case reviews mined from Resource Manager confirmed varied and incomplete assessments, inappropriate antibiotic selection, and delays in connecting with appropriate consult services (eg, general surgery, orthopedic surgery, vascular surgery, podiatry, etc.), all of which were opportunities for improvement in quality of care and LOS outcomes. After project members identified key areas of care variation that were not in alignment with published best practices, an inpatient clinical pathway was developed to target critical assessments and interventions during hospitalization. The pathway stratifies the population into 3 categories of infection severity based on clinical assessment criteria and guides clinicians through an algorithm to suggest consult services, diagnostic testing, and clinical management guidelines to consider for each level of severity. In addition to the pathway, the team developed role-specific admission and discharge checklists for nurses, physicians, and discharge coordinators. These tools provide reminders of the clinical pathway’s essential tasks. The team communicated with stakeholders to raise awareness—especially to internal medicine physicians, acute care nursing staff, and key discharge coordinator personnel—about the improvement initiative and the importance of prosthetics and/or orthotics consults. Pre-intervention surveys were also disseminated to measure baseline knowledge of wound care best practices. Last, the clinical pathway (including new guidelines for appropriate antibiotic therapy) was proposed to various clinical leaders for review and approval to be published on the hospital’s internal clinical reference application. Infectious disease physicians also recommended an evidence-based change from current practice that broad-spectrum antibiotic coverage for pseudomonas infection was not necessary.

Outcomes and Impact. During current state workflow analysis, a potential delay to podiatry consult was identified. Vizient Clinical Data Base data confirmed that patients with a principal procedure by podiatry (23% of the target population) and admitted on Fridays in FY 2019 had a 1.3 LOS index compared with an average LOS index of 0.7 days for those admitted on other weekdays (LOS outliers excluded). This supports review of the inpatient podiatry program structure. Since provisioning of offloading footwear is a vital component of healing and prevention, we sought information on how often this was provided for inpatients. FY 2019 Vizient Clinical Data Base data indicated 48% of the target population received a revenue code 274-prosthetic/orthotic devices. However, connecting Vizient Clinical Data Base data with electronic health record data showed that prosthetics or orthotics were consulted for 70% of patients for the same time frame. This discrepancy may be due to established patients who do not receive new devices, but the goal is for prosthetics or orthotics to consult all target patients regardless. The percentage of target population with a prosthetics or orthotics consult measures checklist effectiveness and clinician understanding of the importance of prosthetics or orthotics involvement. Fully piloting the checklists on our medicine service was delayed due to COVID-19 response. Medicine service patients had a 11% decrease of prosthetic or orthotic consults from baseline (FY 2019) to intervention phase (October 2019 through February 2020). This process metric will continue to be tracked after pilot interventions are reinstated. We also evaluated antibiotic use in this population. FY 2019 Resource Manager data showed that 43% received more than 1 day of broad-spectrum antibiotics (either intravenous cefepime or intravenous piperacillin-tazobactam) during hospitalization. We tracked the percentage of target population discharged from the medicine service with >1-day broad-spectrum therapy use as a process metric for adherence to the newly proposed clinical guidelines that changed practice away from using broad-spectrum therapy to cover pseudomonas infection. Because emergency room care was out of scope for the project, patients receiving only 1 day of broad-spectrum therapy were excluded. A 14% decrease of patients on more than 1 day of broad-spectrum therapy was observed from baseline (FY 2019) to intervention phase (October 2019 through February 2020) for patients discharged from the medicine service. These process metrics will continue to be tracked as interventions are piloted and fully implemented after operations normalize from COVID-19 response.

1.Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health. 2018;21:27–32.

Optimizing the Care Continuum of Pediatric Sepsis: Translating Process to Better Outcomes

Elizabeth Haines, DO, MAS, FACEP


Hassenfeld Children’s Hospital at NYU Langone | NYU Langone

Background. Rapid recognition and treatment of pediatric sepsis improves mortality. Recognizing that there is no single diagnostic test to confirm this clinical entity, institutions rely on close clinical surveillance by highly engaged teams coming together at the bedside. When sepsis is being considered, best practice models support the use of a bedside huddle by clinical care teams to have multidisciplinary input and increase communication around care pathways and family engagement. In our health system, the pediatric sepsis bedside huddle is prompted by electronic best practice advisories. Leadership at our institution recognized a need to optimize the sensitivity of the screening test (the best practice alert) in order to reliably bring the clinical team to the bedside when a patient showed signs of deterioration. Additionally, we further recognized the need to support process measures in bundled care by implementing nursing documentation tools that enhance visualization of the care pathway.

Intervention Detail. To optimize use of the electronic health record clinical decision support tool (best practice advisories) and prioritize sensitivity over specificity, we revised the physiologic parameters that were mapped to the alert triggers and added systolic blood pressure. This broadened our catchment and raised the screening alert’s sensitivity from a unit-dependent range of 35% to 57% to a range of 95% to 100%. To improve bundle adherence and timely care in pediatric patients enrolled in our sepsis care pathway, we built and implemented a nursing narrator that utilized visual, color-coded, and timed cues indicating what was completed versus what was due. This electronic health record narrator served as a digital checklist and dually aided in documentation and electronic capture of the processes around the care bundle. This standardized documentation decreased practice variation and led to efficacious provider feedback loops for patients who were noted on audited reports to have not met bundle metrics. In order to monitor success of the interventions, we tracked both process and outcome measures. During our weekly, unit-based safety huddles, performance feedback was shared with frontline staff to engage teams and emphasize improvements.

Outcomes and Impact. Optimization of the alerts raised sensitivity and, to date, has captured 100% of all state-reported, pediatric cases of severe sepsis. The workflow of alert-driven huddles, reinforced by a nursing narrator to guide care, has resulted in a marked reduction in time to initiation of the fluid bolus and antibiotics. This has been especially notable in our highest-volume units. Our system encompasses 3 emergency departments that oversee the care of more than 30 000 children annually. In calendar year 2019, our emergency departments met the 60-minute care bundle in 100% of severe sepsis cases.

Striving for Unparalleled: Providing Individualized Care


Lauri Noel, MSN, RN, CNOR

Houston Methodist

Background. Organizations across the world struggle with preventing patient falls, with rates in the acute care setting ranging from 1.4 to 18.2 falls per 1000 patient days.1 In 2017, Houston Methodist was at a baseline fall rate of 1.65. A drive to improve this rate guided the selection of a new, evidence-based fall risk predictor. This fall prevention tool is a clinical decision support system for predicting and preventing falls and injuries across the continuum of care. This program has evidenced superior predictive ability and is instrumental in guiding targeted safety interventions to prevent patient injury. Like most fall prevention tools, the assessment is most effective when accurately used. Accurate assessment of fall risk leads to use of appropriate interventions to prevent falls. After initial implementation of the program, however, fall rates were not dropping as quickly as projected in the first year. To determine why the tool was not producing the desired results, an intensive data analysis was conducted. Audits of the accuracy of tool use were conducted on every unit at every hospital. Once the data was compiled, it was discovered patients often had incorrect fall risk assessments—the majority of which were under-scored. These under-scored patients did not receive the full extent of interventions tailored to their score, which sometimes led to falls. Once it was determined that the fall risk assessments were incorrect, focused efforts were put in place to increase scoring accuracy. Accurate scoring of fall risk leads to targeted, appropriate interventions to reduce falls. Sharing these directed efforts can help hospitals determine if fall risk scoring is accurate and if appropriate targeted interventions are in place to prevent falls.

Intervention Detail. The new falls program was put in place in 2017. The Houston Methodist system recognized a decrease in fall rates in 2018 as a result, but felt that the program was not being used to its full potential. To help decrease rates further, an investigation began into the possible reasons the rates were not decreasing to the expected degree. Data were collected through monthly audits of scoring and interventions, discussion in the fall committee and fall champions meetings, and investigations into actual falls. The data indicated that a majority of falls were being incorrectly scored. Most of the inaccurately scored patients were labeled as either low or moderate risk, when they should have been scored as high risk. This meant a number of individualized interventions intended to reduce specific fall risk factors were not being implemented. To gain a better understanding of the challenges regarding accurate scoring, falls for the entire month of December 2018 were audited. Inter-rater reliability tests were performed on 89 falls throughout the Houston Methodist system. Out of 89 falls, 45 were scored lower than necessary. The most common areas that were incorrectly scored included medications and volume/electrolyte status. The scoring inaccuracy in these areas also led to missed interventions to prevent falls. Results of the December 2018 fall audit were discussed at the fall committee and fall champions meetings. Targeted education was developed and implemented at the unit level, with a particular focus on medications and volume/electrolyte status. The data dictionary in our electronic medical record was updated with a focus on these 2 areas. Emphasis was also placed on ensuring appropriate interventions were in place to prevent falls. The focus on accurate scoring and appropriate associated interventions to prevent falls allowed us to see a significant decrease in falls in 2019.

Outcomes and Impact. In 2018, the fall rate dropped from 1.65 to 1.54, resulting in a 7% decrease in falls for the year. This was the first year in which the Hester Davis Scale was used to assess fall risk. While this decrease is not insignificant, the system felt that further reducing the fall rate was necessary. Through analysis of a variety of data sources, a targeted approach to fall reduction was established. Throughout 2019, the focus was placed on accurate scoring and ensuring proper associated interventions were in place. As a result, the fall rate dropped to 1.54 to 1.32 for 2019, resulting in a 14% decrease in falls for the year. The reduction in falls in 2019 doubled from 2018 after the focus was placed on accurate scoring. Accurate fall risk scoring and the associated appropriate interventions to reduce falls were instrumental in helping to decrease fall rates. Our rate decreases correlate with 109 patients who did not fall in 2018 and 209 patients who did not fall in 2019. We are pleased with the reduction in fall rates throughout the system and keeping patients free from falls and safe from harm as a result of falls is a source of utmost pride. Houston Methodist is committed to keeping patients safe, and continued progress toward further reducing falls throughout our system allows us to keep that promise.

1.DiBardino D, Cohen ER, Didiwana A. Meta analysis: multidisciplinary fall prevention strategies in the acute care inpatient population. J Hosp Med. 2012;7:497–503.

Community Paramedicine Program Effectiveness in Reducing Readmissions

Joseph Casciotti, BSN, RN, EMT-P, CEN, CFRN

Harris County ESD 48 Fire Department

Denise McCall, BSN, RN, MHA, CEN, NE-BC

Houston Methodist West Hospital

Houston Methodist West Hospital

Background. Readmission levels at Houston Methodist West Hospital were not at the desired goals. At the same time, one of our local emergency medical services (EMS) providers also identified that patients were calling 911 for help shortly postdischarge. Needs were assessed by looking at 30-day readmission rates, specifically for ST-elevation myocardial infarction and non-ST segment elevation myocardial infarction patients. Readmissions within 30 days cause setback in patient recovery and add to the overall rising costs of health care. ST-elevation myocardial infarction/non-ST segment elevation myocardial infarction patients were selected because there were no specific programs in place through the acute care facility that address this specific service line. Therefore, our data can be identified as truly being a direct result of interventions of the Community Paramedic program. Intervention methods were determined by examining evidence-based research regarding postdischarge follow-up in this patient population. The data suggested that in-home follow-up within 48 hours postdischarge resulted in the most significant reduction in 30-day readmission rates. Follow-up was to be mostly educational in nature by reinforcing medications, discharge instructions, follow-up compliance, and dietary restrictions. As health care costs continue to rise, we need unique and innovative approaches using cost-effective alternatives to reduce readmissions, improve patient adherence with discharge medications, conduct education, and perform follow-up to improve patient care outcomes.

Intervention Detail. Prior to implementation, the average readmission rate internally reported by case management for acute myocardial infarction at Houston Methodist West Hospital was 15.8% (the national benchmark is 16%). The goal was to reduce 30-day readmission rates of participating patients to 10%. The work group of EMS and hospital staff consisted of the EMS assistant chief, the community paramedic lead, the emergency room director, the case management director, and the cardiology director. After identification of the patient population, interventions to be provided were established. Program support was gained from cardiology, internal medicine physicians, and the hospital executive team. An agreement between the hospital and EMS provider was established, addressing access and flow of patient information following Health Insurance Portability and Accountability Act requirements. The best referral process was determined to be case management sending a secure email to the community paramedic with referral information. To protect patient rights, the case managers presented the program to obtain patient permission prior to referral. Once the referral was made, an in-person visit was conducted to introduce the program prior to discharge. In the event the patient was discharged prior to a visit, a phone call was made to set up the postdischarge appointment. In-home visits were established within 48 hours of discharge. During the home visit, a comprehensive medication review was performed, discharge instructions were reinforced, and follow-up appointment adherence was discussed. No time limit was given for the interactions. Visits ranged from 45 minutes to 3 hours, depending on patient and family needs. Vital signs were taken and an electrocardiogram performed at the first visit. Subsequent visits and contact varied by patient. Patients who were noncompliant or had extensive social and financial challenges were evaluated in-person more often than patients who had a greater support system and understanding of disease process and medications. A minimum of a follow-up phone call 1 week post-initial visit was done to address any additional concerns.

Outcomes and Impact. The impact was nothing short of impressive. Since program implementation on May 1, 2019, 90 patients have been referred for evaluation. Of the patients that participated, only 2 were readmitted within 30 days, representing a 2.2% readmission rate. Of the patients who were referred and chose not to participate, 12% were readmitted within 30 days. Even more notable was the fact that, of the 88 nonreadmitted patients, none have returned to the emergency department. These patients were truly managed on an outpatient basis by taking medications as prescribed, complying with discharge instructions, and getting proper follow-up with physicians and cardiac rehab. Long-term results remain to be seen but if the first few months can be extrapolated with more consistent compliance, the overall health of the community can be significantly improved. This will help reduce the strain on acute care facilities and emergency departments, allow patients to be treated in the least restrictive setting, and assist EMS in transitioning to a truly preventive instead of reactive program. For every readmission that was prevented, the hospital saves an average of $10 000. The true cost savings systemwide are not realized as of yet but will likely be significant.

From Environmental Services to Patient Care Assistant Novice: A Transition in Practice

Sonya R. Gaines, MSN, RN, CCRN-K

Houston Methodist West Hospital

Background. Houston Methodist West Hospital is a rapidly growing community hospital in Houston, Texas. Expansion inevitably leads to shortage in various areas of the organization. The nursing units began experiencing increasing demands that required additional staffing needs. There were numerous patient care assistant (PCA) vacancies within multiple nursing units. While brainstorming with managers, directors, and human resources, the education department decided to help current hospital staff transition to the role of PCA. With this idea, the PCA novice course was developed. After meeting with human resources, the selection criteria were created. The individual needed to currently be employed at Houston Methodist West with the desire to transition from a nonclinical role to a clinical role.

Intervention Detail. The inaugural PCA novice course was held over a 3-day period. The program covered topics specific to the organization, including the Methodist experience, hourly rounding, and culture of safety. Additional topics included infection control, restraint management, falls, pressure injuries, code review, and sitter training. Basic skills needed to function in the role were also covered, including blood glucose testing, vital signs, and assisting with activities of daily living. In a simulation environment, the PCA novices learned how to feed patients, as well as proper body mechanics when moving patients and using assistive devices. At the end of the program, the novice PCAs completed skills and written testing to ensure they were ready to transition to the nursing units.

Outcomes and Impact. After successful completion of the course, the PCA novice participants were allowed to begin the unit orientation process, where skills learned in the classroom were reinforced and practiced. The staff became familiar with commonly used medical terminology and various skills specific to their patient population. The PCA novice program coordinator also continues to follow up with program candidates on a monthly basis, similar to meetings for nurse residency programs. Topics discussed include time management, conflict resolution/lateral violence, stress management, working with difficult patients, death and dying, and teamwork. These meetings allow novice PCAs the opportunity to discuss current experiences they have seen in the clinical setting. In addition, monthly meetings provide continued nurturing and growth in the clinical setting. PCAs who have completed the program are excelling on the nursing units, so much so that an additional cohort was added in summer 2020.

Operating Room Real-Time Learning Using a Quick Response Code

Imelda Claudette E. Revote, RN, BSN, CNOR

Anthony Ratajczak, CST

Albert Tia, RN, BSN, CNOR

Houston Methodist West Hospital

Background. In the operating room (OR) at Houston Methodist West Hospital, a complex care hospital, highly skilled staff use over 100 different types of equipment—from routinely used devices such as the electrocautery machine to service line-specific equipment, such as the fracture table for orthopedics or the Shaw scalpel in ear, nose, and throat (ENT). Each device is updated after a few years, further adding to the challenge of staying current. This extensive product selection and change tests the OR nurse’s ability to recall how to operate each piece of equipment safely, efficiently, and comfortably. When a new device, piece of equipment, or version upgrade is introduced, an in-service is arranged. The vendor is also scheduled to be present the first few times the equipment is used. However, there are numerous occasions when a nurse has not used the equipment for an extended period of time, then suddenly a case is scheduled that requires use of the equipment. On other occasions, the nurse is called in after hours for a procedure and there is limited support available. When faced with these situations, additional assistance is essential. The QR code is a 2-dimensional barcode used to easily access stored information on the Internet. Instructional videos and pictures of equipment are uploaded to the Internet and a QR code is created and linked to the educational information. This provides support and guidance to the OR nurse when using equipment that they are less comfortable using. Immediate, real-time support for nursing competency supports a culture of safety in the OR that can be generalized to other patient care areas. This project is a unique application of QR code technology with a process that can be replicated in hospitals with similar needs.

Intervention Detail. To help prioritize OR needs within the QR code pilot project, OR equipment was grouped according to service line. An initial Likert scale survey was performed to assess nurse comfort level with the use of over 100 pieces of equipment. The survey revealed that the OR nurses were least comfortable using ENT equipment, followed by plastics and urology equipment. Vendors were requested to submit instructional videos for uploading, and if no videos existed, we created our own using the expertise of specialty nurses on staff. Video vignettes were standardized to last less than 3 minutes each. Materials to be loaded were reviewed by resource nurses and coordinators for accuracy. Videos were uploaded to a private YouTube account, then linked to the assigned QR codes. Each QR code was placed on a laminated sticker that was secured on the equipment for easy access. OR nurses and staff were in-serviced on how to use the QR code tool in daily OR huddles and through staff lounge poster displays and traveling demonstrations in the OR. OR charge nurses engaged staff to use the QR code tool prior to ENT operations to determine ease of use and impact on OR staff set-up processes. In the months following the launch of the QR code tool, we surveyed the staff to determine their level of comfort with ENT equipment, thereby assessing the impact of the tool.

Outcomes and Impact. We conducted a successful pilot implementing QR code technology to add support for the OR staff in their use of specialized OR equipment. A survey completed at our hospital in August 2019 revealed that only 40% of the OR nurses were comfortable operating ENT equipment. Following implementation of the QR code project, a follow-up survey demonstrated an increase in staff comfort to 75%. Prior to implementing the QR code tool, staff members relied on vendor support and immediate availability of resource nursing to assist in setup and use of infrequently used equipment. For nurses who are trained in but infrequently staff certain cases, the immediate support provided by the QR code tool promoted efficiency and safety in the use of specific OR devices. This project supported a culture of safety in its response to staff needs. Future steps include application of the QR code tool to additional service line equipment and processes. Our process can be generalized to other hospital departments and has now been introduced to the intensive care unit, pharmacy, and radiology.

Preventing Hospital-Acquired Infections: Interprofessional Collaboration for Evidence-Based Care Delivery

Patricia Avila, MSN, RN, OCN, AOCNS

Brian Reed, BSME

Tamera Brown, MS, APRN, ACNS-BC, CWOCN

Lori Delaney, MS, RN, CNS, RN-BC, ACNS-BC

Heather Demaree, MSN, RN, CMSRN

IU Health Ball Memorial Hospital

Background. The delivery of high-quality patient care and elimination of harm events are priorities in hospitals nationwide. Leaders are calling for innovative strategies to enhance patient safety through the translation of evidence into practice. Avoiding patient harm is especially challenging on inpatient units where acuity is high and resources are limited. This evidence-based practice initiative engaged an interprofessional team to advance the translation of research into practice and reduce hospital-acquired infections (HAIs) in a 375-bed, acute-care hospital within a statewide health system. Historically, there were 5 harm prevention teams at IU Health Ball Memorial Hospital that focused on single sources of harm, such as HAIs. Each team was nurse-led and nursing-focused. Meeting times for teams were varied and inconsistent and attendance was often low. Unit managers did not send the same nurses to the team meetings each month, resulting in a lack of ownership among nurses at the unit level. Meetings were focused on harm-specific data analysis and education that translated into isolated practice changes. New initiatives were presented in unit huddles that occurred at the beginning of shifts when staff members’ attention was diverted in many directions, resulting in poor uptake of new practices. Harm data for each unit was reported on Managing for Daily Improvement boards as visual reminders to staff yet was rarely connected to proactive care for harm prevention. Marked increases in HAI rates in late 2018 resulted in a call for immediate and innovative action. Vizient members can benefit from this presentation, as it: (1) addresses a global clinical priority; (2) offers strategies for enhancing the adoption of evidence-based practices; (3) stimulates ideas for building high-functioning interprofessional teams; and (4) describes a transferrable initiative that can be scaled up or down for application in other settings.

Intervention Detail. Nurse leaders and hospital executives agreed on the commitment of resources to create new structure and processes for HAI prevention. Blending skills in communication and relationship building with clinical expertise, a nurse executive convened and empowered an interprofessional group to brainstorm ideas. Following Lean principles, the group assessed current structures and processes and analyzed evidence. As a first step, a facilitywide, interprofessional team was created that was later renamed the “Safety Squad,” a label reflective of the relentless accountability that characterized all aspects of this initiative. All members had protected time to attend monthly meetings. The meetings were structured to provide members with education, a review of local data, and time to observe on units and collect real-time data, which then led to action plans. The Safety Squad identified 9 essential actions to prevent the 3 most common HAIs: catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), and Clostridium difficile infections. The development of interprofessional standard work for HAI prevention followed, including design of the safety tracker, a visual communication tracking tool posted on Managing for Daily Improvement boards. All nursing staff began attending safety huddles each shift and recording on the safety tracker the 9 actions completed for at-risk patients. Nurses then assigned incomplete actions to specific staff with a set time for completion. Managers followed up in real time on incomplete actions and held collaborative discussions to remove barriers. The safety tracker was updated throughout the shift. In some areas, managers and clinical nurses coined a key phrase, “…and that’s not OK!”, spoken after every huddle, reiterating that choosing to not complete standard work for HAI prevention was choosing to harm patients. Lastly, unit celebrations were formalized for units achieving 30 days of harm-free care. Hospital executives, board members, and leaders attended the celebrations.

Outcomes and Impact. Facilitywide collaboration and engagement in harm prevention dramatically improved the hospital’s quality indicators from among the lowest in the statewide system to exemplary levels. Rates of CAUTI, CLABSI, and C. difficile began to decrease in the first quarter of the initiative. After 12 months, harm events decreased from 71 harm events the previous year to 39, a 45% reduction. CAUTIs reduced from 13 events to 5 (a 62% reduction), CLABSIs reduced from 15 events to 10 (a 33% reduction), and C. difficile reduced from 43 events to 24 (a 44% reduction)—leading to the lowest harm event year thus far. The impact of this initiative was measured in human and economic terms. Thirty-two fewer patients experienced HAIs in 2019 than the previous year. Prolonged lengths of stay were averted, as were additional medical treatments for HAIs. In addition, this initiative demonstrated the effectiveness of a nurse-led interprofessional team with facilitywide representation and supported strongly by senior hospital leadership. Safety Squad meetings were more cost-effective, reducing 5 meetings to 1. The results also illustrate the power of face-to-face engagement, designated champions, real-time data collection with action planning, and focusing of resources. This initiative has impact beyond HAIs, as the Safety Squad now addresses additional harm events—specifically patient falls and pressure injuries. This initiative can be replicated in diverse settings following the key components of the implementation plan, including interprofessional engagement, visual tools, carefully crafted communication, safety huddles each shift, recognition and appreciation of staff, removal of barriers to implementation of evidence-based practices, and rigorous accountability.

Translating Evidence Into Practice: Implementing and Sustaining the ABCDEF Bundle

Jynette Querubin, MSN

Li Ding, MD, MPH

Kai-Chen Chan, MS

Carol Peden, MB ChB, MD, MPH

J. Perren Cobb, MD, FACS, FCCM

Joan Brown, MBA CCE

Keck Medical Center of USC

Background. Admission into the intensive care unit (ICU) poses a significant risk to patient long-term morbidity and mortality, stemming from a condition identified as post-intensive care syndrome. Post-intensive care syndrome is characterized by psychological and/or physical debilitation that remain(s) after discharge and contribute(s) to poor patient outcomes, such as increased mortality, harms, and length of stay. To mitigate this harm, the ABCDEF bundle aims to integrate key assessments and interventions identified by the pain, agitation/sedation, delirium, immobility, and sleep guidelines into daily practice, driving significant improvement in patient outcomes. Although this and several other evidence-based bundled strategies are in abundance, significant challenges remain in translating these best practices from controlled research into the culturally diverse climates of health care. Leaders often face common barriers, such as ineffective education, resource utilization, culture, and data availability that often inhibit sustainability beyond the initial implementation phases. Although these barriers are not unfamiliar within our health system, strides to promote interprofessional collaboration and standardized care have been driven by the Critical Care Working Group, an interprofessional team including clinical leaders and performance improvement partners that supports the implementation of clinical operations and improvement across 8 highly acute and culturally diverse ICUs. Over the past year, the Critical Care Working Group tackled implementation of the ABCDEF bundle, understanding that education on the bundle elements alone was insufficient to drive sustainable change. The group implemented a multimodal implementation plan that promotes interprofessional collaboration and education during rounds, continuous feedback, and an innovative approach to engage frontline staff with their own data that drives solutioning, improvement, and sustainability within each ICU. Our implementation approach expands beyond clinical education to support how interprofessional collaboration and strategic data training has transitioned unit-based leaders to implement, improve, and sustain evidence-based practice.

Intervention Detail. Each unit developed an interprofessional unit leadership team, consisting of a medical director, a nurse manager, a nurse educator and clinical nurse specialist, a respiratory therapist, a physical occupational therapist, a social worker or case manager, and a pharmacist to support implementation and drive continuous improvement. Understanding the gaps in effective change management, our systematic and interprofessional approach leveraged learning and motivational theories to drive implementation and sustainability of the program. This approach expanded beyond clinical education of bundle processes, providing a multimodal strategy that promotes collaboration through biweekly interprofessional meetings, standardization of practices and definitions (especially in daily rounding and communication), and continuous feedback through shared team meetings. These interventions not only developed a stronger adoption of practice through built in reeducation and iteration, but also supported an improved unit culture. Additionally—and understanding the significance of continuous monitoring and measuring performance—patient outcome metrics are monitored and shared with each ICU unit weekly to drive continuous performance improvement and sustainability. To measure success, we leveraged evidence and calculations of the Society of Critical Care Medicine’s ICU Liberation Campaign, measuring bundle compliance for each element, along with the individual element compliance in aggregate, and provided data-driven insights to promote change in real time across the interprofessional team. Still, sharing data alone did not promote improvement. A unique strategy, fondly known as data literacy training, went a step beyond generation of compliance reports to provide education to frontline clinicians on how to read and understand the data. Our main focus in data literacy was to provide transparency in individual and group performance, empowering frontline staff to identify their own gaps and make changes in their everyday practice, as well as stimulate conversations of barriers or clarifications required to sustain best practice beyond the implementation phase.

Outcomes and Impact. The impact of our implementation approach for the ABCDEF bundle is continuously measured through quantitative data, weekly performance and outcome reports, and staff satisfaction survey qualitative data. This multimodal approach has exhibited higher compliance compared with a national average of 18%1—increasing total bundle compliance with statistical significance, not only throughout each ICU during the implementation phase, but also sustaining over 40% and rising beyond implementation. Across each element, performance has improved from as low as 40% to reaching nearly consistent performance of 75% or higher. This analysis further suggests that increased compliance with the ABCDEF bundle, whether wholly or partially, resulted in enhanced value of care. This is evidenced by a statistically significant decrease in mechanical ventilator hours, with reductions ranging between 12 and 18 hours; a total ICU length of stay reduction ranging between 0.5 and 1.5 days; and a decrease in negative patient outcomes, such as delirium. Furthermore, this approach strives to improve unit culture, communication, and collaboration across the interprofessional team. Our results indicate that most staff and faculty members are satisfied with our implementation approach, noting improvement in interprofessional collaboration and understanding of their role in the ABCDEF bundle. Staff and faculty also noted the positive impact data provided in identifying opportunities and improving ABCDEF bundle implementation. Although further statistical analysis is required as we complete implementation across the remaining 3 ICUs, our initial evaluation identifies this approach as feasible and beneficial in carrying out this complex, evidence-based practice initiative.

1.Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med. 2019;47:3–14.

It’s a Bug’s Life!

Florence Ahenkorah, MSN, RN, CPHQ

Catherine Canamar, PhD

Laura Sarff, DNP, RN, CPHQ, NEA-BC

LAC + USC Medical Center

Background. There is an abundance of published articles on improving hand hygiene compliance in the health care setting. However, most research excludes specific areas of the hospital such as the emergency department, perioperative, behavioral health, and the outpatient setting. Patients and their loved ones are excluded as well. If we are to successfully implement a systematic approach to improve hand hygiene compliance, all parts of the framework that make the system need to be included—this means every patient, family, health care worker, and area within the hospital. Another glaring knowledge gap is that despite over 1 million articles about improving hand washing, many health systems do not discuss methods to achieve sustainability. The interventions utilized to obtain positive outcomes are important; however, the critical need is to describe the methods used to sustain improvements. Our project implemented a systematic hand hygiene awareness campaign to protect all employees, patients, and loved ones from illness. When health care workers are more equipped to protect themselves, they are in a better position to help their patients. Empowered patients can prevent self-infection and collaborate with their health care team for the best care. The aim of this initiative was to improve and sustain the hand hygiene compliance rate over a period of 4 years (between 2015 and 2019) from 28% to 95% in a large, 600-bed academic hospital with over 6800 employees, 57 units/clinics, and an emergency department that includes a trauma center. As increased hand hygiene compliance is positively associated with improvement in hospital-acquired infections, we analyzed the outcomes in some of these measures in relation to our compliance rates. This project can help other organizations learn methods to improve and sustain hand hygiene rates and the approach is replicable, simple, and clear.

Intervention Detail. With the support of executive leadership, the quality improvement department, and the hand hygiene improvement team, the project began by applying The Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool (TST). The TST uses Lean Six Sigma and change management techniques to identify specific causes of hand hygiene noncompliance in hospitals and recommends specific interventions to remedy the most important causes. The Institute for Healthcare Improvement’s Model for Improvement was introduced after the first year of the project. This methodology traces back to the application of Deming’s conceptual framework known as the theory of profound knowledge. The interventions focused on 4 areas, including appreciation of the system, theory of knowledge, understanding variation, and psychology of change. These interventions did not follow in chronological order, as they are interrelated. Appreciation of the system included making sure all stakeholders were part of the improvement team and that all areas of the hospital were included. We introduced structural changes and materials that the staff required, including additional dispensers, lotions, and sinks. Next, we implemented marketing strategies and tools to engage and disseminate information to all staff, patients, and visitors. Some of the tools used were screen savers, posters, educational fairs, flyers, and newsletters. The theory of profound knowledge framework included training for auditors and coaches and also supported the development of our hand hygiene intranet site. New protocols, policies, and procedures were established. Various tests of change were performed using the Plan-Do-Study-Act cycle. The third intervention, understanding variation, included many unit-specific projects that helped the team understand each area-specific challenge, such as defining boundaries. Lastly, the psychology of change pillar held the other 3 interventions together. It began with having leaders who were passionate about improving care and protecting their staff. Interventions included rewards, actively listening to staff, and accountability.

Outcomes and Impact. There was a significant positive change in the hand hygiene compliance rate following application of both the TST and the Institute for Healthcare Improvement Model for Improvement. Our baseline compliance rate hospitalwide was 28% in December 2015; by January 2020, the rate increased to 87%. Overall, hospital-acquired infections decreased since the initiative began. Catheter-associated urinary tract infection has significantly improved from a rate of 2.59 in December 2015 to zero in December 2019. Central line-associated bloodstream infection has shown a significant improvement, from a rate of 4.44 in December 2015 to 0.5 in December 2019. All indicators have shown steady, sustainable improvements over the last 4 years. Historically, it was difficult to have a conversation about hand hygiene at Los Angeles County + University of Southern California Medical Center. However, it has become second nature and employees feel comfortable reminding everyone to wash their hands or praise them for doing so because they care. The hospital has kept hand hygiene at the forefront and we continue to discuss hand hygiene every day in hospitalwide briefs, unit-specific huddles, and various team and committee meetings. An important outcome of this initiative is not just about numbers and percentages of improvement—it is that health care workers know that leadership is interested in their well-being. Our success was due to the use of a holistic scientific conceptual framework that addressed all aspects of the areas to be improved. What made our efforts sustainable was the use of a unified purpose to continuously improve, and transformational leaders who have a passion to do what is best for our patients and employees. As health care workers, we need to be innovative. We see new illnesses and infections that we do not know how to treat. We must constantly test new ideas, learn, and share knowledge.

Increasing Registered Nurse Staff Satisfaction Amidst Role Redesign

Gina M. Von Ruden, MSN, RN

Mayo Clinic Health System, Franciscan Healthcare

Cheristi Cognetta-Rieke, DNP, RN, MBOE

Mayo Clinic Health System

Jason Fratzke, PhD, RN

Mayo Clinic Health System, Southwest Wisconsin

Christine Feller, MHA

Mayo Clinic Health System, Franciscan Healthcare

Amrika Ramjewan, MS

Mayo Clinic

Mayo Clinic Health System and Mayo Clinic Health System-Franciscan Healthcare

Background. Historically, hospital readmission efforts were focused on the inpatient setting. In 2017, a diverse, multidisciplinary team was formed to review trends, past efforts, and gaps in current processes. The 30-day All-Cause Readmission Reduction Team identified that while many separate processes were working toward the same goal, there were missing links in how care was coordinated and patient understanding was verified. There was also no process to address any potential gaps in care, including who owned the overall scope of this work. The registered nurse (RN) care coordination team in primary care was engaged to concentrate its efforts on patients in the immediate post-hospital discharge phase, to ensure the plan of care was understood and feasible once the patient had left the confines of the hospital. This was a significant change, because historically, the focus of readmission reduction was owned by inpatient teams, and this work transitioned the traditional paradigm to the ambulatory setting.

Intervention Detail. Transitioning the RN care coordinator role from focusing on emerging risk, chronic condition patients to focusing on patients recently discharged from the hospital required education, tools, and coaching. Leadership support was evidenced though involvement and support from the nurse administrator, the 30-Day All-Cause Readmission Reduction Team, and the nurse manager. An important piece of changing the role’s focus was implementation of the care transition huddle. This was initiated as a daily virtual huddle between inpatient charge nurses and RN care coordinators from all 10 of our primary care sites, allowing an opportunity for hand-offs and dialogue related to areas of concern. The ambulatory RNs could anticipate the needs of patients through this vulnerable phase. The care transition huddle is an innovative means to connect inpatient nursing with ambulatory staff in real time, ensuring the best possible plan of care. Hospital readmission data was utilized to determine the need to change the focus and measure success of efforts surrounding readmission prevention. Institutional staff satisfaction survey results demonstrated a 16% increase in individual engagement following implementation of the care transition huddle, with prior scores moving from 69% to 85% post-implementation. The process was rolled out with the post-hospital follow-up tool kit developed by the nurse manager. The purpose of the tool kit was to create tools for standard documentation and general workflow outlines. Care was taken to avoid overengineering of the process, as the goal was to allow RN care coordinators to practice to the top of their scope by utilizing their critical thinking skills rather than a task list. This created the opportunity for staff members to truly make this work on their own and continuously utilize the Plan-Do-Study-Act cycle approach to identify opportunities for improvement. RN care coordinators were empowered to dig deeper and continuously seek means to improve patient outcomes.

Outcomes and Impact. Outcomes of the intervention were measured utilizing 30-Day All-Cause Readmission rate data and staff satisfaction survey results. Readmissions data was reviewed monthly and shared with the RN care coordinators. The staff satisfaction survey results were reviewed prior to and 1 year following the RN care coordinator role redesign. Hospital readmission rates were at 12.6% prior to role redesign implementation but have since decreased and have been sustained at 8% or below. Staff satisfaction survey results reveal a positive increase, resulting in 85% in the individual engagement domain, an increase of 16%. Further improvement scores were noted in all areas of Commitment to Mayo Culture, Commitment to Work Area Culture, and Commitment to Mayo Clinic. Staff continuously shared feedback related to their change in focus, such as, “This work is hard, but so rewarding. We really get to use our critical thinking and we’re making such a big difference.” These positive results of decreased hospital readmission rates and increased staff satisfaction were accomplished without full-time equivalent increase. Key lessons learned from implementation include the need to further increase the knowledge and scope of the inpatient interdisciplinary lens beyond immediate symptom management. There is also a need to further appreciate the importance of understanding where the patient is coming from and how this impacts their discharge needs. It is well understood that discharge planning begins upon admission. Further work is needed to continue incorporating utilization of artificial intelligence across interdisciplinary teams to better predict indicators of patient needs and social determinants of health, as well as their impact on the success of the patient’s discharge plan.

Moderate/Deep Sedation: Are You Safe? Do You Have a Protocol?

Sheila C. Blogg, MSN, BSN, BA

Medical College of Wisconsin

Amy Komp, BSN

Froedtert Hospital

Jessica Zenga, MD

Froedtert & the Medical College of Wisconsin

Carolyn C. Pinkerton, MD

Medical College of


Kathryn Lauer, MD

Medical College of Wisconsin

Medical College of Wisconsin

Background. Our process for administering conscious sedation did not differentiate between moderate and deep sedation and included irregular monitoring and nonstandardized processes throughout our hospital. Patients receiving moderate or deep sedation provided by nonanesthesia providers experienced adverse events requiring intervention or rescue measures. An interdisciplinary project team was assembled. Led by process improvement experts using the Plan-Do-Study-Act methodology, the team completed a map of the current state and future state processes. Improvement opportunities included pre-procedural assessment; medical optimization; differentiating deep sedation from moderate sedation; and the need for the anesthesia care team, nursing education on sedation practices, patient monitoring requirements, and post-procedural criteria. These changes, which included development of electronic medical record tools, led to a transformation in the delivery of care with more efficient use of health care resources and improved outcomes and patient experience. While designing the future state for sedation clinical protocols, all team members placed the patient at the core of all proposed improvements, rather than around the design of the current system. The nursing staff anecdotally believed patients were safer with the revised sedation practices, resulting in fewer adverse events. This was shared with other institutions within our health system and has implications for other organizations. The interdisciplinary leadership structure consisted of our vice-chair of quality for anesthesia, chief medical officer, chief safety and quality officer, chief nursing officer, director of pharmacy, director of nursing, unit managers, and frontline nursing staff.

Intervention Detail. Sedation-related adverse events were tracked in our Vizient safety intelligence reports. Sixty-three of the 10 146 adverse events in 2016 were sedation-related. Analysis of these 63 events focused on our areas of improvement for protocols that addressed pre-assessments, procedural monitoring, physician/advanced practice provider credentialing, and nursing education. We standardized the use of monitoring equipment and practices, as well as nursing education in medication administration. Guidelines were developed that standardized the pre-procedural assessment, including a cardiorespiratory and airway assessment that complies with American Society of Anesthesiologists standards for sedation. The protocol differentiated between deep sedation and moderate sedation privileges and processes, with separate and distinct credentialing through the medical staff office. Deep sedation included the use of propofol, ketamine, and etomidate and carried stricter credentialing criteria (board-certified eligible emergency physicians, intensivists, and oral surgery physicians after demonstrating competence). Moderate sedation included narcotics and benzodiazepines. Providers who ordered and nurses who administered these medications were required to complete learning modules to gain expertise. Standard monitoring was defined and hardwired with the use of standard sedation narrators for nurses, and providers were able to utilize electronic smart tools to ensure documentation compliance. Sedation monitoring included the Ramsay Sedation Scale, vital signs, and Aldrete scores for discharge. Our implementation phase consisted of training, building clarity reports, outcomes review, and nursing and provider education. We experienced 66 sedation-related adverse events in 2017, 9 in 2018, and 4 in 2019. Our team sits on the Vizient PSO advisory committee for moderate sedation, and we participated in designing best practices for sedation by nonanesthesia providers entitled Vizient PSO Topical Safety Web Conference Series: Procedural Sedation. We designed guidelines in relation to our essential elimination of sedation-related adverse events by following a strict protocol, credentialing, and training of all personnel.

Outcomes and Impact. The outcomes tracked included the use of reversal agents, aborted procedure, Ramsay scale >4, unplanned admission, unplanned transfer to intensive care unit setting, and unplanned respiratory complication. Reports were built to identify gaps in documentation and enable easy reporting of adverse events through the electronic medical record. This promoted extracted versus self-reported data. Quantitatively our adverse events related to sedation decreased by 82% in 2018 and 93% in 2019 despite more standardized reporting. Our organization has had very few adverse events since implementing this protocol. Sustainability has been achieved for 3 years running. Qualitatively, our team receives reports from nursing staff members that they feel better prepared to provide sedation to patients and competent in supporting interventions when unplanned events occur. We can facilitate real-time nursing and provider feedback related to adverse events. An anesthesiologist reviews all adverse events and creates learning experiences for the organization, with leadership accountability to share with frontline nurses. Although standards for conscious sedation have been in existence since 2004, the development of a standard, robust process that facilitates safe patient care has been an iterative activity. Our experience of developing a deep and moderate sedation practice has improved outcomes and standardized care. The PSO Advisory Group for Vizient has identified many gaps in care despite intravenous moderate sedation leading practice recommendations (patients age 18 y and older) being an old standard. Our team feels this is an important topic because there are many organizations that have not created a protocol for sedation practices, and this could be used as a template for other health care organizations.

Agency for Healthcare Research and Quality Patient Safety Indicators: A Multidisciplinary Review and Data Wrangle

Hanan Foley, MSN, RN, CPHQ

Donna Sanford, RN

Elizabeth Freedman, MPH

Kathleen Davison, BSN, RN

Folubi Salami, MD, CCS, CDIP

Sharon R. O’Brien, MD

MedStar Georgetown University Hospital

Background. The performance of MedStar Georgetown University Hospital (MGUH) on the Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) consistently scored among the worst performing academic medical centers (AMCs). This influenced our scores in the Pay-for-Performance and Star Ratings programs. Given our nationally recognized areas of excellence, the scores did not match the high-quality care provided to our patients as a tertiary care center. Despite the concurrent work performed by our clinical documentation improvement (CDI) specialists to address PSIs, both the same and new PSIs continued to appear after full and final review and coding of the medical record was completed by the coders post-discharge. Retrospective review revealed that many of the PSIs were not valid due to coding errors or physician documentation lapses. Additionally, we used Resource Manager, a Vizient Clinical Database tool, to perform a deep dive into the data. This uncovered that our expected PSI rates, when compared with like service lines at other Vizient participating AMCs, were often much lower. As the MGUH quality team and MedStar Health coding team were each siloed in their workflows, physical location, and leadership structure, our ability to collaborate to address errors was limited. The lack of a structured review and resolution process to optimize our claims-based outcomes data interfered with our ability to showcase the excellent care provided by our organization. It also impacted our quality team in its effort to provide accurate quality data to physicians. This created a culture wherein the data was not trusted, thus decreasing physician accountability and ownership.

Intervention Detail. Our goal was to authenticate the PSIs, parse out opportunities for improvement, and assure the integrity of our data. A cross-system task force was created, comprised of members from quality, analytics, coding, CDI, and physician leadership. When a PSI is identified by coding after discharge, the bill is placed on hold pending review by the multidisciplinary team from both a coding and clinical perspective. Using 3M 360 Encompass software, the MedStar Health coding team assigns International Classification of Diseases, 10th Revision diagnoses and procedure codes. When a PSI is flagged in 3M 360, an alert is sent to the coding team to review the codes and correct any discrepancies. The record is then sent to the clinical quality coordinator and CDI specialist for review. The quality coordinator reviews the record and compares the clinical documentation to the specifications for the applicable PSI. If a documentation issue warrants clarification, the CDI specialist initiates a physician query. If other clinical documentation issues are identified, they are noted for discussion by the task force. In addition, 2 physician leaders on the task force act as clinical experts and physician liaison consultants to facilitate record review and PSI resolution and provide ongoing provider education. A weekly interactive meeting is conducted with all parties, who come to a consensus regarding any changes to the coding of the record or the need for further queries prior to the bill’s release. As a result of this validated review, trends have been identified and shared with clinical services to identify opportunities for improvement. When Resource Manager is populated, the PSI data is extracted into an interactive Tableau dashboard, allowing providers to drill down into each PSI. Users can also review expected values from an aggregate level to compare MGUH rates to other AMCs.

Outcomes and Impact. The coding and documentation issues were diverse in nature and etiology. Some common issues included:

  • Variations in the definition of sepsis
  • Present on admission events that received a hospital-acquired code
  • Suspected conditions not documented as ruled out by the provider resulting in erroneous codes
  • Chronic diseases that received an acute code
  • Missing diagnosis codes that would eliminate a PSI based on exclusion criteria

In the 9 months after we started this process of reviewing cases, 28% of the PSIs were found to be invalid and were therefore removed. There has been an across-the-board improvement of our observed/expected ratios for PSIs. In particular, PSIs 9, 11, 12, and 13 have each seen a rate reduction between 30% and 45%. As a result of data validation, the “true” PSIs are now evident. Record review has determined that most patients receive high-quality recommended care. That said, on our journey toward excellence, we continue to evaluate all opportunities for care improvement and learning. The task force is empowered to communicate these opportunities to stakeholders and ensure best practice in both delivery of care and documentation. The data that is displayed in the Tableau interactive dashboard has been validated and is now trusted. This has increased physician engagement, data ownership, and accountability throughout the organization.

Less Is More: Sepsis Alert Optimization

Jacqueline M. Zimmerman, BSN, RN, MBA-HCM

Gopi J. Astik, MD

Emilie Powell, MD

Susan Russell, MD

Sheila Wade, RN

Rebecca Sweeney, RN

Adarsh Manjunath, MD

Kevin O’Leary, MD

Northwestern Memorial Hospital

Background. Early identification and treatment of septic patients saves lives. Roughly, 30% of patients diagnosed with severe sepsis do not survive.1 To drive the desired clinical behavior, it is crucial to identify appropriate sensitivity and specificity of a sepsis early detection system. At our institution, we saw a 515% increase in sepsis alerts when changing from a severe sepsis alert to a sepsis alert model. We conducted a survey of staff nurses to evaluate perception of the current best practice advisory (BPA) that resulted in 100% of respondents stating that the BPA erroneously triggers on patients not meeting sepsis criteria. A multidisciplinary group was convened to guide an eventual process change. We aimed to address the lack of sensitivity and broad specificity of the current sepsis BPA. Additionally, it was important to evaluate the scope of the units, resources, and staff education and training. Our septic patients, when identified quickly, receive a streamlined bundle treatment that improves mortality and prevents medical complications. Improving the accuracy of the sepsis early warning detection system will lead to improved quality of care and patient outcomes. Sepsis is a complex medical condition and many people, even health care providers, do not understand the rapid evolution of the disease process. Early and accurate diagnosis is key to improving sepsis outcomes, which is why it is important to share our experiences and observations with other Vizient members.

Intervention Detail. The multidisciplinary team identified 2 root causes during a rapid improvement event. First, the current alert does not assist providers with identifying septic patients. The multidisciplinary group was given 4 different BPA algorithms, ranging from sepsis (the current Northwestern Memorial Hospital model) to severe sepsis criteria, and had the opportunity to list the positives and negatives of each model. Given the complexity of patients at our academic medical center, the multidisciplinary team overwhelming voted in favor of the severe sepsis criteria—increased specificity, which we defined as tighter systemic inflammatory response syndrome plus organ dysfunction. The second root cause identified was the lack of provider education surrounding the alert. We addressed this via another multidisciplinary subgroup that included nurses, physicians, and our academy learning department. This subgroup developed a comprehensive sepsis education e-learning module along with a post-assessment quiz. Following implementation, the sepsis quality committee reviewed the initial findings and decided to pursue an additional intervention surrounding the “remind me later” option of the BPA. The committee partnered with nurse managers from each unit to determine why nurses were selecting “remind me later.” Nurse managers met individually with nurses who frequently chose the “remind me later” response to review the reasoning and provide education. Following completion of the meeting, the nurse manager filled out a form so we could identify and learn themes. We continue to track the project’s success monthly by reviewing the process and outcome metrics.

Outcomes and Impact. In April 2018, the sepsis committee identified the sepsis BPA as a pain point that created interruptions in care and did not accurately identify septic patients. By September 2019, the severe sepsis BPA, with tighter systemic inflammatory response syndrome plus organ dysfunction, was launched—and immediately the alert decreased by 70%. Additionally, the identification of patients coded with sepsis who received a BPA almost doubled from 8% to 15%. Of those patients, the percentage of patients screened as severe sepsis or shock increased by 1%, which aligns with improved alert sensitivity and specificity. The alert also improved antibiotic compliance by 3% in septic patients, which is considered the most crucial element in the sepsis bundle for survival—the Centers for Disease Control and Prevention recommends that doctors and nurses treat sepsis with antibiotics as soon as possible.2 In a post-survey, over 70% of the nursing staff prefer the new alert, and 59% are more concerned when the severe sepsis alerts fire that patients might be septic, compared with 15% pre-intervention. Lastly, Northwestern Memorial Hospital had a 100% education and training participation rate across all units that receive the alert. Following our post-project intervention of nurse manager feedback on “remind me later,” the alert had a 7% decrease in overall utilization. Lastly, the observed-to-expected sepsis mortality decreased by 1 quartile following alert and education interventions. The sepsis quality management committee plans to monitor and reassess the interventions monthly to determine if the severe sepsis BPA is providing accurate sensitivity and specificity. Overall, the project’s success was in the collaboration of the multidisciplinary team, which allowed for all stakeholders to work together to develop an intervention best suited for our academic medical center.

1.Sudore RL, Lum HD, You JJ, et al. Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi Panel. J Pain Symptom Manage. 2017;53:821–832.e1.

2.Centers for Disease Control and Prevention. How Is Sepsis Diagnosed and Treated? Updated August 18, 2020. Accessed November 13, 2020. https://www.cdc.gov/sepsis/diagnosis/index.html.

A 21:1 Win! Engaging Advanced Practice Providers in Short-Stay Documentation

Teresa O. Arrington, MBA, LSSBB

Ochsner Health

Background. In early 2018, quality leadership at Ochsner Health hosted a meeting with the vascular surgery physician champion, Taylor Smith, MD, in which an internal documentation guidance dashboard was reviewed. This dashboard includes complication or comorbidity/major complication or comorbidity (CC/MCC) capture rates by specialty and contributing physician, along with normalized case mix index. Several charts without CC/MCC diagnoses were reviewed. It was theorized that these were likely patients who came in for carotid endarterectomies and went home the day after surgery. Patients like these would be expected to have a diagnosis of carotid artery disease along with other likely cardiac issues, yet the documentation was not showing this pattern. Leadership realized that a short history and physical (H&P) review process prior to surgery, combined with a length of stay less than 3 days, meant that clinical documentation improvement did not have the opportunity to review these charts for accuracy or query potentials before they were final-coded at the time of discharge. Therefore, the documentation was being accepted and billed without the extra layers of quality review. Given this idea, the documentation team proposed a pilot in which an advanced practice provider (APP) would round on patients the evening after their surgery to collect a more complete H&P.

Intervention Detail. Once it was determined that the APP pilot model could be supported from a staffing perspective, the work began. The chosen APP, Stephen Saenz from the medicine department, moonlighted in this role for approximately 2 weeks. The patients went through the usual process of an anesthesia-led H&P collection prior to their morning surgery. However, during the evening of postoperative day 0, Saenz rounded on the patients. Prior to this visit, he had already reviewed past clinical history so that he could begin with an established baseline and guide patient conversations with more focus. The APP was fully trained on appropriate monitor, evaluate, assess/address, treat criteria regarding what can and cannot be coded, so his documentation was rich. At the end of the pilot, our coding partner was able to identify which diagnoses were made possible due to Saenz’s notes, and they collated a coding comparison of what the quality and billing picture would look like with and without the additional rounding. We saw tremendous results, given that only 10 patients fit the short-stay criteria for this pilot during the designated time period.

Outcomes and Impact. Ten adult inpatients were rounded on in June 2018. The coding changes made possible due to the APP rounding were analyzed by a vascular surgery coding partner for impact to quality and financial metrics. From a financial standpoint, the moonlighting cost approximately $660 for the month, but the revenue gained from the coding changes totaled $13 609. That accounts for a 21-to 1 return on investment. Some of the biggest changes came about due to catches made regarding a patient’s diabetic status, as well as 1 patient who had a myocardial infarction event within 30 days prior to admission. A more complete clinical picture of the patient was established, which supported a safer admission. Patient quality and coding changes include: (1) 50% saw coding/quality changes; (2) 50% saw an increase in severity of illness and/or risk of mortality score by 1; (3) 20% saw a change in diagnosis-related group D, resulting in heavier weighting; (4) 10% saw an additional MCC captured; (5) 10% saw an additional CC captured; and (6) 20% saw an increase in average length of stay captured.

I Can’t Drive 55 in the Drug Take-Back Lane

Kimberly E. Cimarelli, RPh, MHA

Penn State Hershey Medical Center

Background. Unused pharmaceuticals within the community pose a number of potential public health risks, including environmental impacts to ecosystems and addiction. They also encourage criminal activity, including theft and burglary. Measurable concentrations of pharmaceuticals have been found in marine settings and in wildlife. Used needles and syringes have been discovered in public areas such as parks and playgrounds, creating infectious and injurious hazards for humans and pets. The long-term impacts of this exposure are unknown. Community members may not be aware of available waste disposal options for pharmaceuticals, needles, and syringes. The central Pennsylvania region had Drug Enforcement Agency (DEA) drop-off kiosks at police stations available for limited medication disposal, but the kiosks would not accept liquids, injectables, needles, or syringes. Additionally, a small annual take back event occurred each year at the medical library. Unfortunately, knowledge and utilization of these options was not universal. Penn State Health had previously developed a highly successful model of providing a public health service utilizing a drive-thru event in the form of an influenza vaccination clinic. The pharmacy department at Penn State Health had a goal of improving public health through an activity planned around National Pharmacy Week. The purpose of this project was to duplicate and enhance this drive-thru model for the disposal of unused pharmaceuticals and used or unused needles and syringes. Penn State Health Milton S. Hershey Medical Center is one of the leading teaching and research hospitals in the country and is committed to enhancing the quality of life through improved health, the professional preparation of those who will serve the health needs of others, and the discovery of knowledge that will benefit all.

Intervention Detail. In summer 2015, a group of Penn State Health pharmacy team members met to brainstorm ways to give back to the community, and ultimately recommended involvement with National Prescription Drug Take Back Day. This idea was pursued by the operations pharmacy manager, resulting in a group convening to execute a drive-thru drug take back day as part of the Drug Enforcement Administration’s National Prescription Drug Take Back Day. Planning committee members included the operations pharmacy manager, the director of nursing for community relations, the manager of emergency preparedness, the director of security, a nurse manager, a facilities manager, a pharmacy technician, a police officer, the manager of strategic services, the college of nursing instructor, and an administrative associate. The following is a description of the preparation and delivery of the biannual event, which has been administered 9 times since fall 2015. This narrative will assist the reader in facilitating a similar event. A risk assessment is sent to the risk department. Weeks prior to the event, a work order is placed with facilities and advertisement of the event is planned with strategic services. The week of the event, 500 medication safety bags are compiled that include a pill box, Mr. Yuk stickers, and various medication safety leaflets. Team leads meet at the hospital print shop to acquire event signage, volunteer items, safety vests, and scales. The evening before the event, volunteer food and balloons are purchased. The day of, signage is placed to direct traffic, stations are positioned, volunteers are educated, DEA and police representatives are present, and drive-thru stations begin promptly at 10 AM and continue until 2 PM. Boxes of pharmaceuticals are weighed and recorded. As police and DEA are excused after the event, any remaining community members present are directed to local kiosks for disposal. Volunteers are given thank you gifts and asked to return for future events.

Outcomes and Impact. Outcomes and impact from this program fall into 3 categories: amount of product recovered, improvements and lessons learned for constructive program enhancement, and employee satisfaction. The first event in fall 2015 yielded 143 pounds of pharmaceuticals and 7 full sharps containers of needles and syringes. For the 9 total events, the mean weight of pharmaceuticals recovered was 347.13 pounds (143 to 900 pounds) and the mean number of full sharps containers recovered was 13.22 (9 to 26). The event at which 900 pounds of pharmaceuticals was recovered was considered an outlier, as a local college used the event to dispose of multiple cabinets full of expired medications. This prompted one of the opportunities for constructive program improvement, as local institutions were no longer allowed to use the event as a regular waste disposal stream. Other enhancements over years of administering the event included placement of signage on the day of as opposed to the night before and a strict “no admittance before 10 AM” policy, as some community members were dropping off medications early without law enforcement present. We also added traffic cones to better direct wrong-way drivers. Volunteers identified a need to distribute small, empty sharps containers to individuals dropping off needles and syringes. A final enhancement was the expansion to a fourth drive-thru site. Lastly, this program has had a large impact on staff satisfaction. Verbal reports from volunteers show this to be a highly rewarding experience. Positive, patient-specific stories such as overwhelmed family members with remaining hospice medications have led many team members to earnestly request to serve during future events. Other inspiring stories include those from diabetic patients with excess needles and syringes for which they did not have a disposal plan. Our expectation is that our program will assist in alleviating health care worker burnout.

A SIRious Approach: C the Difference Clinical Decision Support Alerts Have Made

Dwan Gathers, MBA, MHA, SSGB

Shanetta Williams, MSN, RN-CIC

Prisma Health

Background. Clostridium difficile infection (CDI) is the leading cause of infectious nosocomial diarrhea. According to the Centers for Disease Control and Prevention, it is responsible for approximately 500 000 cases per year.1 Prisma Health Midlands (Columbia Market) uses nucleic acid amplification test (NAAT)-only testing for diagnosing CDI. This testing is highly sensitive with an excellent negative predictive value. Studies have shown that 3% to 26% of all hospitalized patients may be colonized with C. difficile. NAAT-only testing may lead to false-positive results in colonized patients, and subsequently, over-treatment and over-reporting to the National Healthcare Safety Network. In 2016, an internal review was done to look at inappropriate testing at our institutions. We found that of our hospital onset CDI, 47% had end-of-therapy or test-of-cure tests done and 57% did not have 3 or more documented bowel movements over 24 hours prior to testing. The following leverage points were used to decrease inappropriate testing:

  • Select appropriate patients for testing: avoid testing patients who have received recent laxatives (24 to 48 h), have less than 3 loose stools within 24 hours, or have formed stools.
  • Improve identification of community-acquired C. difficile within 3 days.
  • Partner with lab personnel to enable hard stops for formed stools and order discontinuation if stool is not collected within 24 hours of order.
  • Appropriate use of single NAAT test: discourage testing within 7 days of a negative test and 14 days of a positive test, avoiding test of cure.
  • Provider education: clinical decision support alerts, testing algorithm.
  • Nursing education: importance of stool documentation, testing algorithm.
  • Appropriate use of multitarget gastrointestinal (GI) polymerase chain reaction (PCR) testing as C. difficile is the only nosocomial target.
  • Data analytics: QlikView application used for housing and analyzing data for future alert refinements.
  • Forum to review C. difficile-positive cases: harm elimination team.

Intervention Detail.

  • May 1, 2017: C. difficile testing algorithm created and education began around its use.
  • June 1, 2017: a QlikView application was developed.
  • June 26, 2017: introduced 2 clinical decision and stool discontinuation criteria: (1) a soft-stop alert if a negative test was present within 7 days of order. This can be overridden by the provider and (2) a hard-stop alert if a positive test was present within 14 days of order. Discourages test of cure, cannot be overridden, and order cancelation if stool not collected within 24 hours of order.
  • August 10, 2017: presented C. difficile-positive cases at harm elimination team meetings. Provided bedside evaluation of appropriateness of testing and determined areas of improvement.
  • January 15, 2018: introduced laxative alert. Soft-stop alert if laxative received within 24 hours. Encouraged discontinuation of laxative and reevaluation of patient prior to testing.
  • March 29, 2018: introduced pediatric alert. Hard-stop alert preventing testing in patients <1 year old. Conversion of negative test within 7 days from soft to hard stop. Review of QlikView data confirmed negative results in patients with overridden soft stop.
  • May 15, 2018: hard-stop alert restricting use of GI panel after 3 days of hospitalization.
  • November 19, 2018: provider-only ordering for C. difficile by PCR and GI panel by PCR orders.
  • January 21, 2019: conversion of laxative alert to 48 hours based on national recommendations.

Outcomes and Impact.

  1. Total C. difficile testing events pre- implementation (July 2016 through May 2017) versus post- implementation (July 2018 through May 2019) for inappropriate C. difficile order attempts: pre- implementation, 1382, versus post-implementation, 422—a 69.46% reduction. Single C. difficile PCRs performed: pre-implementation, 2341, versus post-implementation, 1061—a 54.68% reduction. All C. difficile PCRs performed (C. difficile PCR + GI panel): pre-implementation, 2806, versus post-implementation, 1509—a 46.22% reduction.
  2. Impact on standardized infection ratio (SIR): the average SIR in the pre-implementation period was 1.236, while the average SIR during the post-implementation period was 0.429—a 65.3% reduction.
  3. Cost avoidance: the laboratory cost avoidance associated with clinical decision support related to GI panel hard-stop alert was $355 300, while the laboratory cost avoidance associated with clinical decision support related to C. difficile PCR testing was $57 750.

Our clear and measurable learning objectives included how the use of clinical decision support can improve appropriate testing for C. difficile, appropriate C. difficile testing, and the impact on the overall C. difficile SIR.

1.Centers for Disease Control and Prevention. Clostridium difficile Infections in a Single Year. February 25, 2015. Accessed July 14, 2020. https://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html.

A Proactive Approach to Improve Maternal Safety: Driving to Zero Preventable Maternal Deaths

Trina Jellison, BSN, MHA

Courtney Jackson, MBA

Providence St. Joseph Health

Background. The United States is the only developed nation where maternal deaths and injuries have increased over time. Approximately 700 women in the United States die annually from pregnancy-related complications.1 According to the Centers for Disease Control and Prevention, about 3 in 5 of these pregnancy-related deaths are preventable.1 Postpartum hemorrhage (PPH) and cardiovascular/coronary conditions are the 2 leading causes of these complications, each accounting for 14% of maternal deaths.2 As one of the nation’s largest health care systems with more than 72 000 annual births, Providence St. Joseph Health (PSJH) took these alarming statistics to heart. The situation hit home after a PPH-related maternal death devastated caregivers. The executives of our Women and Children’s Institute, which was formed to promote best practices among our 51 hospitals, called for volunteers to review PPH protocols and processes, an effort they later expanded to include maternal hypertension. These volunteers were tasked with making organization-wide changes to prevent future maternal deaths and injuries. The 20-member PPH team represented a variety of stakeholders from across the health system: obstetricians, midwives, nurses, pathologists, laboratory personnel, operating room staff, educators, and administrators. Communicating through virtual meetings and regular check-ins, the team began by reviewing the case that framed its purpose and underscored its urgency. A young and healthy pregnant woman had been admitted to a PSJH hospital with a prenatal record that did not suggest she had any areas of concern during her pregnancy. Her labor progressed and appeared normal, and she delivered a stable newborn. However, the patient began hemorrhaging shortly after delivery. Despite the rapid response of all involved and several units of blood products and other emergent procedures, this young mother passed away. The case became the team’s rallying call.

Intervention Detail. Standardize protocols and transition from reaction to prevention: the team reviewed the maternal death case, along with other PPH cases that resulted in massive blood transfusions, intensive care unit (ICU) admissions, and hysterectomies, ultimately identifying 2 issues at play. First was lack of protocol standardization. The situation was amplified for PSJH, given the health system’s rapid 5-year growth following several mergers and affiliations. During this period, the health system was working to transition from a holding company, where decisions were made locally, to a more centralized operations company, but changing cultural norms to embrace collaboration and standardization had been difficult. The PPH team was an excellent example of systemwide collaboration. The second challenge was changing from a reactive to a proactive perspective to prevent complications in the first place. Most of the available PPH protocols were written to respond to an emergency. However, the team realized that serious maternal morbidity could be avoided by identifying patient risk factors as early as possible. Data specialists created a tool to help evaluate a patient’s PPH risk upon admission and provide caregivers with standardized protocols for care. The primary requirements for the tool were that it be embedded into the electronic medical record (EMR), be easy to use, appear on just 1 screen, and provide easy-to-follow instructions for care. This resulted in the EMR Hemorrhage Risk Assessment. The evaluation process is purposefully brief: upon intake, the caregiver records responses to just 5 key data points recommended by the California Maternal Quality Care Collaborative for PPH risk assessment. The tool then uses an algorithm to assess these data points along with the health history available on the EMR, stratifying the patient as high, medium, or low risk. The caregiver sees a green, yellow, or red screen based on the patient’s risk level and is provided corresponding instructions for care.

Outcomes and Impact. With the new tool, there is a systemwide preventive response in which caregivers know their roles and act in a standardized manner to prevent and respond to a PPH situation. Continued review of experiences and key metrics from each market, including ICU admission rates, hysterectomies, and blood product usage, ensures progressive quality improvement. Teams make necessary changes to enhance outcomes and their ability to respond to each patient’s individual needs. Among the lessons learned is the importance of didactic devices to ensure compliance with new tools and procedures across a large health system. The teams used comprehensive tool kits to teach caregivers how to perform the EMR risk assessment and respond effectively and rapidly to emergent situations. In tandem, exercises with simulation manikins and participation scenarios specific to maternal hemorrhage were introduced. Additionally, the team discussed and tested the risk assessment tool with a wide range of stakeholders. When lab personnel expressed concerns that the protocols within the tool would trigger an unnecessary increase in type and hold for blood products, the situation was closely monitored. With more patients having their blood typed as part of the preventive protocols, blood testing costs did initially increase. However, usage rates decreased over time because the massive transfusions necessary in an emergent PPH case were avoided. Staff concerns associated with EMR changes were also overcome. Collaboration among caregivers and information technology specialists helped us build an assessment screen that was intentionally simple and involved just a few basic questions. As we found, many clinical teams were already asking these questions, although not with the assistance of the electronic risk assessment tool. Therefore, the time spent in assessment was mostly unchanged. Blood transfusions, ICU admissions, and hysterectomies—all associated with PPH—have decreased at PSJH hospitals. We recognize that there is more to do, and we are clearly on the right path. Since implementation of the protocols and EMR tools, PSJH has screened 98.7% of patients for obstetric hemorrhage and is tracking improvement in the identification and treatment of hypertension, including readmissions. In the last 3 years, we have had 1 preventable maternal death while delivering approximately 72 000 babies annually.

1.Centers for Disease Control and Prevention. Pregnancy-Related Deaths; Saving Women’s Lives Before, During and After Delivery. 2019. Accessed November 13, 2020. https:http://www.cdc.gov/vitalsigns/maternal-deaths/.

2.Reviewtoaction.org. Report From Nine Maternal Mortality Review Committees. 2018:16. Accessed November 13, 2020. https://reviewtoaction.org/sites/default/files/national-portal-material/Report%20from%20Nine%20MMRCs%20final_0.pdf.

A Trojan Horse? A Pharmacist’s Approach to Combatting Protocol Deviations

Ray Iannuccillo, PharmD, RPh, MBA, BCPS, BCOP

Rhode Island Hospital

Andrea Monckeberg, MS, RPh, BCOP

Rhode Island Hospital

Andrew Zullo, PharmD, RPh, PhD

Brown University School of Public Health

Rhode Island Hospital

Background. Oncology clinical trials can be incredibly complex and pose a number of challenges to pharmacists. Prior to October 1, 2018, the outpatient oncology pharmacists at the Lifespan Cancer Institute at Rhode Island Hospital were tasked, as part of their scope of practice, with performing the assessment of treatment appropriateness. They were also responsible for the compounding and dispensation of investigational drugs. The time allotted to perform the aforementioned tasks completely, thoroughly, and as defined in the protocols was limited due to the volume of patients that the outpatient oncology pharmacists serve. Fiscal year (FY) 2018 saw 24 207 total medications dispensed in the Lifespan Cancer Institute, with 1260 (5.2%) being investigational products. FY 2019 saw 28 093 total medications dispensed, with 1660 (5.9%) being investigational products. This amounted to a 31.7% increase in investigational products dispensed from FY 2018 to FY 2019, whereas noninvestigational products only increased by 15.2% in the same time frame. Enrollment in oncology clinical trials in FY 2018 was 199, while enrollment in FY 2019 was 275, representing a 38.2% increase in participation. The growth of the oncology clinical trials program presented numerous challenges to the outpatient oncology pharmacists. A creative solution was needed to ensure that this patient population received the safest and highest quality of care possible.

Intervention Detail. As of October 1, 2018, the incorporation of a dedicated Investigational Drug Service (IDS) oncology pharmacist into both the clinical oncology research team and an outpatient infusion center mitigated the challenges faced by the outpatient oncology pharmacists staffing the infusion center. Besides being a protocol expert, the IDS oncology pharmacist performs a number of clinical and operational tasks. The most important workflow addition is that each patient receiving treatment in a clinical trial is reviewed by the IDS oncology pharmacist and a pharmacy clearance note is documented in their medical record. The addition of this pharmacy note adds an additional layer of safety, as the patient is also cleared by the research nurse and treating physician. The IDS oncology pharmacist is responsible for protocol review and collaboration with a multidisciplinary team to build medication entries and treatment plans in the electronic medical record. The IDS oncology pharmacist also participates as a member of the institutional review board and the Phase I Developmental Therapeutics Clinical Trials Portfolio weekly meeting. During FY 2019, the IDS oncology pharmacist entered notes on all patients participating in clinical trials. Pharmacist intervention data was collected for the years prior to and post-workflow modification (October 1, 2018) to assess the IDS oncology pharmacist’s impact. The types of interventions and their collective impact resulted in optimized therapy, cost savings, avoidance of adverse drug event and protocol deviation, and a reduced number of adverse drug events. The number of protocol deviations/violations associated with study treatments that were reported during FYs 2018 and 2019 was also collected. Additionally, the time it took from order release to delivery of the investigational product to the clinic during both periods was examined.

Outcomes and Impact. During FY 2019, a total of 1660 notes were entered on all patients participating in oncology clinical trials. During the same time frame, 118 interventions were made on research patients by the IDS oncology pharmacist. FY 2018 only had 22 interventions. This was a 5.4-fold increase in pharmacy interventions on patients in oncology clinical trials. Sixty-six of the interventions made by the IDS oncology pharmacist resulted in avoidance of potentially 19 major (15.6% of interventions) and 47 minor (44.5% of interventions) deviations. FY 2019 had 2 protocol deviations related to pharmacy management of clinical trials, whereas FY 2018 had 12, resulting in an 83% reduction in deviations related to pharmacy. In FY 2018, it took an average of 75 minutes for investigational order(s) to be reviewed and dispensed. After the intervention in FY 2019, it took an average of 57 minutes for investigational order(s) to be reviewed and dispensed, resulting in a 24% time reduction.

Breakthrough Approach Yields Breakthrough Improvement for Clinic Patient Experience

Sherry Laniosz, MBA

Kristen Gast, MBA, MSN, RN, CNL

Darren Reynolds, MBA, PMP, CSSBB

Rush University Medical Center

Background. Approximately a year after opening, Rush Oak Park Specialty Care was consistently delivering lower patient experience scores than other multispecialty clinics within the medical group. Staff and providers were generally satisfied with the clinic and felt that it provided an attractive place to practice. In spite of that, the overall patient experience score averaged around the 37th percentile. As a high-volume clinic within the Rush University Medical Group, these results reflected poorly on the clinic and also brought the overall medical group performance down. Nearly all the providers also practiced at other locations, and the rotating schedule made it challenging to standardize processes. The clinic was also physically divided into 2 pods, and each operated somewhat independently from the other. These factors made it difficult for staff members to connect their individual roles and improvement efforts to the overall patient experience. It seemed like all of the right ingredients were present, but not fully aligned.

Intervention Detail. In January 2019, the clinic held an after-hours rapid improvement event to find change opportunities within our 3 key drivers of patient experience: waiting/time spent, care provider, and coordination of care. The event included a cross section of medical assistants, clinic coordinators, nurses, and providers, along with the practice administrator and nurse manager. Facilitation was provided by staff from the patient experience and transformation office departments. Two 4-hour sessions were broken down into 4 main sections. The first session focused on discussion about patient experience scores, comments, best practices, and the 3 key drivers of overall patient experience, followed by process mapping of the patient visit with staff identification of barriers and opportunities. The second session involved prioritization/selection of improvement opportunities, followed by the creation of a plan for ongoing change management and support. Six changes were identified and implemented within the following week: a daily morning huddle, an on-time status board in the waiting area, a provider/ medical assistant morning huddle, standard work for gathering outside record information, patient signage to identify check-in and check-out areas, and removal of visual barriers to improve front desk visibility. Implementation and adjustments were supported through a weekly check-in call between leadership and the facilitation team. Clinic leaders also rounded regularly with frontline staff to coach and support.

Outcomes and Impact. Since the rapid improvement event, Rush Oak Park Specialty Care has shown significant improvements. Over the first 6 months, the overall patient experience score increased 20 points to the 57th percentile. While team members celebrated this success, they were still falling short of the medical group patient experience goal. To keep the momentum going, an additional improvement session was held with the team, and the clinic subsequently achieved top quartile performance. Staff engagement has also increased at the clinic as a result of the improvement events. Understanding of the patient experience and building solutions together have given them a stronger sense of ownership in the implemented changes. This also built a strong foundation for ongoing teamwork and improvement thinking that truly represents the values at Rush. In addition to achieving top quartile scores, the improvement initiative also earned the clinic an internal Rush Quality Improvement Award. The lessons learned from Rush Oak Park Specialty Care have been adapted at other clinics within the medical group with similar positive results. At University Cardiologists, an on-time status board was incorporated into the ongoing development of a clinic visual operating system. At River North Multispecialty Clinic, an on-time status board and customer service concepts were used to tune up their existing processes. Both clinics used the same solid platform of education about patient experience results and drivers to develop a sense of engagement and ownership by staff.

The 2-Minute Annual Wellness Visit

Michael A. Hanak, MD

Rachel Kirsch, RN

Rush University Medical Center

Background. With the rapid pace of enrollment in Medicare Advantage plans and the growing importance of beneficiary attribution in shared-savings arrangements, the Medicare annual wellness visit (AWV) has become an important element in achieving success in population health. It serves to identify and mitigate health risks, complete overdue health screenings, reduce overall utilization, and solidify patient-physician attribution. According to Rush University Medical Center accountable care organization data, the organization completed AWVs for only 8% of eligible beneficiaries in 2018, while the national average hovered in the 20% range (potentially higher now).1 The framework and narrative for these visits lacked physician buy-in, resulting in the opportunity to improve performance of this important service. Physicians desired to address the elements of the AWV but not at the expense of room utilization, lost visit revenue, and conflicts with the patient’s agenda. The following model was assembled to address these challenges and centralize outreach such that primary care physicians could spend more time talking with these patients and less time checking boxes.

Intervention Detail. This pilot project began with organizing in grid format all required and optional elements of an AWV for documentation purposes. We then created a telephone encounter template designed to capture the required elements of a health risk assessment. We looked ahead at scheduled appointments to identify eligible patients who had a visit scheduled for any other reason, and a nurse contacted those patients with a pre-scripted message detailing the purpose of the AWV and its importance, setting up a time to call back (if the patient was not immediately available) to complete the required questions. The health risk assessment was documented in a phone call within 1 week of the planned visit and the required clinical elements of the visit were documented using a pre-charting functionality of the electronic health record. All necessary and overdue tests were teed up and scheduling information was provided to the patient. Upon the patient’s arrival, the provider only needed to document a cognitive assessment while providing the patient with previously arranged signed orders. The AWV is done and can be co-billed with existing evaluation and management (E/M) services.

Outcomes and Impact. This workflow allowed our primary care clinicians to spend minutes on the AWV while having all the important information from the visit available to guide clinical decision-making. In many cases, a level 3 E/M visit and even a level 4 E/M visit was paired with an AWV within a 20-minute time slot on the physician schedule. The pilot project saw 20 successful visits of this type completed within a 45-day window, with an additional 440 visits across the service line in the following 3 months. Patients had more time to answer questions, reconcile medications available to them at home, and sort out the logistics involved with scheduling recommended preventive services. Physicians were assured nothing was forgotten in a condensed visit window while patients did not feel rushed through their interactions. The medical group now funds a 1.0 full-time equivalent registered nurse and 1.0 patient navigator with a goal of completing 2000 AWVs over a 12-month period—more than tripling current performance.

1.Misra A, Lloyd JT. Hospital utilization and expenditures among a nationally representative sample of Medicare fee-for-service beneficiaries 2 years after receipt of an annual wellness visit. Prev Med. 2019;129:105850.

Great Places, Familiar Faces: Linked Care for the Multivisit Patient

Jennifer Haubert, APRN, FNP-BC

Melissa A. Eberhard, APRN, FNP-BC

Doreen Miller, MS, RN, CNS, GCNS- BC

Sanford USD Medical Center

Background. In 2012, the Centers for Medicare & Medicaid Services’ Hospital Readmissions Reduction Program reduced reimbursement by up to 3% of Medicare dollars for 30-day readmissions. As a result, readmission reduction is a major hospital focus for quality and effective care. Hospital readmissions are often associated with poor patient outcomes and high costs. As health care evolves in the United States, quality measures are continually being developed to ensure accountability of hospitals to their patients. To reduce readmissions at Sanford USD Medical Center, a transitional care team was developed consisting of 2 certified nurse practitioners (CNPs) and a registered nurse case manager (RN CM). In partnership with the Vizient Performance Improvement Collaborative Program and the MVP Method, developed by Amy Boutwell, MD, a multivisit patient (MVP) program was developed. MVPs are defined as those with 4 unplanned admissions to the hospital in 12 months. This small population often has both complex medical and social issues. The current health care system is lacking programs that provide high-quality, cost-effective care for these complex patients. Traditional readmission programs exclude patients with severe mental illness, substance abuse, homelessness, or no access to a phone or computer. The focus of the MVP program is to improve population health and reduce recidivism by addressing these exclusions. The MVP Method outlines how interdisciplinary care can impact the “unimpactable” through a team effort to link MVPs to cross-setting resources. The success with the MVP Method at Sanford USD Medical Center led to continued work with Vizient and Boutwell in a teaching collaborative. This teaching collaborative included 80 members representing 35 states, highlighting the national interest to learn new methods to improve care delivery for complex patients. Nationwide, it is imperative to continue to target patient populations with high utilization and directly link them with existing community resources to better manage health, improve social determinants, and prevent readmissions.

Intervention Detail. Sanford USD Medical Center utilizes Epic tools to assist with reporting and notification of hospitalized MVPs. Several steps were taken to identify MVPs upon admission that include: (1) a daily report to compile a list of patients meeting the criteria of 4 or more admissions in a 12-month period; (2) a brief chart review to ensure admissions are not observation or short-stay related; (3) a list of MVPs is emailed to key stakeholders, including mental health, social work, RN CMs, directors, the vice president of nursing, the medical director, and ambulatory case managers; (4) MVPs are managed by 2 CNPs; (5) MVP identification is added to sticky notes to physicians and case management communication; (6) a transitional care referral order is placed; (7) Epic MVP-specific lists are updated with patients meeting criteria; (8) transitional care CNP signs onto treatment team to inform other care team members of each patient’s status; (9) transitional care CNP signs onto care team to receive emergency department (ED) and admission alerts; and (10) focused follow-up nursing care by transitional RN CM. The transitional care CNP aligns with the interdisciplinary team to provide seamless care for MVPs. A thorough bedside assessment of social, medical, and behavioral determinants of health is completed. During this process a review of barriers to achieving optimal disease management, current resources, current responses to health, palliative care needs, advanced age, and disengagement with care are considered for the care plan. Weekly MVP and extended stay rounds are held to discuss interventions that will reduce readmission and improve utilization in the outpatient setting. Communication is ongoing with hospital providers, care management, primary care providers, social work, mental health, spiritual care, palliative care, administrative leadership, and community resources to link MVPs with resources and transition them to the community. This systematic approach enhances care for each MVP, improving outcomes and patient care.

Outcomes and Impact. Qualitative: Through implementation of the MVP Method, transitional care has improved communication and coordination across the continuum. By doing this, we are improving outcomes and improving patient quality of life. This is evident through the development of weekly MVP interdisciplinary team meetings, extended stay rounds, and ED and hospital care plans. Meetings are held weekly to address the highest and most challenging utilizers. Members at the table include CNPs, RN CMs, social work, ED, directors, mental health, palliative care, quality leadership, ambulatory case management/social work, and community partners. Communication with the ED case manager (CM) has been instrumental in improving care and preventing admissions. Outcomes include development of admission, discharge, transfer alerts, and comprehensive ED care plans. Transfer alerts allow transitional care to be notified when an MVP is in the ED. Interventions can then be applied with ED providers and ED CMs to prevent admission. Care plans are created for the highest utilizers in collaboration with the ED. These plans of care are individualized to help provide cohesive, patient- centered care across the continuum. Continued process improvement includes completion of advanced directives and focused follow-up nursing care for MVPs. This has directly impacted patient-centered care by allowing conversations about goals of care and encouraging palliative care conversations for appropriate patients. The RN CM also provides hospital follow-ups and phone calls when the patient discharges from the hospital. Quantitative: Since implementation of the MVP Method, we have seen a decrease in the number of admissions in 3 months pre-intervention and 3 months post-intervention. Directly linking existing ambulatory and community resources has reduced hospitalizations and ED visits. By impacting the highest utilizers’ unmet needs, we have seen a reduction in the hospital all-cause admissions.

Who You Gonna Call? Code Sepsis! A Comprehensive Approach to Sepsis Improvement

Natalie Smith, RN, BSN, MBA

SSM Health St. Mary’s Hospital—St. Louis

Background. “Sepsis remains one of the most deadly emergency department arrival or hospital-acquired conditions,”1 and “initial attention of sepsis remains uneven and often slow.”2 In accordance with the literature, “incorporating an interdisciplinary approach to existing decision-support tools improves care and patient outcomes.”3 Furthermore, “continuous education and awareness initiatives can help maintain focus on the importance of early recognition and goal-directed care.”3 With these concepts in mind, SSM Health St. Mary’s Hospital—St. Louis’ sepsis committee utilized a Plan-Do-Check-Act approach to make ongoing improvements and measure impact. Reducing sepsis mortality has been one of our key performance indicators for the past 3 years and, as a result, we have an organized and systemwide accountability structure. Our hospital is included in the St. Louis Region, which is part of a 4-state system of over 30 hospitals. Therefore, hospital, regional, and system executive leaders are held accountable to meeting goals, leading to significant support of sepsis work at the local and system levels. At each SSM Health hospital, the chief medical officer is the executive sponsor of sepsis work and each sepsis team has a physician champion and a quality specialist facilitator. To continuously improve processes, feedback from frontline staff is key. Feedback is obtained from the frontline registered nurse and MD members of the sepsis committee through quality and safety rounds on inpatient units, in the emergency department (ED), and via written feedback on code sepsis visual management tools completed at the point of care. We feel other Vizient members can learn from our experiences because sepsis mortality continues to be high due to delays in identification of sepsis and the complexity of the SEP-1 bundle. Our processes have proven to have an impact on reducing sepsis mortality and these concepts can be shared to reduce the number of nationwide sepsis deaths.

Intervention Detail. Despite an existing Epic predictive analytic sepsis tool and a newly executed inpatient code sepsis process, our hospital experienced an upward trend in its sepsis mortality ratio (observed to expected). In early 2019, the sepsis committee began a Plan-Do-Check-Act approach to sepsis improvements. In February 2019, realizing that most sepsis patients present via the ED and the majority of our SEP-1 core measure outliers were contributed to the ED, we implemented an ED code sepsis algorithm. The algorithm provided a standard treatment process for suspected sepsis patients—from sepsis identification through the 6-hour SEP-1 bundle. Then in March 2019, the quality specialist adopted standard work of reviewing charts daily to provide feedback and education to staff on cases from the previous day. To increase awareness and visibility of code sepsis quantity and chart review findings, sepsis was incorporated into the organization’s daily safety huddle in April 2019. Discussions in safety huddles led to the realization that many nurse leaders, frontline nurse staff, and physicians did not have sufficient general knowledge of sepsis, the SEP-1 bundle, or our own organization’s incidence of sepsis and sepsis mortalities. In June 2019, the “Wheel of Sepsis” rounding began to provide fun and engaging sepsis education to frontline team members. Data evaluation in July 2019 revealed a significant difference in the number of sepsis order sets used compared with the number of times a code sepsis was called. To close this gap, we utilized technology to send notification any time an order set was used. In response to the notification, key team members responded to the unit and ensured a code sepsis was called if indicated. Our most current improvement has been to use visual management of sepsis patients to increase staff knowledge of patients on active sepsis treatment and guide them through the 6-hour bundle.

Outcomes and Impact. Average sepsis mortality at SSM Health St. Mary’s Hospital—St. Louis from September 2018 to April 2019 was 1.33, with a peak of 1.57 in December 2018. After implementation of a multimodal sepsis program of process improvement, mortality decreased significantly month-over-month, resulting in an average sepsis mortality of 0.92 from May 2019 to September 2019. Another quantitative metric utilized, starting in April 2019, was quantity of code sepsis. Between April 2019 and December 2019, the ED performed a monthly average of 170 code sepsis and inpatient units averaged 14 code sepsis. Reporting on the quantity of code sepsis daily in safety huddles was impactful for the team to hear and was important information to use for process evaluation and improvement. Furthermore, prior to April 2019, staff had limited avenues, if any, to receive sepsis education. The sepsis improvements between February 2019 and December 2019 provided several opportunities to increase staff knowledge about sepsis, including “Wheel of Sepsis” bimonthly rounds, quality sepsis chart review emails and report outs, in-the-moment coaching during all inpatient code sepsis, and visual learning with each code sepsis called via the visual management tool. Our data supports current literature, which has shown that code sepsis implementation reduces sepsis mortality.4 While we have sustained a 5-month stretch of improved sepsis mortality, our goal is to maintain a sepsis mortality rate consistently below 1.0 and with limited variation month-over-month, which has been challenging for us in past years. Our hypothesis is that with continued focus on daily sepsis awareness and continuous process improvements rooted in data, we will be able to achieve fewer deaths from sepsis than expected.

1.González Del Castillo J, Martín-Sánchez FJ. Resistant microorganisms in the emergency department: what should we do to meet the challenge? Emergencias. 2017;29:303–305.

2.Yearly DM, Huang DT, Delaney A, et al. Recognizing and managing sepsis: what needs to be done? BMC Med. 2015;13:98.

3.Delawder JM, Hulton L. An interdisciplinary code sepsis team to improve sepsis-bundle compliance: a quality improvement project. J Emerg Nurs. 2020;46:91–98.

4.Candel FJ, Sá MB, Belda S, et al. Current Aspects in Sepsis Approach: Turning Things Around. National Center for Biotechnology Information. Published September 26, 2018. Accessed January 5, 2020. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6172679/.

Better Together: A Team-Based Approach for Managing Diabetes and Depression

Nancy Shin, PharmD, CDCES

Marcie Levine, MD

Kara Rogge, MSW, LCSW, ACM-SW

Mark McGovern, PhD

Cati Brown-Johnson, PhD

Kaitlin Dent, MSEd, MPhilEd

Stanford Health Care

Background. Approximately 34.2 million people in the United States have diabetes (10% of the nation’s population).1 Twenty-five percent of patients with diabetes exhibit depressive symptoms.2 Coexisting depression is associated with poorly controlled diabetes and increases in complications, mortality, and health care expenditures.3 The American Diabetes Association recommends that depression that interferes with one’s ability to carry out daily diabetes self-management tasks must be addressed.4 Collaborative team efforts have demonstrated efficacy in diabetes self-management, outcomes of depression, and psychosocial function. Our primary care setting at Stanford Health Care is primed with the tools to help address diabetes and depression in a collaborative approach. Our integrated team of primary care providers (PCPs), licensed clinical social workers (LCSWs), clinical pharmacists, and dietitians, supported by medical assistants and clerical staff, allow each team member to work at the top of their licensure to improve care of patients with diabetes and depression. In addition to our multidisciplinary staff, we also have access to a population health dashboard to help measure and track our patients with diabetes. The aim of this project was to explore how to best utilize a multidisciplinary team and population health tools to improve chronic disease care. The measured objectives of this project were: (1) to improve depression screening via the Patient Health Questionnaire-9 (PHQ-9) among our patients with diabetes; (2) to improve depression treatment in our patients with diabetes and a PHQ-9 score >8 (mild to severe depression); and (3) to improve A1c control and/or PHQ-9 scores within 6 months within a cohort of patients with poorly controlled diabetes.

Intervention Detail. The first step in our process was to improve depression screening in all patients. Usage of real-time patient registry data allowed us to identify patients needing an updated depression screen (PHQ-9). With the assistance of support staff, these patients were given a screening form at each visit that they completed prior to seeing the provider. The next step was to improve treatment of patients who had been screened for depression. A subset of highest-risk patients with an A1c >8 and a PHQ-9 >8 were targeted for interventions. Treatment of depression included counseling by the PCP, referrals to behavioral health clinicians (LCSW, psychology, or psychiatry), and/or initiation of antidepressant medication. There was protected time for the behavioral health clinician to see identified patients. Treatment of poorly controlled diabetes included referral for medication management to a clinical pharmacist/certified diabetes educator or a dietician/certified diabetes educator or a referral to diabetes education classes. Our efforts were measured by A1c improvement and percentage of patients that achieved A1c <8% (Healthcare Effectiveness Data and Information Set measure) and by PHQ-9 scores. Dedicated time for monthly team case conferences, including the PCP, LCSW, pharmacist, and dietitian, was a key intervention. This time allowed for team review of patient registry data for those with poorly controlled diabetes.

Outcomes and Impact. In April 2019, our primary care clinic increased depression screening of all our patients, including those with diabetes. Over a 6-month period, our first goal of depression screening among patients with diabetes improved from 38% to 74%. Our second goal of improving depression treatment and follow-up in our patients with both A1c >8 and a PHQ-9 score >8 improved from 50% to 70% during the 6-month period. Our third and ultimate goal was to improve the A1c and PHQ-9 scores of our patients with poorly controlled diabetes. In April 2019, we identified 99 patients with poorly controlled diabetes, defined by A1c >8. We followed this cohort for 6 months, during which time 22 (20%) patients were no longer part of the practice. Of the remaining 77 patients, 40% improved their A1c to less than 8%, with an average A1c improvement of 1.3%. In the subset of patients that were followed by one or more team members including a pharmacist ± LCSW and dietician, 45% improved their A1c to less than 8%, with an average A1c improvement of 1.8%. PHQ-9 scores of these 77 patients also improved, on average, by 1.04. Those followed by an LCSW had the greatest PHQ improvement with an average of 5.17. We learned that patients who received collaborative efforts involving our team of a pharmacist, an LCSW, and a dietician had more improved diabetes control than those who did not. We also identified that it was more difficult to treat diabetes in those patients with higher depression scores.

1. Centers for Disease Control and Prevention. What Is diabetes? Published June 11, 2020. Accessed November 11, 2020. https://www.cdc.gov/diabetes/basics/diabetes.html.

2. Huang Y, Wei X, Wu T, et al. Collaborative care for patients with depression and diabetes mellitus: a systematic review and meta-analysis. BMC Psychiatry. 2013;13:260.

3. American Diabetes Association. Facilitating behavior change and well-being to improve health outcomes: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(suppl 1):S48–S65.

4. van der Feltz-Cornelis CM, Nuyen J, Stoop C, et al. Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2010;32:380–395.

Surviving Sepsis in the Emergency Department

Shenee Laurence, MPH, BSN, RN, CPHQ

Laleh Gharahbaghian, MD, FACEP, FAAEM

Hilary Street, MPH

Alexander Wessels

Alison Kerr, RN, MSN

Patrice Callagy, RN, MPA, MSN, CEN

Sam Shen, MD, MBA, FACEP



Paul Mohabir, MD

Stanford Health Care

Background. Our performance management approach is ongoing weekly meetings with the sepsis quality analyst, emergency department (ED) nursing quality manager, and emergency medicine unit-based medical director to discuss successes and opportunities for improvement. The role of ED nursing and physician leadership is to educate staff and provide feedback to clinicians about sepsis mortality and opportunities for improvement. In Stanford Health Care ED, all clinical disciplines (nurses, physicians, and pharmacists) are accountable for present-on-admission (POA) sepsis mortality. Sharing our process improvement successes can provide guidance to other health care systems in their efforts to decrease POA sepsis mortality.

Intervention Detail. Stanford Health Care ED interdisciplinary sepsis leadership team used the A3 problem and process approach to identify root causes of why fewer sepsis patients survived than expected. Our baseline POA mortality index in 2015/2016 was 1.14. Sepsis bundle compliance monthly data was used to identify gaps and drive our process improvement focus. We used an Ishikawa diagram to identify possible causes of our low bundle compliance. The causes identified were: (1) inconsistent clinician documentation; (2) lack of coordinated communication between care teams; (3) ineffective management of sepsis fluids by physicians; and (4) unclear expectations regarding appropriate nursing care for sepsis patients. The following measures were implemented: (1) created smartphrases/doc phrases, which are user-created or system-created phrases that can be pulled into notation by starting with a period or dot following the name or abbreviation of the phrase (ie, sepsis), to guide nursing and physician sepsis compliance documentation; (2) aligned care coordination; (3) created fluid order sets for actual body weight, ideal body weight, congestive heart failure, and pulmonary edema; and (4) designed onboarding education for new nurses outlining expectations and care requirements.

Outcomes and Impact. In 2015/2016, our POA was 1.14. During this time, the ED launched the ED Sepsis Leadership Team. In 2016/2017, the group continued to review cases and modified the code severe sepsis alert, proposed 24/7 coverage for ED pharmacy, and added emergency critical care nurses to the code severe sepsis workflow. During this time, the POA sepsis mortality index decreased to 0.97. In 2018, the ED Sepsis Leadership Team transitioned to a focused, in-depth case review performed by the ED nursing quality manager and the emergency medicine unit-based medical director. The information from these case reviews identified trends, provided registered nurse and physician feedback, and guided future process improvement projects. During this time, the POA sepsis mortality index decreased to 0.84. In 2019, the ED process improvement focus for POA sepsis was improving fluid compliance. The ED created fluid order sets for actual body weight, ideal body weight, congestive heart failure, and pulmonary edema. As of November 2019, the ED POA sepsis mortality index was 0.77. We are increasing the likelihood of patients surviving sepsis in the ED.

Perioperative Telehealth: The Future Is Here

Lisa J. Cianfichi, NP, MSN

Samuel H. Wald, MD, MBA

Amy K. Semple, RN, BSN

Guillermo E. Burga-Hogan, NP, MSN

Amy C. Lu, MD

Clifford A. Schmiesing, MD

Stanford Health Care

Background. Stanford Health Care’s Anesthesia Preoperative Evaluation Clinic (APEC), started in 1992, introduced an outpatient model of preoperative assessment and preparation for surgery. The program grew from a single clinic with 2 exam rooms evaluating 20 patients per day to 6 sites, 13 exam rooms, and over 125 patients per day. Despite marked growth in health system resources and robust efforts to schedule at maximum efficiency, APEC was unable to meet the growing demand. Clinic space was at a premium and acquiring additional space was uncertain. This coincided with several positive developments. There was growing organizational interest and technological support for video patient visits. Patient clinical information and records available in the electronic medical record (EMR) system were increasingly rich and comprehensive, especially since most surrounding health care systems were also using the same EMR vendor. The information was easily accessible to Stanford clinicians through health information exchange data-sharing agreements. Importantly, there was growing emphasis on and demand for patient-centered care. In 2018, APEC evaluated 23 503 patients in person with 13 physical rooms for over 33 300 anesthetics. Requests for more space proved challenging due to constraints. APEC leadership, along with Stanford’s digital health and technology teams, spearheaded development of an ambulatory telehealth program. Little was known about virtual anesthesia preoperative assessment and support of preoperative processes. New clinical workflows and training materials were developed and modified based on initial experience. Criteria for appropriateness of video visits were created and updated continuously. Video visits and telehealth proved different than live assessment.

Intervention Detail. The initial intervention started with scheduling and went well beyond updates to date and time fields. We also needed to (1) provide patients the ability to enroll via our electronic portal and (2) allow our team to perform technology assessments. Staff developed technological sophistication to troubleshoot real-time problems and found the need to be punctual. Staring at a mobile phone or desktop waiting for a provider was a different experience for patients than sitting in a waiting room; therefore, expectations that a patient’s appointment would be on time were heightened. Prereview of patient information was essential before a video visit. Trying to connect with a patient virtually on a computer monitor while simultaneously looking at a computer monitor to learn and review new patient information was awkward and taxing. Obtaining preoperative diagnostic testing, such as blood draws or electrocardiograms, was more challenging. Staff members were resourceful in finding and using preexisting test results, often found in our nearby health care organizations through the EMR portal. Using outside facilities, including commercial labs and private physician offices often located in the patient’s hometown, proved useful and convenient for patients as well. Additionally, a program enabling clinical staff to work from their own home doing video visits was also piloted in early 2020. This was done in response to burdensome staff commutes, the goal of staff retention, and emerging video visit technology that negated the need for both patients and staff to meet in 1 physical location. The result of adopting video visits and a work-from-home program significantly mitigated space constraints and enabled total patient visits to increase. APEC led the organization in percentage of video visits (25% versus 3% organizationwide) and was the first to enable a telehealth work-from-home model for clinical and support staff. The clinic’s early and vigorous adoption of telehealth helped pave the way for the organization’s overall adoption of telehealth.

Outcomes and Impact. Since inception, APEC telehealth visits increased from less than 1% of total volume in December 2018 to 28% of total volume in December 2019. Successful implementation was attributed to several factors: (1) daily morning huddles with staff opened discussions about problems and solutions; (2) attention was focused on creating useful and standardized approaches to training and clinical workflows; and (3) staff support and physician buy-in were encouraged, as was interdisciplinary collaboration with information technology colleagues. Patients responded favorably to telehealth, with 78% likely to schedule another telehealth visit and 87% being very satisfied with the care of their provider, based on 717 patient experience satisfaction surveys. Total patient visit volume also grew from 23 503 in 2018 to 26 046 in 2019, a 15.6% increase. The work-from-home pilot was also successful and integrated well with the growth in video visits. Having established telehealth and work-from-home programs proved prescient when the COVID-19 pandemic started. When California initiated a shelter-in-place mandate on March 16, 2020, Stanford had already suspended all elective surgeries on March 13. In response, APEC pivoted overnight to a 100% telehealth model, as patients and staff were also reluctant to come to the hospital. Continuation of clinic operations, although 100% virtual, helped maintain urgent surgeries and the resumption of elective surgeries in May 2020. APEC volume quickly returned to normal and exceeded pre-pandemic numbers. Two years of preparation to implement video visits and pilot a work-from-home program allowed APEC to pivot, almost overnight, to a 100% virtual patient visit program and a nearly 100% work-from-home model as well. The pandemic has had disruptive and unsettling effects on our clinic and operating rooms. COVID-19 shows no sign of retreating; APEC similarly will not retreat from telehealth and the positive results achieved.

Reducing Medicare 1-Day Write-Offs Due to Inappropriate Admission Orders

Lisa Shieh, MD, PhD

Stanford University School of Medicine

Olufolarin O. Oke, MD

Stanford Health Care

Michaela Sullivan, RN, MSN, ACM

Stanford Health Care

Stanford University School of Medicine

Background. The designation of a patient as outpatient versus inpatient status at time of discharge affects how hospitals bill Medicare for services because the Centers for Medicare & Medicaid Services (CMS) reimburses hospitals at a higher rate for inpatient when compared with outpatient designation.1 Since fiscal year 2014, one of the major benchmarks for outpatient status as defined by CMS is that the expected patient stay was less than 48 hours, with a few exceptions, such as certain procedures listed by CMS. To discourage hospitals from designating patients as inpatient when not appropriate, CMS established the Recovery Audit Program to identify and correct past improper payments to hospitals.2 At Stanford Hospital, case managers are supposed to review each patient’s designation prior to discharge for compliance with CMS criteria for inpatient stay. When this safety net fails, Stanford Hospital does not bill Medicare for patients erroneously designated as inpatient. These write-offs lead to a significant loss of income to Stanford Hospital on a yearly basis.

Intervention Detail. A best practice alert (BPA) intervention was developed and could fire upon signing of discharge orders for Medicare patients who have the designation of inpatient but have stayed less than 2 midnights, provided they were in an acute level of care. Upon firing, the primary team is asked to confer with the case manager, who also gets a message to review the patient’s designation as inpatient. All patients who were admitted between July 18, 2019, and October 18, 2019, at Stanford Hospital were randomized to the intervention arm (BPA fires) or control arm (BPA is silent). Chart review was then conducted and based on information regarding the patient’s designation either as inpatient or outpatient at time of discharge, the case manager notes whether inpatient designation was appropriate, and also documents the BPA override reason in cases where a patient was not converted from inpatient to outpatient. The estimated number of write-offs was calculated in the intervention arm using the number of patients that were not converted from inpatient to observation as a surrogate, followed by the deduction of those who met criteria for inpatient stay after case manager review. A similar calculation was done for the control arm, but because not all patients were reviewed by a case manager due to lack of a BPA reminder, the number of patients that would have met criteria for inpatient stay was estimated using the intervention arm as a surrogate.

Outcomes and Impact. There were 88 patients in this study—40 in the control arm and 48 in the intervention arm. In the intervention arm, 40 were converted to outpatient status after case manager review of the patient’s designation. Seven out of the 8 patients who were not converted were deemed to have met criteria for inpatient stay by our case manager, leading to an estimated Medicare write-off of 1. There were 40 patients in the control arm, of which 23 were designated as inpatient at time of discharge, for an estimated number of write-offs of 17. Using a BPA to remind the primary team and case manager to review the patient’s designation to ensure appropriate classification as inpatient or outpatient, we reduced the estimated number of write-offs from 17 to 1—which ultimately can reduce potential write-offs and prevent millions of dollars in unnecessary income loss.

1. Locke C, Sheehey AM, Deutschendorf A, et al. Changes to inpatient versus outpatient hospitalization: Medicare’s 2-midnight rule. J Hosp Med. 2014;10:194–201.

2. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Rules and regulations. Fed Register. 2013;78:50943. https://www.govinfo.gov/content/pkg/FR-2013-08-19/pdf/2013-18956.pdf.

Healing Hearts and Clearing Minds: A Personal Journey of Self-Discovery

Despina Garcia, RN, BSN, CNML

Karen Wentworth, MPH, MSW, RRT, CPXP

Amanda Armstrong, MSN, RN

Jessica Hughes, RN

SUNY Upstate University Hospital

Background. Medical intensive care unit patients with a prolonged length of stay were not receiving interventions to address post-intensive care syndrome (PICS), which includes the development of cognitive, psychiatric, and/or physical disabilities. Nursing staff can assist in identifying patients at high risk for developing PICS/intensive care unit (ICU) delirium and initiate documentation of a patient’s course of stay in an ICU patient journal as a supportive intervention. An ICU patient journal gives patients the opportunity to understand and reflect upon their ICU stay, decreasing the risk of PICS and improving patient satisfaction and Press Ganey scores. The ICU patient journal is initiated upon admission to the ICU. Journaling topics include but are not limited to: events leading to the admission; patient’s daily status; activities the patient participated in that day (eg, procedures and treatments); references to the ICU environment (eg, sights and sounds); discussions regarding current events, missed birthdays or holidays; updates on family, friends, pets, and coworkers; and most importantly, words of encouragement. Entries are written by hospital staff, the patient, family, and friends and may sometimes include photos; these are written messages of caring and kindness. Through journaling, family members are engaged in their loved one’s daily ICU stay experiences, thus creating transparency, improving communication, and instilling trust. Journaling often provides an opportunity to clear up any misunderstandings or misconceptions in real time. Educating staff on appropriate guidelines regarding journaling documentation was instrumental in assisting the health care team in providing factual narratives that prevented misconceptions by the patient or family members. Including the ICU journaling initiative as a learning session in the 2020 Vizient Connections Education Summit can assist other institutions in implementing a similar process to decrease the incidence of PICS and ICU delirium, as well as improve patient satisfaction, caregiver engagement, and nursing retention.

Intervention Detail. The criteria for those who receive an ICU journal include: (1) patients who have been in the ICU for more than 48 hours; (2) patients having procedures requiring sedation; (3) patients intubated, sedated, or scored positive for delirium; (4) patients with a Richmond Agitation and Sedation Scale equal to or greater than –2; and (5) patients with a condition indicating the potential for memory lapses. These criteria were selected based on literature review from organizations that have implemented ICU journaling and the effects that long length of stay in an ICU has on both patients and families. Although the number of organizations that currently participate in ICU journaling is small, this practice should be implemented by many more—not only for patient and family care but also staff well-being and health. Staff was educated on appropriate journal guidelines, including: (1) activities the patient participated in during the day, particularly central line placements, intubations, urinary catheter insertions, or any invasive procedures. These were selected because patients with altered cognition often recall them as acts of violence committed against them; (2) sights and sounds of the ICU environment, with a focus on explaining frequent alarms or excessive noises related to delivery of care; (3) general observations regarding the patient’s overall health status; (4) updates from family and friends, about pets, etc; (5) missed holidays, special events, and current events; and (6) words of encouragement, hope, and caring. The education of proper journaling guidelines included important changes that were required to facilitate a successful project. Understanding that “journaling” was not the same as the legal documentation our caregivers place in the medical record was an initial performance gap we needed to overcome. As we began to see our success, the staff members were pleased with their efforts and journaling became our norm.

Outcomes and Impact. An increase in Press Ganey patient satisfaction scores was noted shortly after the ICU patient journaling was implemented, with most Press Ganey domains reaching the 99th percentile. These improvements have been sustained for 3 months. Additionally, families and patients are expressing satisfaction with the ICU journal because it provides an opportunity to reflect on recently documented events to gain clarification, consolation, and support. Most notably, family members of deceased patients have expressed gratitude, as they intend to utilize the ICU journal as part of memorial services and/or as a family heirloom that can be shared with future generations. The medical intensive care unit nursing staff also expressed satisfaction with the initiative because it provides them an opportunity to offer patients support that reaches far beyond the boundaries of our institution. Providing them a tool they can utilize to express care and empathy to the patients they cannot cognitively reach has, in turn, reduced burnout and positively impacted nursing retention. We intend to continue journaling and monitoring of patient satisfaction scores, as well as those of staff retention and burnout. Since this is a multidisciplinary project, we will also be gathering data regarding retention and burnout for other members of our team.

Get Bold: Advertising Your Patient Safety Score

Joseph F. Golob Jr., MD, FACS, CPHQ

Nicole Rabic, MSN, RN, CIC

Elizabeth Pagnard, MSN, RN

The MetroHealth System

Background. The MetroHealth System (MHS), an urban, academic, level I trauma health care system, set a goal of increasing transparency. Consistent with Institute for Healthcare Improvement priorities, we display performance on preventable patient harms for the organization utilizing a systemwide platform with the hope of reducing harms. A multidisciplinary group of physicians, nurses, information technologists, and administrators within the MHS Quality Institute led the initiative. Using iterative development techniques, the group created the patient safety score, a comprehensive measure to summarize the current system performance of 18 preventable harms as the average number of days between harms. Seven types of nosocomial infections identified by the National Healthcare Safety Network and 11 Agency for Healthcare Research and Quality patient safety indicators are summarized in the score. These 18 harms were selected because they are validated, publicly reported measures that impact hospital reimbursement. Harms are identified through hospital coding, safety event reports, and the infection prevention team. The score is a dynamic measure that changes daily when preventable harms are identified and/or a new calendar day begins. The higher the patient safety score, the better our performance. An interactive data display was created with the support of our systems leadership and displayed at the top of the MHS intranet home page, visible to all employees. By clicking a link at the top of our home page, employees can see performance details for each measure. In 2018, MHS experienced one of these 18 preventable harms every 1.61 days. We knew this number had to be improved. We are pleased to be included in the summit because we realize initiating bold transparency can be frightening, but our work proves it is safe and supports a culture of improvement. Using data transparency creates actionability among health care providers and is an implementable strategy for improvement.

Intervention Detail. The multidisciplinary team utilized multiple cycles of Plan-Do-Study-Act to create the patient safety score, followed by creation of data visualizations. We planned to create a single measure of performance that was dynamic and easy to understand, with daily changes. A specific measure of performance was created, analyzed using previous years of data, and vetted with the group. Multiple rapid cycle changes were used before we identified and agreed on the average days between all 18 harms as the patient safety score. A similar process was utilized for data visualization. The interactive performance graphs were created by the information technology department using Visual Studio software and SharePoint programs. The visualizations were then subsequently modified until the team agreed that the visualization was encompassing and easy to understand and use. Data analysis and creation of 2019 patient safety score goals were performed by utilizing an event distribution model for all 18 harms with data from 2016 to 2018. A capability analysis was then performed to evaluate our current practice of preventing the harms. Utilizing the distribution of occurrence and capability of prevention, threshold (1.67 d), target (1.80 d), and stretch (2.02 d) goals were created.

Outcomes and Impact. The patient safety score uses real-time data to increase transparency and actionability of patient safety. This score continues to be utilized as a transparent performance measure located at the top of the MHS intranet. It is also announced daily during the MHS organizationwide safety huddle. Having executive leadership support, as well as collaboration with the legal department, are keys to success. Selecting the correct platform to display the measure is also important. Everyone in the organization must commit to a culture of safety by visualizing the patient safety score. We chose to place the measure at the top of our intranet home page, which averages approximately 17 000 views per day. Our recommendation to other organizations is to trust that bold transparency will not introduce panic and despair, but rather will establish a sense of urgency to continuously improve patient safety and outcomes. The use of the tool affords the entire organization a clear vision of our performance for preventing patient harms. Our employees take to heart the great responsibility that they have to keep our patients safe. After implementing the patient safety score, we reached our target goal and finished 2019 with a score of 1.99 days with 183 total harms. This was an improvement of 19.4% compared with 2018 and equated to 44 fewer patient harms in 2019. The safety score was reset to zero on January 1, 2020, and new institutional goals were set. If we reach our stretch goal for 2020, MHS will have decreased the number of preventable harms by an additional 24, corresponding to a patient safety score of 2.37 days.

Patient Itinerary: Guiding Patients Into Engagement and Satisfaction

Kelsey Accurso, MS, APRN, AGCNS-BC

Janice Jones, MSN, RN, CRRN

The University of Kansas Health System: HaysMed

Background. Multiple safety organizations urge hospitals to emphasize the importance of including patients in their care by asking questions about their medications, goals, and diagnoses. Patient itineraries are an organized way to inform patients and families of what to expect for the current day and throughout their hospital stay. According to Spath,1 “simple mistakes that lead to patient harm may be prevented when the patient is part of the checks and balances of the health care system.” The personalized patient itinerary helps engage patients by increasing communication and collaboration with their care teams. The itinerary is utilized by providing information to the patient about medications, diagnostic testing, procedures, diet, and therapy, allowing the patient to act as a member of their own care team. The itinerary is updated and given to the patient during the bedside staff report twice a day. The tool can have a significant impact by educating patients to help them feel more in control as they face their health care needs. The goal of the tool is to engage patients more on a daily basis in terms of goal setting, medication knowledge, increased awareness of potential safety concerns, and anticipating discharge needs. The personalized patient itinerary was created by a multidisciplinary team and then piloted on an 11-bed orthopedic unit.

Intervention Detail. The multidisciplinary team included administrators, nursing, providers, patient advisory council representatives, and information technology. The itinerary was piloted on an 11-bed orthopedic unit. The personalized itinerary was updated and printed twice a day. The itinerary reflected the orders entered into the patient’s electronic medical record and summarized the next 12 hours of the patient’s hospital stay. This included medications, therapy orders (physical, occupational, respiratory, and speech), labs and other tests, dietary guidelines, and any additional orders. By reviewing the upcoming 12-hour plan with patients and families, care team members were actively engaged and able to participate in conversations. The medication section on the itinerary is a large portion and focuses on hand-off. All medications are listed so that this information can be used for education and referenced during medication administration. This education process helps inform the patient while setting expectations. Care team members are able to mark through medications that have been discontinued or highlight those that staff are focusing on for education. Education was completed with care teams on the itinerary’s layout and how to utilize the tool. Daily reminders and updates at staff meetings were helpful in sustaining use of the new tool. Another method that helped sustain use of the tool was having the supervisor make rounds during which the itinerary was referred to for questions and education.

Outcomes and Impact. The itinerary was found to be helpful not only to patients but also to family members and staff. Four months prior to implementation the average ranking of overall score for patient satisfaction was 47.5. After implementation, average ranking for patient satisfaction increased to 87.25, a 46% improvement (n = 86). Increased awareness and education about medications on the itinerary led to an increase of overall ranking in medication understanding from 60.25 to 87.75, a 31% improvement (n = 59). During the pilot phase, evaluation was completed to determine if potential errors were found utilizing this tool. Increased safety was observed, with examples of family members noting allergies that their loved ones forgot to mention. A family member stated, “I wasn’t aware mom was taking so many medications. This has opened my eyes.” It has also helped decrease some patients’ pain medication by giving a complete list in an easy-to-read format so that duplicate classes of meds can be reviewed and decreased. Patients and families also voiced appreciation for the tool in terms of improving communication and planning; for example, “I knew what to expect in the morning when the lab came in at 5 to draw blood because I had seen it listed,” and “it helps me to remember what I need to tell my family when they ask how things are going and what did I do today.” The tool has also helped identify and anticipate discharge dates and needs. Patients are able to arrange for rides more appropriately and communicate with family and friends any needs they may have. Overall, the staff, and more importantly patients, have found benefits in adopting this tool, which has helped enhance education, facilitate self-management of care, and increase patient satisfaction.

1. Spath PL, Nash DB. Partnering With Patients to Reduce Medical Errors (Guidebook for Professionals). Institute for Healthcare Improvement. 2004. Accessed February 7, 2020. http://www.ihi.org/resources/Pages/Publications/PartneringwithPatients.aspx.

Building a Transgender Surgical Program at a Community Hospital

John Renzi, DNP, MBA, RN, CCCTM

NE-BC, Thomas Jefferson University Hospitals, Inc.

Dennis Delisle, ScD, FACHE

The Ohio State University Wexner Medical Center (formerly employed at Thomas Jefferson University Hospitals, Inc.)

Emily Trask-Young, MBA, MPH

Thomas Jefferson University Hospitals, Inc.

Thomas Jefferson University Hospitals, Inc.

Background. Approximately 1.9 million people in the United States identify as transgender.1 From 2016 to 2017, the market for gender affirmation surgeries increased by 155% in the United States, and the market is expected to grow at a compound annual growth rate of approximately 25% from 2018 to 2024.1,2 Despite this increase, there are few surgeons in the country that perform both male-to-female and female-to-male gender affirmation surgeries. Initiating new surgical programs at hospitals is a common strategy for business development. Transgender surgical programs include layers of complexity because of the diverse needs of the LGBTQ+ community and the cultural sensitivity it requires. To successfully integrate the surgeon and transgender program into Jefferson Methodist Hospital, leaders quickly engaged key stakeholders across various departments, including billing/registration, perioperative services, inpatient nursing, pharmacy, performance improvement, operations, guest relations, and other support services. Staff completed over 8700 hours of technical and cultural training. Additionally, the team prepared for and completed a comprehensive Department of Health (DOH) site visit to gain approval for the program.

Intervention Detail. Successfully transitioning a new surgical program in 3 months required a transition plan to engage staff. The preplan included 4 main parts: (1) communication; (2) sensitivity training; (3) technical training; and (4) program development.

  1. Communication: Once the decision was made to initiate this program, leaders engaged the surgical practice and key departmental leaders to identify needs. The next step involved engaging and educating all staff about the program and patient population. Bringing together stakeholders as a first step in the process enabled the early escalation of issues. Engaging with frontline staff allowed us to address concerns and provide a burning platform regarding community need and diversity and inclusion.
  2. Sensitivity training: Through research, we identified free online modules developed by the National LGBT Health Education Center. These modules ensured all staff members had a basic understanding of the transgender community and their health care needs. Clinical staff took additional modules related to infectious diseases and more specific medical needs. Through information and practical examples, the modules helped staff feel prepared to interact with patients and their families in a respectful and professional manner.
  3. Technical training: Our surgical fellow provided in-person training to the operating room, post-anesthesia care unit, and inpatient unit staff. Jefferson Methodist Hospital also hired a physician assistant and operating room tech experienced in transgender surgery.
  4. Program development: Initiating a program is complex and requires a wide variety of departments, including supply chain and information technology/electronic health records. An operations manager led an interprofessional work group through weekly project meetings to ensure all deliverables and tasks were completed in advance of the DOH visit.

Outcomes and Impact. As with other services, the transgender surgical program has a robust quality and safety dashboard and financial assessment. It is imperative to build quality into the workflows and ensure training meets the specific needs of a new patient population. Results are reviewed monthly with an interprofessional team to monitor challenges and opportunities. The surgical program successfully completed the DOH survey in early July 2019, and the surgeon began operating on July 9. A huge part of the DOH survey involved ensuring staff received sensitivity training. As described, staff completed over 8700 hours of training. During the first 6 months, the surgeon completed 159 surgeries. Additionally, the latest quality scorecard shows all metrics met the goals determined by the performance improvement department. Selected fiscal 2019 year-to-date metrics include:

  • Readmissions: zero (benchmark: 4.5%)
  • Length of stay: 2.81 (benchmark: 5.18)
  • Mortality: zero (benchmark: zero)
  • Hospital Consumer Assessment of Healthcare Providers and Systems, MD communication: 83.3% (benchmark: 82.0%)
  • Likelihood to recommend care: 91.7% (benchmark 76.9%)

Overall, patients report extremely positive feedback regarding friendliness and attentiveness of staff. Press Ganey comments include: “The nursing staff during my stay was phenomenal! They were very attentive to my needs…I felt like I was in good hands with them keeping everything going, they were personable and always treated me with dignity.” Since the program began, staff members continue to express their satisfaction and interest in providing this service to the LGBTQ+ community. The hospital embraces and demonstrates diversity and inclusion.

1.Advisory Board Research Report. Playbook for Building a Comprehensive Gender Affirmation Health Program. Updated August 29, 2019. Accessed October 2, 2019. https://advisory-prod.azureedge.net/-/media/project/advisoryboard/shared/research/mic/resources/2019/playbook-for-building-a-comprehensive-gender-affirmation-health-program.pdf?rev=e58887a06db4402b865656fe6ae97939&hash=5362872ED724400AD703D0D7009DDC59.

2.Market Insider. Sex Change Surgery Market Will Surge at 25% CAGR to Hit USD 968 Mn by 2024. Published December 18, 2018. Accessed November 5, 2019. https://markets.businessinsider.com/news/stocks/sex-change-surgery-market-will-surge-at-25-cagr-to-hit-usd-968-mn-by-2024-1027819341.

Interprofessional Skin Team Tackles Hospital-Acquired Pressure Injuries

Marty Vander Noot, MD

Amy A. Armstrong, MSN, RN, CWOCN, CNL

UAB Medicine

Background. Hospital-acquired pressure injuries (HAPIs) occur in 2.5 million patients per year and impact 3.5% to 4.5% of all hospitalized patients.1 The annual cost of HAPI care in the United States is $9.1 million to $11.6 billion.2 The National Quality Forum list of Serious Reportable Events includes any stage 3, stage 4, or unstageable HAPI. Decreasing HAPI is important to clinicians because of the effect on patients’ well-being and the financial implications to the health care system. Traditionally seen as a strictly nursing quality indicator, HAPIs in reality require collaborative efforts between multiple disciplines to both prevent and treat—particularly as patient care has become increasingly complex. In 2016, UAB Medicine, a large, urban, academic medical center invested in the expansion of its wound, ostomy, and continence nurse (WOC nurse) team from 4 WOC nurses to 12. A medical director, an advanced practice provider and 2 nonlicensed/support personnel were also added to form a comprehensive wound, ostomy, and continence team. In 2017, with executive leadership support, an interprofessional skin team (IST) was formed. Led by a WOC nurse and the medical director, the IST brought together the wound, ostomy, and continence team, physicians, nutrition, nursing leaders, coding, finance, supply chain, informatics, physical therapy, respiratory therapy, academia, and others to address pressure injuries in a way never done before at the facility. The group meets monthly to discuss trends and opportunities, and then implements improvement solutions on HAPIs.

Intervention Detail. In 2018, a HAPI reporting platform was created to internally track all stages of pressure injuries daily, including a subset of postsurgical patients. Simultaneously, a rounding checklist was built in the electronic medical record to view, in real time, any stage pressure injury documented by the frontline nursing staff. The WOC nurses changed their workflow and began to validate nursing staff documentation of all pressure injuries and provide feedback and education to staff as opportunities were identified. As the IST began to pinpoint needs across the institution, perioperative, data analysis, education, and medical device-related pressure injury (MDRPI) subcommittees emerged. The perioperative group began to perform root cause analysis on any possible perioperative-related pressure injury. The MDRPI group created a tracheostomy-related pressure injury prevention bundle that was implemented by the acute care surgery group. The data subcommittee honed their efforts to provide valid, actionable data to nursing leadership. Information available to nurse managers includes location of pressure injuries, staging of injuries over time, length of stay of patients with pressure injuries, and other reports. Additional reports were created as needs of the subcommittees developed, such as pinpointing all the MDRPIs. The education group has concentrated on increasing the number of teaching modalities to bedside nurses, such as online learning modules and unit-specific in-services. An external consulting firm then evaluated our housewide processes, with both direct and broad advice given.

Outcomes and Impact. Perioperative services has implemented prevention protocols in high-risk groups such as cardiac and vascular surgery patients. The group developed hand-off communication protocols for use as the patient is moved through the perioperative areas. New support surfaces were placed in the post-anesthesia care unit and several operating rooms. Service lines using the tracheostomy-related pressure injury prevention bundle have had only 1 pressure injury related to the tracheostomy faceplate in the 13 months since implementation. Pressure injury prevention is now being taught to perioperative, respiratory therapy, physical therapy, and nutrition staff. Our efforts have led to a 56% reduction in all stages of pressure injury since the internal reporting platform was implemented. Patient Safety Indicator-03 (HAPI stage 3, 4, or unstageable) has decreased by 32% in the first year and is on target to decrease by 50% in year 2. The IST continues to work diligently as our institution strives to reach as close to zero HAPIs as possible.

1. Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc. 2012;60:1603–1608.

2. Berlowitz D, Lukas CV, Parker V, et al. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Agency for Healthcare Research and Quality. Published September 2012. Page updated October 2014. Accessed December 4, 2018. https://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/index.html.

Assess, Don’t Suppress: A Nursing Campaign for Sepsis

Stacy Hevener, RN, MSN, CSSGB, CPHQ, CCRN-k

Leandra S. Neal, MHA

UC Davis Health

Background. Sepsis is a life-threatening response to infection that can lead to tissue damage, organ failure, and death.1 Sepsis is the third-leading cause of death in the United States, and studies estimate up to an 8% increase in mortality rate for every hour sepsis treatment is delayed.2 At UC Davis Health, early identification of sepsis is critically important, as 50% of our inpatient mortalities had a sepsis diagnosis present. To support early identification of sepsis, we use a best practice alert (BPA) within Epic (our electronic medical record), which triggers for adult patients who meet systemic inflammatory response syndrome criteria. In response to this alert, bedside nurses are empowered by a patient care standard to rapidly respond and autonomously obtain a lactic acid for patients triggering a systemic inflammatory response syndrome BPA. Despite these standards and clinical support tools, initial lactic acid compliance was low for inpatient units and little progress had been made with past initiatives. Fueled by past shortcomings, the multidisciplinary team set out with open minds to analyze current state, identify a new process metric, and assess outcomes. Through data analysis and observations, the team identified 2 key findings that set the direction of this initiative. First, it appeared the BPAs were frequently being suppressed by the nursing team(s) without action. Second, it was unclear to nursing as to when or what determined the sepsis start time for the initial lactic acid component of bundle compliance. Led by the vision of improving early identification of sepsis at UC Davis Health, what followed was the creation of the Assess, Don’t Suppress nursing campaign.

Intervention Detail. Overseen by the multidisciplinary Sepsis Improvement Collaborative (SIC), a work group formed to address the key findings previously highlighted. The work group, led by an executive nursing director, was structured to report progress regularly to the SIC. As a start, feedback was obtained from nursing staff indicating the lack of a clear start time. The metric previously used was a submetric of bundle compliance for initial lactic acid within 3 hours of sepsis start time. This start time was defined through retrospective chart review and coding. Recognizing that the metric was retrospective, rather than based on real-time inputs, we developed a proxy metric that used the time of the first inpatient BPA as the start time for obtaining lactic acid within 3 hours. To support our efforts, we incorporated a decentralized education approach utilizing clinical resource nurses, quality and safety nurse champions, nurse managers, and our Center for Simulation and Education Enhancement. This involved presenting at staff meetings, conducting simulation trainings and real-time coaching, and providing individual-level feedback to frontline nurses. The messaging behind the campaign focused on using judgment and a nurse-driven protocol to assess patients for sepsis upon the first inpatient alert, rather than suppressing the alert. To ensure reporting was transparent and actionable, a Tableau dashboard was created and distributed at our morning safety huddle, as well as through a daily email. During the huddle, each unit is visited by a facilitator and time is spent huddling with unit representative(s) around the unit’s visual management board to review recognition, announcements, issues in the last 24 hours/anticipated issues for the day, and nurse-sensitive indicators or outcome metrics. This already-existing management structure provided us with a phenomenal means to quickly disseminate information and review performance for this initiative.

Outcomes and Impact. The SIC was regularly updated on the progress of the initiative, as well as related outcomes data. To measure compliance, we set a goal at 50% of lactic acids drawn within 3 hours from the time of the first inpatient alert. The goal was set at 50% to account for nursing judgment, external factors, and circumstances that do not warrant drawing a lactic acid. At the time of identifying a goal, we identified and tracked our baseline period (May 2018 through April 2019) and began tracking performance at a unit level (June 2019 through November 2019). Over the course of a few weeks beginning in June, we saw compliance with the measure gradually increase from baseline performance of 15% to 53%. In the 6-month performance period, the nursing units collectively met and maintained performance above the goal of 50%. In addition to the compliance goal, we monitored the percent of lactic acids drawn that resulted above 2, which is an indicator for sepsis, and observed 30% of draws meeting this threshold. Even though we had done an analysis showing that this initiative could indeed result in improved bundle compliance for initial lactic acid, there was a possibility that our efforts had been for nil. To reaffirm our efforts, we monitored sepsis bundle compliance for initial lactic acid within 3 hours and observed an increase from 66.42% to 85.14% for the pre- and post-period, respectively. In conclusion, we created a robust sepsis initiative to monitor compliance of this proxy metric, reviewed the counter measure of lactic acids that resulted above 2, and sought to ultimately improve mortality through bundle compliance. Although this initiative has already seen great success, there is still much more on the horizon.

1. Sepsis Alliance. What Is Sepsis? 2020. Accessed February 20, 2020. https://www.sepsis.org/sepsis-basics/what-is-sepsis.

2. Radius Global Market Research. Sepsis Awareness Study. Sepsis Alliance. 2019. Accessed February 20, 2020. https://www.sepsis.org/wp-content/uploads/2019/08/SepsisAwareness_Summary_2019_FINAL-8-30-19.pdf.

Optimizing Neurology Inpatient Documentation by Targeting Vizient Risk Models

Melissa Reider-Demer, DNP, MN, CNP

Katherine A. Fu, MD

Cecilia Borja, Principal

Russell Kerbel, MD, MBA

UCLA Health

Background. Robust clinical documentation is important to reflect accurate hospital performance regarding downstream effects on mortality indices, length of stay (LOS), and payer reimbursement. However, the challenge remains to create and implement effective documentation tools that optimize these variables, while also minimizing documentation burden with improved efficiency. University of California, Los Angeles (UCLA) Health historically underperforms within the efficiency domain of the Vizient Comprehensive Academic Medical Center cohort of the Quality & Accountability Performance Scorecard. Despite having a systemwide clinical documentation integrity (CDI) infrastructure focused on capturing principle diagnoses and present-on-admission conditions, subspecialty observed-to-expected ratios remain suboptimal. As a strategy to optimize the observed-to-expected ratios, the UCLA neurology department sought to develop and implement a service line-specific electronic health record (EHR) countermeasure. Building on prior Vizient presentations by Duke University and Memorial Herman Health systems, UCLA neurology quality improvement leadership targeted 10 common neurology-associated diagnosis-related group (DRG) triplets and utilized the corresponding Vizient mortality, LOS, and direct cost risk-adjustment models to determine the most common and highest-weighted variables across the 3 models. The goal was to then use these variables to implement an EHR tool that would improve documentation of discharge diagnoses to be used in the documentation of the inpatient general neurology service at UCLA. The creation of this tool would thereby facilitate improved documentation of the appropriate DRG of each patient’s case, more accurately reflecting complexity or severity of illness while also improving ease of clinician documentation. The hypothesis was that we could, by more robust documentation, better capture the complexity and associated comorbidities of our patients and improve the Vizient risk-adjusted indices of cost, LOS, and mortality—thereby improving hospital rankings.

Intervention Detail. We utilized the 2017 academic medical center hospital risk model summary from the Vizient Clinical Data Base to identify the top 10 neurology DRG triplets for the general neurology department. We reviewed the Medicare severity-DRG major complication or comorbidity and complication or comorbidity list for each of these 10 conditions. We also reviewed the corresponding Vizient model variables across the mortality, LOS, and direct cost models. This information was used to create a general neurology discharge documentation tool, which was a “SmartList” for discharge diagnoses in the Epic CareConnect EHR. When a health care provider selected a relevant diagnosis from the DRG SmartList, each of the 10 diagnoses then listed a subsequent drop-down menu prompting the provider to click on the relevant explanatory variables, or associated clinical diagnoses, for a patient. Our team was comprised of multiple neurology clinicians, medical informaticists, and the CDI team. The clinicians recommended revisions that would enhance usability and adoption by fellow clinicians, while the CDI team offered changes that would reduce hospital queries. Our medical informaticists applied these revisions to the subsequent iteration of the documentation tool. Multiple resident physicians on the inpatient general neurology service piloted this tool for an initial 3-month period and provided additional feedback regarding its use. Examples of revisions included changes in wording that would be more useful for clinicians, such as replacing “brain disorder” with “structural brain damage.” We implemented these revisions and the tool was piloted for another 3 months. Upon conclusion of the pilot, the team of neurology clinicians collaborated with the neurology chief residents to incorporate the tool into a standardized discharge note template for use among all neurology residents during the 2019–2020 academic year. We then analyzed data from Vizient service lines regarding mortality indices and LOS and compared the data from the years before and after the tool was formally implemented.

Outcomes and Impact. We analyzed Vizient data regarding expected mortality, LOS, and direct cost to determine the effect of our intervention. The documentation tool was formally introduced to a cohort of 27 residents in July 2019. We compared neurology service line data for expected LOS during the years before (2018) and after (2019) implementation of this tool. Between 2018 and 2019, the expected LOS increased by 0.1 days per case. In addition, the expected LOS for 2018 was 4.16 days per case averaged over the year, compared with 4.26 for 2019, representing a 2.17% increase. There was also improvement seen when we created trend lines for expected LOS in 2018 and 2019 (R2 for 2018 = 0.1035, R2 for 2019 = 0.2274). There was no additional change in mortality, which was not surprising since mortality of the neurology service at baseline was already less than 0.5% annually, and further decrease would not be measurable. Analyses comparing direct cost between 2018 and 2019 demonstrated slight improvement. These preliminary results demonstrate the potential of this innovative documentation tool, despite the limitations of partial adoption by the resident physicians on service due to the use of previously existing templates and a limited amount of data since its formal implementation in July 2019. Using Vizient risk-adjustment models as part of both the creation of the tool and data analyses, this tool demonstrates promise in improving hospital outcomes and efficiency of documentation. Future directions involve analyzing data across longer time periods and determining if other measures such as direct cost will improve. The eventual goal is for this tool to serve as a model for other service lines to adopt.

Moving the Mountain Behind Readmission Reduction

Kelly Gray-Eurom, MD, MMM, FACEP

Allison Martin, LCSW, ACM

UF Health Jacksonville

Background. UF Health Jacksonville had a readmissions problem. Most service lines were in the bottom quartiles. No one was sure what needed to be done to fix the readmission problem for the patient population at our safety net, urban facility. Margins are usually tight at safety net programs, and UF Health Jacksonville was no exception. Purchasing the services of a third-party vendor to provide data with potential action items was not an option from a budgetary standpoint. Our solutions needed to be developed internally using known best practice ideas. Because we are an academic institution, Vizient service line data was not extremely helpful to engage physician partners. Our data analyst engineer customized the service line data into departmental-specific reports. The data in the reports belonged to the department that provided the patient care. Our engineer also customized data based on disease-specific patient conditions to focus work projects where they would have the greatest return on investment from a patient perspective. We knew that care coordination in our patient population would be difficult, but we also knew it would be the cornerstone to success. Case management (CM) and complex case management (CCM) partnered with the quality division, ambulatory clinics, inpatient physicians, respiratory therapy (RT) department, and information technology services to create specific performance improvement projects around discharge appointments and chronic obstructive pulmonary disease (COPD) care, as well as to delineate the specific readmission vectors that impacted each patient by leveraging a predictive analytics tool available in the electronic medical record (EHR).

Intervention Detail. The first interventions were designed to help the patient help us reduce readmissions. Prior to this work, most patients were given instructions to call for follow-up. A discharge appointment project was initiated by CM. The initial pilot consisted of 1.5 full-time equivalent care coordinators who worked with the patient, family, and UF primary care clinics to secure 1- to 2-week follow-up appointments. After running the pilot for 3 months, it was so successful that the program was expanded (over time) to 5 days a week with 7 full-time coordinators who work with all adult medical and surgical patients. Our COPD patient population had an extremely high readmission rate. Identifying these patients in real time was challenging. Patient problem lists were coded after the encounter. The team used the nursing assessment of home breathing treatments to identify COPD patients and create a real-time electronic work queue for CM, CCM, and RT. The RTs developed patient education scripts during medication treatment. CM and CCM initiated COPD discharge planning from hospital day 1. Home medication treatments and home health care were in place prior to discharge. These patients were also enrolled in a COPD-specific discharge call-back program. The EHR contained a readmissions predictive analytics tool based on licensing, accreditation, certification, and education criteria. It was a validated tool, but it provided a patient list that was too large to work. Using Vizient data and known trends, this patient list was further risk stratified by adding high-risk conditions known to be factors in our specific patient population. The ambulatory clinics documented social determinants of health (SDOH) in the EHR. The SDOH were utilized to further risk stratify the list. CCM completed any missing information. The result was a user-friendly, high-yield screen in the EHR for CM and CCM interventions.

Outcomes and Impact. Each intervention reduced readmissions in the target population and progressively decreased the readmission rate for the facility. Follow-up appointment scheduling started as a pilot with 1.5 full-time equivalent care coordinators. The primary care physician visit show rate in the pilot group was over 70% and readmissions dropped by 19% for the pilot patients. The pilot has now grown to 7 care coordinators with full scheduling capabilities. These care coordinators impact nearly 80% of the adult discharged population. Patients complete 60% to 70% of scheduled primary care physician visits. The COPD readmission rate in the pilot declined by 69% with the COPD education, home care initiatives, and scheduled appointments. The feedback from RT, CM, and patients was extremely positive. Anecdotally, the number of COPD patients returning to the emergency department for gaps in home care decreased. The largest overall reduction in readmissions occurred with the incorporation of the EHR predictive analytics tool. Unmodified, the tool gave an unwieldly list that did not provide significant value. Incorporating risk factors specific to our patient population and including the SDOH created a valuable tool for workflow and impact prioritization. There was a learning curve with the predictive analytics tool. Initially, the highest-risk population received the highest priority. Unfortunately, very few things within our control impacted that population. The decision was made to focus work on the second-highest risk population. In our facility that selection still represented a very high-risk group. Through CM and CCM interventions, the readmission rate in this population decreased from 48% to 35%. The SDOH in the predictive analytics tool were built with bidirectional communication so the SDOH information from CCM was shared across the campus. These combined projects have decreased the readmission rate from 15.8% to 9.89% at UF Health Jacksonville.

Optimizing Care Delivery by Creating a Nurse Call Center

Karen Donato, BSN, RN, OCN

University Hospitals Cleveland Medical Center

Background. Telephone communication is a primary means by which ambulatory oncology nurses provide care to patients. Challenges at this large cancer center included numerous providers, multiple locations, varying workflows, and all nurses providing clear and consistent messaging based on the most recent evidence. Prior to the nurse call center, nurse partners received multiple and varying numbers of phone calls from patients and families with medical concerns or questions. This prevented the nurse partners from interacting with patients at the clinic and providing valuable nursing assessment, interventions, and education. It also created overtime, as less-urgent calls were often answered once clinic was over. Patients were not satisfied because calls were perceived as not being returned in a timely manner. Depending on the experience of the nurse partners, information provided to patients and families varied, as did documentation of the call and patient response. The primary resource for telephone triage was Telephone Triage for Oncology Nurses (second edition), from the Oncology Nursing Society. Nurses did not have ample time to read through all of the protocols while on the phone advising patients. Finally, health literacy was not taken into consideration. This presentation is important because it demonstrates how 1 solution solved multiple challenges and can be adapted at other institutions.

Intervention Detail. The volume of patient phone calls was analyzed to determine the number of nurses required to staff the call center. This information was obtained through the book Telephone Triage Protocols for Nurses, by Julie K. Briggs. The oncology telephone triage protocols, with permission from the Oncology Nursing Society, were translated into algorithms that were built directly into the electronic medical record. The algorithms were based on patient symptoms, prompting nurses on the necessary questions to ask and the appropriate advice to give, pending the answers. This was uniquely innovative. Further groundbreaking steps were taken to apply plain language and health literacy directly into the protocols. The center’s automated phone tree was redesigned. Staff education on the reorganization of interprofessional communication was completed.

Outcomes and Impact. Creation of the nurse call center freed up the nurse partners to care for those patients present in-clinic as the call center nurses fielded phone calls. Although there was initial pushback from the nurse partners that others were triaging the calls that would normally come to them, they soon realized the benefits and appreciated the additional support. Overtime was decreased by 60%. Success of this project was also measured by improvements in patient satisfaction scores regarding timeliness in response to calls, which increased from 64.1% to 74.9% in 1 year. The median time between initial patient contact and nurse response improved dramatically, as calls were completed within an average of 45 minutes versus, at times, by end of day. Patient care and documentation was streamlined as the algorithms assured that advice was based on the most recent evidence. The integration of plain language into the protocols was a novel approach to help provide clear, consistent, and efficient communication. The work and lessons learned from this project may be useful to other cancer centers seeking to improve existing practices or institute nurse call centers and/or telephone triage protocols, while also promoting health literacy.

Closing the Gap: Unleashing Assistive Potential by Reimagining Education

Laura F. Startsman, MSN, RN, CNL

Rebecca Weisner, MSN, RN

Gina P. June, MSN, RN, NPD-BC

Lori Rawlings, MSN, RN, NPD-BC

University of Cincinnati Medical Center

Background. In July 2019, our organization had a vacancy rate above 50% for unlicensed assistive personnel (UAPs). Over 6 months, the shortage led to 14 450 overtime hours. The deficit was projected to intensify over the summer as nursing students graduated and promoted out of the UAP role. As the region’s only urban academic medical center in a competitive hiring market, we needed to evaluate our recruitment strategies. Candidates applying for UAP positions did not meet existing criteria, which included nursing student with a completed medical-surgical clinical or nursing assistant credential. However, applicants demonstrated organizational core values, personal executive skills, or other health care experience, such as home health or long-term care. In an effort to meet the needs of our acute care units, our team designed an innovative, on-site training program to capitalize on this population, educating those unfamiliar with health care. This multidisciplinary service line development effectively removed various hiring obstacles by implementing a curriculum tailored to our organization. Other health care organizations can learn how to execute a successful, entry-level UAP program to develop clinical skills for an acute care setting. We share how we removed the barriers we faced in hiring UAPs and how we educated and prepared these employees to provide excellent patient care.

Intervention Detail. We first explored whether we could solve the UAP shortage through conventional means. Our team investigated existing UAP training programs in our community and concluded that these programs were neither cost-effective nor intended for acute care. We then regrouped with our stakeholders and formed an advisory board composed of human resources, nursing leadership, clinical units, and staff development to identify our vision and determine desired outcomes. A review of the literature was a key driver in curriculum development. We used current UAP educational standards and teaching materials, reviewed available skills proficiencies for applicability and standardization across service lines, and cross-referenced our own competencies and unit orientation. We hired a full-time coordinator to take the lead in designing and developing the program. We then designated a simulation space for UAP training. Operationalizing the program included generating schedules and holding in-person meetings with unit leaders to communicate goals and requirements. Since our benchmarks were defined as the skills of our current UAPs, we created check-off documents based on those proficiencies, each with observable, step-by-step criteria. Our curriculum is designed with 24 hours of didactic content and 16 hours of precepted clinical immersion. We created lists of skills that had been reviewed in a classroom setting and sent them to unit UAP preceptors for practice on proficiency goals. Throughout the process, we collected feedback from our advisory board and the UAP novices themselves to optimize outcomes. For instance, we administer a quantitative pre-assessment to all novices at the start of the program and are then able to adapt instruction to meet any perceived deficiencies.

Outcomes and Impact. The organization hired 48 employees into our first 7 UAP novice cohorts. This program provided entry-level opportunities to a new demographic of candidates, supporting economic growth in our community. Clinical managers are now able to hire people who have not had the opportunity to complete their nursing assistant credential or student clinical; there is less impetus to hire individuals with a state-issued certification as their most distinctive characteristic. The retention of these employees is 83%, which has impacted both the vacancy rate and overtime hours for the role. Senior leadership reported high levels of satisfaction with the UAP novices and the program. Pre- and post- assessment results gathered from the cohorts revealed both their knowledge gained and their understanding of safe patient practices such as fall precautions, ambulation techniques, and communication protocols. These results afforded real-time feedback to the novice group and assisted with their role confidence; all 14 novices educated in November 2019 stated that they were “very confident” in their role after attending, with one commenting, “I was clueless before I started this program.” Clinical managers also reported positive relationships among the nursing staff and the UAP novices on their units. For example, a clinical manager describes one of her UAPs (a former bank teller) as a “rock star” team player. Nursing staff appreciated the development of on-site training tailored specifically to the needs of the acute care patient. The current program coordinators intend to expand education to professional development of the existing UAP workforce, dedicating those efforts to Mieshia Wyatt, MSN, RN, our foundational program coordinator. We anticipate new opportunities for professional growth, a formalized preceptor program, recognition programs, and continuing education to build employee engagement and increase retention.

How Do You Heal a Broken Heart? Behavioral Health Integration

Laura Peters, DNP, FNP

University of Colorado

Background. Identifying and responding to mental health concerns is important in the care of patients with chronic disease states, given the increased rates of concomitant mental health disorders. However, implementation of mental health screenings has the potential to significantly increase the clinical care burden, as well as resource utilization due to behavioral health interventions. Yet patients who have adequate mental health care report similar outcomes to patients who have no mental health concerns, as well as an increase in quality of life. Finding creative ways to implement mental health screenings while minimizing the added clinical burden improves the care provided to patients, increasing both patient and provider satisfaction. In our clinical example, we look at patients with heart transplant and depression. It is established that patients with a heart transplant who have depression have higher rates of graft failure and noncompliance; however, patients identified and treated early have outcomes similar to those without depression. The aim of this quality improvement project was to assess feasibility of implementing a universal depression screen—via the Patient Health Questionnaire (PHQ)—in a busy ambulatory heart transplant clinic. We highlight an innovative approach to depression screening that resulted in successfully embedding a routine depression screen in a heart transplant clinic with follow-up while minimizing increased provider burden. Due to the increasing mental health burden, we are seeing in our society, it is vital to understand ways to identify and treat mental health disorders in clinics that patients frequent while working to minimize additional provider responsibility.

Intervention Detail. The 2010 International Society for Heart and Lung Transplantation Guidelines recommend routine assessment of depressive symptoms in the care of patients with heart transplant via a user-friendly, validated screening tool. Patients with elevated scores should be referred for specialized treatment. The University of Colorado heart transplant program developed a universal depression screening process using the PHQ—a user-friendly, validated depression screening tool developed by Drs. Robert Spitzer, Janet B. W. Williams, Kurt Kroenke, and colleagues. The PHQ-2 is a 2-question screening instrument; a score ≥3 requires further assessment using the PHQ-9. The PHQ-9 is a 9-question instrument administered to patients to screen for the presence and severity of depression. The PHQ-9 has a sensitivity of 86% and a specificity of 93% in heart transplant recipients. Online education regarding the PHQ-9 tool and its utility in depression screening was completed by all transplant clinicians (n = 21), and the tool was embedded into the electronic health record. A 1-page mental health resource guide was developed that included online resources, counseling options, local mental health agencies, and crisis numbers. Positive PHQ-9 scores (= 10) were given to providers prior to the patient visit, allowing them to consider a mental health intervention and whether or not to provide a copy of the mental health resource guide. Patients who had a PHQ-9 = 10 received a follow-up phone call from a provider at 1 week, 1 month, and 3 months. Patients were evaluated for engagement in mental health care—defined as a visit with a primary care physician to discuss depression, a visit with a mental health provider, or medication initiation/titration for depression—at 3 months post-PHQ-9 assessment through follow-up phone calls. Measures of feasibility, acceptability, and clinic burden were assessed. A survey was provided pre- and post-implementation to transplant clinicians (MD = 7; registered nurse = 5). The burden of incorporating the PHQ assessment—PHQ-2 screen + the PHQ-9 when applicable—into the heart transplant clinic visit was assessed on a 5-point Likert scale (1 = no burden, 5 = significant burden). Time to complete the PHQ-2 and PHQ-9 was assessed via transplant coordinator documented completion time. The perceived benefit of implementing a routine depression screen, as enhancing the care provided to patients with a heart transplant, was assessed on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree).

Outcomes and Impact. During the 6-month implementation phase, there were 834 outpatient heart transplant clinic visits. Participants included all patients completing a heart transplant clinic visit. PHQ-2 screens were completed during 779 of those visits (93%). Initial PHQ-2 screening identified 40 patients (6%) who screened positive for depression, of which all 40 (100%) had a PHQ-9 assessment. The PHQ-9 identified 33 patients (4%) as having moderate or severe depression (defined as a PHQ-9 score = 10). At 3-month follow up, 30 of 31 patients (97%) were engaged in mental health care. The patient who was not reported as engaged in mental health care was referred to palliative care and did not return any attempts at contact. Two patients reported they were no longer having symptoms of depression and their subsequent PHQ-2 screenings were negative (<3). Therefore, they were not included in the mental health engagement assessment. The median assessment of burden was reported as 2 (slight burden) by 100% of clinicians. The mean time to complete the PHQ-2 was 2 minutes, while the mean time to complete the PHQ-9 was 6 minutes. Prior to implementation of this initiative, 94% of clinicians agreed or strongly agreed that screening enhances care provided to patients with a heart transplant. Post-implementation, 100% of clinicians agreed or strongly agreed that screening enhances this care. Incorporating universal depression screening and early mental health referral for heart transplant patients was found to be feasible and identified a subset of patients that might benefit from a mental health intervention. This study adds valuable evidence that depression screening is possible with a validated measure. Additionally, team members reported only a slight burden to clinical workload with the implementation of a universal depression screen. The clinicians also noted that early identification and treatment for depression enhanced care provided to patients with a heart transplant.

Unfreezing Case Reviews: Do You Wanna Build a Process?

Aurora Davis, MSN, RN, OCN

UCHealth University of Colorado Hospital

Background. Case reviews are a frequently leveraged health care improvement tool to capture adverse events and propose solutions. Oftentimes, however, cases are only referred by word of mouth, emotional reporting, or to fill the allotted time. There is great potential to miss true opportunities for system learning by relying on such informal feeders. A systematic referral and review process not only provides a method for ensuring that no serious adverse event or systems issues are overlooked, but it also increases the value of case reviews; provides insight into the need for higher-level reviews (such as the National Patient Safety Foundation’s Root Cause Analyses and Actions); and ensures that regulatory requirements are met for reviews that are truly thorough, credible, and timely.

Intervention Detail. A multidisciplinary team of providers, leaders, and clinical quality members worked to develop a service line-specific trigger list to provide clear criteria for review. An apparent cause analysis (ACA) tool was designed to guide reviewers through a series of questions pertaining to system elements—such as environmental and equipment factors, organizational goals, professional performance, and standards—as well as human factors. Subsequently, a multistep review process was created to provide overall guidance for reviewers on how cases would be identified, who had a role in reviewing, and potential outcomes of an ACA review. Finally, the case review process was streamlined by leveraging Root Cause Analyses and Actions best practices, including flow diagramming and timelines, causal statements, identification of solutions, strong action planning and auditing, and support from a dedicated and trained patient safety specialist.

Outcomes and Impact. Implementation of the systematic trigger list dramatically increased the total number of cases targeted for review by this service line. However, use of the ACA tool allowed us to winnow these cases to only those that represent the largest gaps in care and thus the largest opportunity for improvement. As a result, the net effort to perform formal case reviews stayed the same, while the quality of each formal review was substantially improved.

Utilization of Interprofessional Practice to Optimize Patient Care Delivery

Kiran Lukose, MD

University of Florida

Joy Wright, BScPhm, PharmD, CPh, BCPS, TTS

UF Shands Hospital

Tiffany Phillips, MSW

University of Florida

University of Florida

Background. Each year, approximately 65 000 patients are seen at the UF Health Shands Emergency Room/Trauma Center. Additionally, roughly 62% of all UF Health emergency department (ED) visits between 2009 and 2019 were rated as low acuity (Emergency Severity Index [ESI] = 3 to 5) on the ESI. Visits that were rated least severe (ESI = 5) comprised approximately 3% of all ED visits and may have been due to conditions that could have been addressed by a primary care physician. Overutilization of the ED poses many consequences to the health of individuals and the health care system. Specifically, overutilization of the ED can cause system stress, gaps in patient care coordination, inadequate delivery of preventive care, and unnecessarily high health care costs for patients and hospitals alike.1 The Care One Clinic (COC) at UF Health was established by the division of hospitalist medicine in 2012 to meet the needs of clinically and socially complex patients in Alachua and surrounding counties. One of the main goals of the COC is to reduce frequent utilization of the ED by connecting superutilizers to primary care and other health resources. Other goals of the clinic include reducing the readmission rate and average length of stay (LOS) of COC-enrolled patients, providing adequate follow-up to uninsured/underinsured patients, and connecting patients to affordable medications. The COC consists of an integrative team of professionals devoted to the care of complex patients. This unique clinic utilizes an interprofessional practice and education (IPE) approach to optimize the delivery of patient care. In this approach, professionals from medicine, pharmacy, dentistry, and social work learn with and from each other how to enable effective collaboration and improve the health outcomes of their patients. As patient conditions and care plans become increasingly complex, the use of an IPE model will be necessary for the efficient and effective delivery of comprehensive and quality health care.

Intervention Detail. The COC has integrated numerous innovations and modifications since 2012. Many advancements in the clinic’s operations have increased the ability to provide personalized and complete care to patients. These innovations include the addition of pharmacy services in 2013 and dental services in 2019. Pharmacy services were included in 2013 in response to a hindering disconnect between the COC and hospital pharmacists that suggested on-site pharmacy services were necessary to optimize care delivery. Our pharmacist and pharmacy students provide basic medication reconciliation and counseling and assist in obtaining prescriptions for uninsured/underinsured patients and/or patients who cannot afford the cost of their medication(s). They work in partnership with physicians and social workers to help patients obtain their medications at a low cost and increase their medication compliance. Every day in our main adult ED, an average of 12 people seek relief from dental pain and infection. Dental services were incorporated into the COC in September 2019 to address this time and resource drain on our ED. A dentist and dental students provide basic dental assessments and education, as well as referrals to specialty care for patients in need. For many of our patients, improving their oral health has led to better management of their chronic medical conditions, resulting in an enhanced quality of life. Quantitative measures used to assess the COC’s efficacy in optimizing the care of enrolled patients include the difference in ED visits, emergency treat and release visits, inpatient and observation visits, and average LOS (inpatient/ observational) post-graduation from the COC compared with pre-graduation. This data was obtained from the COC’s scorecard, which provides these parameters broken down by month and year since November 2012. The COC scorecard data is complete through June 2019. Qualitative measures assessed include patient responses to phone-administered surveys.

Outcomes and Impact. From November 2012 to June 2019, the COC has seen 2576 patients and conducted 9408 visits. Data from the COC scorecard shows that enrollment in the COC program has prevented 2355 hospital visits, 918 inpatient visits, 238 observation visits, 1199 emergency treat and release visits, and 2392 ED visits to date. Additionally, the average LOS (inpatient/observational) for enrolled patients has decreased by 0.77 days, amounting to a 13.76% decrease in inpatient/ observational LOS. This data suggests that participation in the COC program is associated with reduced ED utilization, emergency treat and release visits, and inpatient/observational LOS in enrolled patients. Additionally, this data indicates that the IPE approach utilized by the COC team is efficient in delivering holistic care to clinically and socially complex patients. Patient testimonials were obtained during 4-week, post-graduation follow-up calls. During the follow-up call, a survey was administered to gauge patients’ ability to initiate primary care and their satisfaction with the care provided at the COC. In response to the question, “Do you agree or disagree with the following statement? The care you received at the Care One Clinic is essential in teaching you healthy habits,” 7/8 of the respondents stated that they somewhat, mostly, or completely agreed. Currently, our survey response rate is small, a limitation of working with this particular population. We hope to continue this 4-week, post-graduation follow-up survey to obtain more complete patient satisfaction data. Future efforts will be focused on obtaining information regarding how many patients initiate and maintain contact with a primary care physician. We are also interested in determining how effective our approach is in helping patients meet their personal health goals while enrolled in the COC program. We hope that this information will guide us as we continue to improve our patient care techniques.

1. Nester J. The importance of interprofessional practice and education in the era of accountable care. N C Med J. 2016;77:128–132.

Stopping Wasteful Admissions and Readmissions Mechanism: A Quality Improvement Initiative

Rachel A. Locke, BS

Michele N. Lossius, MD, FAAP

Nila Radhakrishnan, MD

Brandon Allen, MD, FACEP

Carolyn Holland, MD, MEd, FACEP

Tom Johns, PharmD, BCPS

Julie Richter, MBA

University of Florida

Background. Stopping Wasteful Admissions or Readmissions Mechanism (SWARM) is a multidisciplinary team and protocol created as a University of Florida quality initiative. At our institution, we noticed that patients were being admitted from the emergency department (ED) for reasons other than medical necessity. There are many reasons as to why patients might be admitted to the hospital instead of being discharged, including difficulty in placement, lack of follow-up, inability to access medications, or the need for durable medical equipment. These admissions or readmissions are considered avoidable if the patient does not meet clinical criteria for admission. Therefore, the goal of SWARM is to decrease avoidable hospital admissions and readmissions by 4 per day within a year by providing community and institutional resources to patients in the ED.

Intervention Detail. We envisioned a method to SWARM a patient to prevent an avoidable admission. A multidisciplinary team consisting of physicians, social workers/case managers, pharmacists, and nurses was created. In the initial phases of SWARM, we sought to first identify common barriers to discharge. Identified barriers included the need for durable medical equipment and lack of follow-up due to not having an established primary care physician or insurance coverage. After multidisciplinary discussion, we postulated that social work/case management (SW/CM) services were underutilized in the ED. An Epic query of current ED SW/CM consults was conducted. In a 2-month period, SW/CM was consulted in the ED 151 times. Fourteen percent of patients seen by SW/CM were treated and released, while 86% were admitted. Next, the SWARM protocol was created, which required an SW/CM consult by the ED provider upon activation of SWARM. A conversation between the admitting hospitalist and ED physician was then required before admission. Providers were educated regarding the project and protocol, and a SWARM radio button was created in the Epic SW consult order to facilitate SWARM activation.

Outcomes and Impact. After SWARM, there were 271 SW/CM consults by the ED within a 2-month period. Forty-five percent of these patients were treated and released, while 55% were admitted. The number of SW/CM consults to the ED increased by 79%, highlighting that many of our patients have social determinants of health or other factors that significantly impact potential discharge. Most notably, the SWARM protocol generated collaboration and communication between the hospitalist and the ED physician to focus on alternatives to admission where possible. Our current Plan-Do-Study-Act cycle is to increase SWARM utilization and documentation while assessing potential barriers to activation. In addition, we are measuring how many activations are resulting in saved admissions, with a balancing measure of readmission within 30 days. In our future Plan-Do-Study-Act cycles, we plan to continue multidisciplinary engagement to troubleshoot and support staff in SWARM activation. We are also integrating collaboration with pharmacy and physical therapy to see what services can be provided in the ED and we plan to utilize alternative modalities to admission, such as home health.

2020 Nursing Vision: Pursuing Excellence Innovators

Anna Lambert, RN, MS, CCRN-K

University of Rochester Medical Center Strong Memorial Hospital

Nicole Telhiard, DNP, CPN, NE-BC

Our Lady of the Lake Hospital

University of Rochester Medical Center Strong Memorial Hospital

Background. The Accreditation Council for Graduate Medical Education’s Clinical Learning Environment Review reports in 2016 and 2018 identified key findings impacting the delivery of health care and graduate medical education. The 6 focus areas included: patient safety, health care quality (including health care disparities), supervision, care transitions, fatigue management, and professionalism. Additionally, the 8 academic medical centers selected for the Pursuing Excellence Innovator (PEI) project identified many challenges in today’s health care settings. These challenges included increasing complexity of care, changing financial models, siloes in learning, variability in faculty engagement, lack of a responsive learning environment, and general disparities between interdisciplinary groups. The PEI organizations were charged with innovating change in the clinical learning environment while aligning with key primary drivers of the initiative. The primary drivers were developed collaboratively between the 8 organizations at multiple learning session meetings. The voice of nursing leadership was included and integral in all aspects of the initiative. The innovative projects of the 8 centers can be spread to the 800 ACGME accredited sponsoring institutions in the United States to address the findings of the Clinical Learning Environment Review reports for overall health care improvement.

Intervention Detail. This presentation includes a nursing panel discussion of the projects from 3 of the organizations participating in the initiative. The following is a description of the 3 organizations’ projects:

  • University of Rochester Medical Center, Rochester, New York: The University of Rochester Medical Center PEI project is based on dyad leadership of the nurse manager and medical directors of a unit or service. The dyad is immersed in training and education of topics, including a patient safety curriculum, promoting teaming, Lean principles, and rapid cycle improvement. A unit- or service-based performance program is also supported by a coach. Cohorts of 15 teams are additionally supported by quarterly educational meetings and an annual symposium to celebrate their successes.
  • University of Chicago Medicine, Chicago, Illinois: The University of Chicago began a program called Improving Graduate Medical Education and Nursing Interprofessional Team Experiences (IGNITE) aimed at engaging residents and nurses together in performance improvement projects and institutionally sponsored performance improvement events, with the ultimate goal of improving health care delivery for patients. Interestingly, all dyad cohorts launched to date have chosen projects to improve nurse/physician communication and collaboration.
  • Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana: The Our Lady of the Lake PEI project is based on coordinating care among a complex patient population with increased social determinants of health. The daily interdisciplinary team huddles, known as tiger rounds, are led by nurses and designed to coordinate patient care with attendings, residents, and other interprofessional team members. The interdisciplinary team huddles were designed to improve communication among team members, identify quality improvement opportunities, facilitate conversation between nurses and medical staff on quality topics, and enhance patient and team member engagement.

Outcomes and Impact.

University of Rochester Medical Center: Teams from our first PEI cohort decreased average length of stay by 3.8 hours on their units and achieved an absolute reduction in readmissions of 1.3%. This translated to 1 in 6 patients going home a day early, 2.5 more beds being available daily, 187 more patients who can be accepted for transfer, and a significant revenue increase.

University of Chicago Medicine: Units in which IGNITE was implemented have shown a decrease in length of stay ranging from 1.16 days to 0.15. This reduction leads to an aggregated quarterly cost reduction of $2.9 million. Further, units that participate in IGNITE have seen a year-over-year positive improvement in clinician engagement in the domains of teamwork and collaboration, as measured by the organization’s annual employee engagement survey.

Our Lady of the Lake Regional Medical Center: Our Lady of the Lake has seen several significant improvements on its Med 5 unit, including a reduction in length of stay from 4.0 in fiscal year (FY) 2018 to 3.6 in FY 2019 and an increase in the Press Ganey nurse engagement interprofessional relationships domain from 4.02 to 4.25, with the greatest question improvement related to communication between physicians, nurses, and other medical personnel increasing from 4.00 to 4.36. The unit has had zero central line-associated bloodstream infections or catheter-associated urinary tract infections for FY 2019. Patient experience scores using Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems domains have increased from zero domains above the 75th percentile to 6 domains above the 75th percentile in FY 2020.

Improved Sickle Cell Pain Management Reduces Length of Stay

Christopher T. Zemaitis, PharmD, BCPS, Yale New Haven Hospital

Stefanie Zassman, PharmD, BCPS, Yale New Haven Hospital

John Roberts, MD, Yale School of Medicine

Yale New Haven Hospital

Background. Sickle cell disease is an inherited blood disorder characterized by acute pain episodes known as vaso-occlusive crisis (VOC). VOC is the most common reason for emergency department (ED) visits and hospital admissions. In response to high utilization of acute care services and widespread patient and health care personnel dissatisfaction, our institution set out to improve care of adults living with sickle cell disease. This effort included recruitment of additional full-time personnel, relocating inpatients to a single nursing unit, reducing the number of involved or consulting providers, creating personalized care plans for pain management, and emphasizing clinic visits that are focused on pain management at home. Our current discussion focuses on inpatient management. Sickle cell patients are often treated with parenteral opioids upon admission for VOC and then transitioned to oral opioids prior to discharge. Prior to the localization of sickle cell patients to a dedicated unit with trained personnel, the patients were admitted to any general medicine unit covered by both hospitalists and academic medical teams. The teams often did not know the patients’ medical or personal backgrounds and were often concerned with the amount of opioids patients were receiving. The patients were often reluctant to ask for more pain medication to treat their sickle cell pain crisis for fear of being labeled as drug seeking by the care team. Additionally, many of the preexisting patient-controlled analgesia (PCA) order sets were intended for postsurgical and opioid naive patients. These factors contributed to suboptimal treatment of the patient’s pain crisis, a delay in getting the pain crisis under control, and ultimately, longer inpatient stays.

Intervention Detail. When admitted to our institution, patients are switched from intermittent intravenous opioids to a PCA. Our sickle cell-specific admission order sets now incorporate PCA orders of morphine and hydromorphone, along with other typical medications for the management of sickle cell patients. Other major components of our computerized physician order entry (CPOE) optimization for the new sickle cell unit were the implementation of subcutaneous PCA dosing and ED PCA order sets. The subcutaneous PCA is important for patients without intravenous access and were designed specifically for safe and effective subcutaneous delivery of PCA doses. The sickle cell-specific ED PCA orders are optimized to allow simplified starting of PCA dosing in the ED prior to transfer to the sickle cell unit. The ED PCA order set was optimized to reduce the decision points to 2, compared with our typical PCA orders with 6 decision points. When pain has been adequately controlled with PCA, we add an oral tier. We created the oral tier order set to function similar to a PCA. The first order in the oral tier specifies an amount of an opioid to be administered on a scheduled basis every 3 hours, although the patient may refuse. This order assures that the nurse will be at the bedside every 3 hours, during which the patient is assessed for pain and participates in the decision about oral dosing. The second and third orders specify additional amounts of opioid to be administered on an as needed (PRN) basis for either moderate or severe pain, to be administered at the same time as the scheduled dose. The purposes of the oral tier are to prevent painful medication delays associated with typical PRN orders, offer varying dosing of oral opioids to treat various degrees of pain, and to quickly identify an appropriate oral regimen for discharge.

Outcomes and Impact. During the 3 years prior to creation of the sickle cell unit and CPOE optimization (2011–2013), the average length of stay for a sickle cell patient was 11.58 days. The average length of stay after implementation (2017–2019) was 5.92 (P < 0.001). This equates to a 49% reduction in average length of stay. Additionally, a telephone survey was conducted for patients with significant outpatient and inpatient experiences before, during, and after creation of the sickle cell unit. Of the 32 patients surveyed, 57% of patients reported improved inpatient care. The combined effort of a dedicated sickle cell team on a single unit with optimized CPOE pain management ordering substantially impacted the care of our sickle cell patients.

Additional Power Huddle Sessions

Check Please! Automated Surgeon Supply Receipts to Further Cost Transparency

Jessica Mody, MHA, and Andrew Pierce, MHSA; Barnes-Jewish Hospital

How a New Health Care System Collaborated to Maximize Intensive Care Unit Capacity

Sarah Nguyen, MPH, and Richard Nesto, MD, FACC, FAHA, FRCP (Edin.); Beth Israel Lahey Health

Better Together: Using Quality and Accountability Study to Drive Systemness

Kate Dickhut, MPH; Jordan Shapiro, MPH; and Michael Lane, MD, MPHS, MSc, CPPS; BJC HealthCare

High-Value Pharmacy Enterprise: Blueprint for 2025

Rita Shane, PharmD, FASHP, FCSHP; Cedars-Sinai Medical Center

Targeted Advance Care Planning and Multidisciplinary Care Using Machine Learning

Jonathan Walter, MD; Noppon Setji, MD; and Yvonne Acker, RN, BSN, CPHQ; Duke University Health System

Shining Light on Early Deaths

Jamie Gollon, BSE, MSE, and Jillian Hauser, BS, MIE; Duke University Hospital

Early Warning System to Reduce Mortality: Impact and Unintended Consequences

Siddhartha Singh, MD, MS, MBA; Bradley H. Crotty, MD, MPH; and Ann B. Nattinger, MD, MPH; Froedtert & the Medical College of Wisconsin

Culture of Health: How to Lead, Manage, and Measure

Lisa M. Nichols, MSW, Intermountain Healthcare; Terri M. Scannell, MBA, Vizient; and Piya Baptista, MSc; Global Reporting Initiative

The Benefits of a Centralized Labor Program When Facing a Global Pandemic

David Crawford, MBA; NewYork-Presbyterian Hospital

Supplier Diversity: From Zero to 60 (or $50M)

Lynnise Smith, Mandie DeWine, and Jamie Yolles, BA; OhioHealth

Physician Governance Within the Value Analysis Structure Drives Success and Engagement

Renee Edwards, MD, MBA, and Erin Gilbert, MD, FACS; OHSU

Lean, Mean, Fighting Machine: Designing a Sustainable Health System Antimicrobial Stewardship Program Model

Nicholas Bennett, PharmD, BCPS, and Sarah E. Boyd, MD; Saint Luke’s Health System

Virtual Nursing: Supporting the Bedside

Amy Cripe, BSN, RN; Tracy Duran, MSN, BSN, RN; and Barbara Columbus, MA, BSN, RN; Stormont Vail Health

Making Something From Nothing: Physician Executives Leading Organizational Change

David Berman, MD, MBA, FACP, and Claire Raab, MD; Temple University Hospital

Instant Replay of the Multivisit Patient Game Plan

Colleen Booz Dittrich, LMSW, ACM-SW, CCM, and Melissa Awbrey, LMSW; The University of Kansas Health System

Sustaining the Gains: Redefining Inpatient Unit Operations

Tori Butler, MSN, RN, NEA-BC; Rachel A. Pepper, DNP, RN, NEA-BC; and Chris Ruder, MS, RN, NEA-BC; The University of Kansas Health System

Cost-Effectiveness of Emergency Department HCV Screening and Linkage

Daniel Moore, MD; Ryan Korosec, CPA, MBA; and Patricia K. Howard, PhD, RN; UK HealthCare

Procedural Analytics and Actualyzer: A New Frontier of Clinical Collaboration

Ian O’Malley, MS; University of Chicago Medicine

A Systematic Approach to Hospital Surge Capacity Management

Sheri Salas, RN, MSN, CNL; Lisa G. Mestas, RN, BAS, MSN; and Michael C. Chang, MD; University of South Alabama Health System

Additional Poster Presentations

Implementing and Expanding the Patient Photos Program to Reduce Wrong-Patient Errors

Hojjat Salmasian, MD, MPH, PhD; Brigham and Women’s Hospital

Say Goodnight to Delirium: Nurse-Driven Protocol to Decrease Delirium

Jessica Thomey, DNP, MSN, RN, NE-BC, CMSRN; Froedtert Hospital

Is Your Chronic Obstructive Pulmonary Disease Patient Ready for Home Self-Care?

Lorilie A. Parker, MEd, RRT, and Sally Wu, MSIE; MU Health Care

Purple Is Going Green: Intravenous Therapy Bag Sustainability at Northwestern Medicine

Amanda Schaumann, MBA, and Chelsea Vines; Northwestern Medicine

Aspiration: The Most Lethal Hospital-Acquired Condition

Henry Pitt, MD; Jonathan Shinefeld, RN, MEd, MAUB, CPHQ; and Thomas A. Santora, MD, MBA; Temple University Health System

Find the Skeleton in the Closet: Identify Malnutrition and Increase Revenue

Michele A. Ondeck, MS, RD, LDN; Temple University Hospital

To Affinity and Beyond: A Patient-Centric Model of Collaborative Improvement

Kimberly Blanton, MSN, MHA, RN, NEA-BC, and Patricia G. Bondurant, DNP, RN; UK HealthCare

Use of the Electronic Medical Record to Implement a Cardiac Surgery Enhanced Recovery After Surgery Program

Jacob Gutsche, MD, and Stephanie Ottemiller, RN; University of Pennsylvania Health System

Project Inspire: A Hospital-Based Injury Prevention Program Aimed to Reduce Recidivism for Youth Delinquent of Gun Crimes

Andrew Haiflich, MSN, RN, USA Health University Hospital, and Ashley Williams, MD; University of Pittsburgh Medical Center (formerly USA Health University Hospital)

Using Surgeon Scorecards to Reduce Cost and Waste in Pediatric Surgery

Nathan Wilke, MBA, PMP, CMRP, UW Health, and Keon Young Park, MD, PhD

Current affiliation: University of California San Francisco (formerly employed by University of Wisconsin School of Medicine and Public Health)


Blessing Health System S81

Brigham and Women’s Hospital S16–S17, S81

Carilion Clinic S18

Columbus Regional Hospital S82

Cone Health S18

Deaconess Hospital S83

Denver Health S19, S84

Emory Healthcare: Integrated Memory Care Clinic S85

Froedtert & the Medical College of Wisconsin S20, S21–S22, S86

Harborview Medical Center S87

Houston Methodist S23, S24, S25, S89, S90, S91, S92

Houston Methodist Coordinated Care S23

Houston Methodist Hospital System S24

Houston Methodist West Hospital S25, S91, S92

Intermountain Healthcare S26, S27, S28

IU Health Ball Memorial Hospital S93

Keck Hospital of USC S29

Keck Medical Center of USC S94

Keck Medicine of USC S30

LAC + USC Medical Center S95

Lehigh Valley Health Network S31

M Health Fairview S34

Mayo Clinic S35

Mayo Clinic Health System S96

Mayo Clinic Health System—Franciscan Healthcare S96

McAlester Regional Health Center S36

Medical College of Wisconsin S37, S86, S97

MedStar Georgetown University Hospital S98

Memorial Hermann Texas Medical Center S39

Memorial Hermann Texas Medical Center/McGovern Medical School S38

MU Health Care S40

Nebraska Medicine S41

NewYork-Presbyterian Queens S42

Northwestern Memorial Hospital S44, S99

Nuvance Health (formerly Western Connecticut Health Network) S45

NYU Langone Health S46, S47

Ochsner Health S48, S100

Penn State Health S49

Penn State Hershey Medical Center S101

Pomona Valley Hospital Medical Center S50

Prisma Health S52, S102

Providence St. Joseph Health S53, S54, S103

Rhode Island Hospital S104

Rush University Medical Center S105

Saint Barnabas Medical Center S55

Sanford Health S56

Sanford USD Medical Center S107

SSM Health St. Mary’s Hospital - St. Louis S108

Stanford Health Care S56, S109, S110, S111, S112

Stanford University School of Medicine S112

Stony Brook University Hospital S57

Stormont Vail Health S58

SUNY Upstate University Hospital S113

SwedishAmerican Health System, A Division of UW Health S59

Tampa General Hospital S60

Temple University Health System S60

The MetroHealth System S114

The Ohio State University Wexner Medical Center S62

The University of Kansas Health System S63

The University of Kansas Health System Care Collaborative S64

The University of Kansas Health System: HaysMed S115

ThedaCare S65

Thomas Jefferson University Hospitals, Inc. S65, S67, S116

UAB Medicine S117

UC Davis Health S68, S69, S118

UCHealth University of Colorado Hospital S124

UCLA Health S119

UF Health S70, S71, S120

UF Health Jacksonville S72, S120

UNC Health S73

University Hospitals Cleveland Medical Center S121

University of Cincinnati Medical Center S122

University of Colorado S123

University of Colorado School of Medicine S74

University of Florida S124, S126

University of Iowa Hospitals and Clinics S75

University of Kentucky HealthCare S76

University of Missouri Health Care S77

University of Rochester S78

University of Rochester Medical Center Strong Memorial Hospital S126

Vanderbilt University Medical Center S79

Yale New Haven Hospital S127

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