Fletcher Allen, a Vermont university hospital and medical center, serves all of
Vermont and the northern New York region. Located in Burlington, Fletcher Allen is a regional, academic healthcare center and teaching hospital in alliance with the University of Vermont.
2013 Quality Improvement Initiatives
The following are three examples of the numerous quality improvement initiatives that Fletcher Allen staff engaged in during 2012. For more information on these or other QI initiatives, contact the James M. Jeffords Institute for Quality & Operational Effectiveness at Fletcher Allen at 802-847-0554.
- Pressure Ulcer Prevention Nurse: A Success Story
- Transforming Elder Care in the Hospital
- Transforming Primary Care
Time Frame: March 2010-Ongoing
The cost of treating pressure ulcers is, on average, $37,800 – over twice the cost of preventing them. In addition, as of 2008, CMS has said that hospitals will no longer receive additional payment in hospital-acquired conditions, including Stage III and IV nosocomial pressure ulcers. In 2011, unstageable pressure ulcers were added to the list of Vermont reportable events.
- Identify a process for prevention or early detection of patients at high risk for pressure ulcer, utilizing best practices in pressure ulcer prevention.
- Develop a process to prevent further deterioration of a pressure ulcer utilizing best practices in pressure ulcer management
Five years ago, we developed a pressure ulcer team consisting of a physician, a nurse, a nutritionist, the director of Nursing Education and a Quality Improvement consultant. The pressure ulcer team rounds at least once a week on any nosocomial pressure ulcer patients. In 2010, a dedicated pressure ulcer RN position was created. The pressure ulcer RN routinely rounds on patients based on consults, follow-up status and Braden score on ICU patients.
Other interventions include:
- We’ve improved the process of documenting pressure ulcer staging to improve accuracy – now only pressure ulcer team members document staging to ensure accuracy and interrelater reliability.
- We have also developed a process for improving provider documentation by providing positive reinforcement to providers who correctly document a pressure ulcer on admission.
- We began re-educating inpatient nursing staff on a unit-by-unit basis regarding pressure ulcer prevention and healing, including care, treatment, dressing education, the importance of repositioning and documenting the refusal of care.
- We have worked with ICU staff to develop a team approach to pressure ulcer care.
- The Pressure Ulcer Prevention nurse has tracked the number of consults, number of nosocomial pressure ulcers seen, and number of pressure ulcers found.
- Education and positive reinforcement have improved documentation of “present on admission” pressure ulcers by house staff. We will continue to reinforce this approach with our new residents.
- The team approach with nursing staff, residents and other members of the pressure ulcer team has improved understanding of best practices in pressure ulcer care.
- Overall, we are seeing a decline in the number of nosocomial pressure-related
Time Frame: 2012-Ongoing
Traditional care of elderly patients in the hospital has been characterized by a disease-focused approach, which does not take into account the unique needs of the elderly. Older adults are admitted at a rate of three times that of younger adults, and they are at significantly higher risk for immobility, pressure ulcers and other problems, which predispose them to prolonged rehabilitative care.
The goal of this project is to optimize the functional status of our hospitalized older patients.
Specific Project Goals
- Create a culture shift from general practice to specialized elder care.
- Encourage staff involvement in creating change.
- Promote the use of evidence-based guidelines to shape clinical practice.
- Initiate appropriate strategies and intervention.
- The Transforming Elder Care in the Hospital (TECH) team has developed a multidisciplinary campaign that emphasizes a patient-centered approach.
- This approach takes into account the unique problems of elderly patients.
- We have started work with staff on our Baird 4 unit, because of their leadership support and strong interest in the care of older patients.
- This unit features a
number of improvements aimed at targeting the elderly population:
- Eighty-four percent of nurses and 67% of nursing assistants have received education on safely assessing the needs of the elderly patients.
- Mobility equipment is made more available to staff, including gait belts, walkers and canes.
- The nursing assistant’s role has been refocused on proper hydration and function/mobility status for each of the elderly patients.
- We are piloting a mobility screening tool and activity algorithm on this unit.
- We have initiated
appropriate strategies and interventions to prevent dehydration in
patients 75 and older. This effort
- Providing educational opportunities on hydration management for staff, patients and families.
- Monitoring and evaluating patient outcomes.
- One of our physicians has led the effort to advocate for transforming elder care with our senior leadership.
- We continue to add other disciplines to the group, working towards a more multi-disciplinary team.
- We have made fall
prevention in our elderly population a key focus:
- We are piloting a fall prevention rounding program in which trained volunteers make rounds Monday-Friday on patients identified as high risk for falls.
- We’ve placed signage to enhance awareness of the risk of falls for staff and patients.
- The project showed an increase in staff knowledge about hydration post-intervention, an improvement in documentation, and a general increase in awareness of the importance of elder hydration.
- The inclusion of the nursing assistants, along with other disciplines, improved teamwork and communication and clinical outcomes.
Time Frame: 2012-2014
Health care reform is driving the need for change in how we deliver primary care:
- Quality standards must be met at a high and consistent level.
- High-quality care must be delivered at a low cost, by focusing on patient wellness, preventive care and careful management of chronic disease.
- Health care providers need to be responsible for certain patient populations and be held accountable for managing the overall health and wellbeing of that patient population.
- The health of these patient populations is the responsibility of the primary care provider, who coordinates the patient’s care.
- The patient-centered medical home must effectively connect patients with community health resources and with specialists
The overall goal is to create an integrated network of primary care clinics, certified as patient-centered medical homes, that provide the highest quality of patient care with a high degree of reliability and efficiency and that offer the patient the best possible experience.
Specific Project Goals
- Support consistency of how and by whom key clinical operating decisions will be made.
- Ensure that activities and investments occur in order to optimize delivery while ensuring efficiency.
- Determine which aspects of operations can be more effectively managed centrally and which should remain within the purview of each practice.
- Define core processes and roles that will be needed to transform care delivery.
- Reassess staffing complements in light of new care requirements.
- Design the right care team model.
A number of key principles are driving the interventions that have taken place so far. First, the patient will be at the center of every decision we make. In addition, our aim is to align the culture of ambulatory operations around the expectation that the organization achieve excellence across all aims – health, patient care experience, total cost, and teaching the next generation of providers.
The interventions also reflect our focus on standardization. Our key processes must systematically and consistently deliver the best care, which requires some level of standardization to an identified best practice. Once that has been achieved, customization for the optimal care experience is an important part of the experience. In addition, the design of the practice must ensure streamlined access to care.
And finally, our aim is to move patients to the most cost-efficient care setting possible, with effective and efficient mechanisms to coordinate care across sites, specialties, conditions and time.
Based on these principles, the following interventions have been implemented:
- Positions within the care team have been restructured, with new staffing models created and in place.
- Based on input solicited in focus groups, we’ve created an ideal patient encounter to use as a model for our efforts going forward.
- We’ve established new processes and protocols.
- We’ve upgraded our electronic health record to reflect the needs of population management and meaningful use requirements.
- We’ve created a self-sustaining management and government structure for our primary care sites.
- We’ve begun creating care pathways to more efficiently manage the flow of patients between primary care and specialty care.