Share

2010 Quality Improvement Initiatives

 

Act 53 Quality Improvement Initiatives

  1. Stroke Certification Program
  2. "Getting to Zero" Health Care-Associated Infection Prevention Efforts
  3. Community Health Team

_______________________________________________________________________

PROJECT NAME: STROKE CERTIFICATION PROGRAM

Time Frame: 2007-2009

Description/Problem:

Stroke is the leading cause of adult disability and the third leading cause of mortality in the United States. It is also a huge financial burden on our society, with billions of dollars in direct and indirect costs.

Project Goals:

  1. Provide excellent, patient-centered care;
  2. Support Fletcher Allen’s mission of community education, improved health care and research;
  3. Set achievable clinical care standards for stroke based on benchmarking data for national/regional stroke care;
  4. Develop clear performance metrics that promote continuous improvement;
  5. Promote compliance with national standards and performance measures;
  6. Improve productivity and control costs;
  7. Help Fletcher Allen achieve recognition as a leader in providing high-quality stroke care;
  8. Achieve Joint Commission Primary Stroke Center certification.

Interventions:

  1. Development of multidisciplinary algorithms;
  2. Development of stroke management protocols;
  3. Development of documentation flow sheets for ED and nursing units;
  4. Development of comprehensive education plan;
  5. Organization of Quality Assurance oversight committee;
  6. Development of screening and education plan on dysphagia (difficulty swallowing) for nurses.

Evaluation:

The program implemented a number of performance measures based on the American Heart Association/American Stroke Association’s “Get with the Guidelines” Program, including:

  1. Deep vein thrombosis preventive measures implemented by the patient’s second day in the hospital;
  2. Assessment for intravenous tissue plasminogen activator (t-PA) – a clot-dissolving medication -- initiated for patients arriving within two hours of the onset of symptoms;
  3. Administration of antithrombotic medications within 48 hours of admission;
  4. Dysphagia screen completed before anything given by mouth;
  5. Anticoagulation prescribed for patients with atrial fibrillation at discharge;
  6. Statins prescribed at discharge or before admission for patients with low-density lipoproteins (LDL) cholesterol >100 mg/dL;
  7. Consistent education of stroke patients provided;
  8. Tobacco cessation advice/medication offered consistently;
  9. Patients evaluated for inpatient stroke rehabilitation.

Results:

Since implementation of the above performance measures, Fletcher Allen has scored well in a number of areas, including:

  • Early antithrombotics, which help prevent recurrent stroke, administered 96 percent-100 percent of the time, compared to an average of 97 percent at other academic medical centers;
  • Deep vein thrombosis prevention measures consistently administered 100 percent of the time, above the 94 percent-96 percent average at other academic medical centers;
  • Patient education at discharge implemented 100 percent of the time, compared to 74 percent-82 percent at other academic medical centers;
  • Smoking cessation advice offered 100 percent of the time, compared to 96 percent-97 percent at other academic medical centers;
  • Anticoagulation prescribed at discharge for patients with atrial fibrillation 100 percent of the time, compared to 94 percent at other academic medical centers;
  • Evaluation for intravenous t-PA initiated for patients arriving within two hours of symptoms 87.5 percent of the time, compared to 77 percent at other academic medical centers.

Fletcher Allen has also received numerous recognitions for the Stroke Program, including Joint Commission Primary Stroke Center certification in January 2009 and a 2008 Bronze Award from The American Heart Association and American Stroke Association’s “Get with the Guidelines Program,” which recognizes medical centers that provide care that is consistent with the most recent scientific guidelines.

Next steps for this project include implementation of a nursing-driven dysphagia protocol; development of a transient ischemic attack (TIA) protocol; and development of a regional outreach program via telemedicine.

_______________________________________________________________________

PROJECT NAME: "GETTING TO ZERO" HEALTH CARE-ASSOCIATED INFECTION PREVENTION EFFORTS

Time Frame: 2009 – ongoing

Description/Problem: Health care-associated infections (HAIs) have increased in incidence and gained visibility nationally. In October, 2008, Fletcher Allen introduced an organization-wide strategic initiative that includes a multi-faceted program to reduce HAIs. It is important to note that our baseline for most of the infections tracked is already below the national average.

Project Goal:

  1. To reduce health care-associated infections by 20 percent.

Interventions:

  1. Improved surveillance of three infections across all inpatient locations – Methicillin-resistant Staphylococcus aureus (MRSA), a bacterial infection that is resistant to some antibiotics; C. difficile, a bacterial infection that can lead to a severe infection of the colon; and primary bloodstream infections. Steps included establishing a composite measure to track improvements over time;
  2. Implementation of mandatory resident training in a number of areas related to infection control, including the microbiology and epidemiology of HAIs, multi-drug resistant organisms, HAI data, case studies and current best practices;
  3. Development and implementation of a nurse advocate program – 26 medical/surgical nurses received 16 hours of infection prevention education that stressed evidence-based practices;
  4. Implementation of enhanced training and monitoring of Environmental Services cleaning practices, including the use of fluorescent marking to monitor the effectiveness of the cleaning process focused on 14 high-touch surfaces, with rapid feedback to staff;
  5. Two rapid redesign teams addressed prevention of ventilator-associated pneumonia (VAP) and central-line blood stream infections, and an environmental assessment resulted in the placement of additional hand sanitizer dispensers in multiple public locations;
  6. A group of volunteers supported these efforts by acting as observers to identify hand-hygiene compliance.

Evaluation:

Measures using the Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) surveillance definitions were developed for the three infections. In addition, a composite rate combining the three was tracked. The rates were tracked monthly by the administration and by the Jeffords Institute for Quality and Operational Excellence. Trends were analyzed with feedback and interventions when required. Environmental Services deployed a process of continuous feedback for cleaning compliance of the 14 high-touch surfaces, along with an incentive system to reward high performers.

Results:

  1. As an organizational initiative, this effort gained significant support and visibility across the organization;
  2. The nurse advocate training program brought best practices to the bedside and has been continued in 2010;
  3. Unit-specific projects resulted in changes in surgical dressing practices, improved hand hygiene, isolation compliance and additional staff education;
  4. The Environmental Services initiative resulted in significant improvement in cleaning compliance for the 14 high-touch surfaces monitored -- from a baseline of less than 60 percent cleaning compliance to 80 percent by mid-year -- and exceeded the goal of 90 percent cleaning compliance by the end of Fiscal Year 2009;
  5. The composite MRSA, C-difficile and BSI prevalence rates dropped by 16 percent across the inpatient unit.

_______________________________________________________________________

PROJECT NAME: COMMUNITY HEALTH TEAM

Time Frame: July 2008 - Ongoing

Description/Problem:

Fifty-one percent of all Vermont adults have one or more lifelong health conditions that likely require ongoing medical care. Eighty-eight percent of Vermonters older than 65 report having one or more chronic conditions.

Project Goals:

  1. To develop a patient-centered medical home that will improve the quality of care for patients with, or at risk of, chronic conditions;
  2. To improve quality;
  3. To engage and empower patients and health professionals;
  4. To educate and foster a team approach to care management;
  5. To improve efficiency within one of our primary care practices.

Interventions:

  1. Developed the Community Health Team (CHT), a pilot program at one of our primary care practices and with a private practitioner, which facilitates partnerships among individual patients, their personal physicians, and their families;

    a. CHT members provide regular ongoing support for patients with chronic conditions;

    b. The team helps patients set realistic goals and a timeline for improving health;

    c. Services offered include nutrition help, exercise advice, diabetes education, medication management, behavioral/mental health counseling and connection to community and financial resources.

Evaluation:

Measures evaluating the success of the Community Health Team include:

  1. A sustained increase in practice adherence with the National Committee for Quality Assurance (NCQA) patient-centered medical home standards;
  2. An increase in the proportion of patients who receive recommended health maintenance and care for chronic conditions;
  3. An increase in the proportion of patients who achieve improved control of their chronic health condition;
  4. A shift from episodic to preventive patterns of health care and resource utilization;
  5. A beneficial shift in total and/or marginal health care expenditures;
  6. An improvement in population indicators that are used to guide community activity and prevention.

Results:

  1. To date, the Community Health Team has had 5,144 patient visits;
  2. The Community Health Team currently has 661 active patients; Approximately 70 percent of the patients say their experience with the Community Health Team impacted them positively:

    a. 41.2 percent of CHT patients said they made changes to their diet, compared to 24 percent for non-CHT patients;

    b. 42.2 percent of CHT patients increased their physical activity, compared to 26.5 percent for non-CHT patients;

    c. 40.4 percent of CHT patients had access to community services, compared to 24.1 percent of non-CHT patients;

    d. 66.7 percent of CHT patients had help after a visit to the emergency department, compared to 34.5 percent of non-CHT patients;

    e. Six-month follow-up reviews after patient graduation from the program have shown sustained improvements in behavioral health and biometric measures.

  3. CHT patient satisfaction was consistently higher than non-CHT patient satisfaction in the following areas:

    a. Team listened to my concerns;

    b. Team supported me;

    c. My care was coordinated;

    d. Team helped me improve my health;

    e. Team helped me set goals;

    f. I will follow through on goals.

4. The Aesculapius medical home as well as Given Williston have obtained a Level 3 rating as a Certified Medical Home from the NCQA – their highest ranking for medical home certification. Milton Family Practice received a Level 2 rating as a Certified Medical Home.