Embed Size (px)
DESCRIPTION
Intermountain-led CMS Hospital Engagement Network Falls and Immobility April 11, 2014 Affinity Call. Marlyn Conti –Patient Safety Initiatives Manager and Eric Crawford, Data Manager Intermountain Quality and Patient Safety. Outline for Discussion. Review of 2013 data through Q4 - PowerPoint PPT Presentation
Citation preview
Intermountain-led CMS Hospital Engagement Network
Falls and ImmobilityApril 11, 2014
Affinity Call
Marlyn Conti –Patient Safety Initiatives Manager and
Eric Crawford, Data Manager Intermountain Quality and Patient Safety
Outline for Discussion
• Review of 2013 data through Q4• ‘High performers’ – Identify and ask what
they are doing?• Falls recommended metrics• “Just-one-thing” – updated document• 2014 plans for improvement:
– Reach out to low performers to provide assistance– Continue Webinars for sharing
Overall Progress Through 2013
Intermountain HEN 2012-13 submitting Hospitals Falls with Injury
Intermountain HEN 2012-13 submitting Hospitals
Falls with Injury
Intermountain HEN 2012-13 submitting Hospitals Inpatient Falls
Intermountain HEN 2012-13 submitting Hospitals
Inpatient Falls
HEN Falls Measures
• Metric specification resource manual http://www.henlearner.org/wp-content/uploads/2012/03/HEN_measure_Feb5.pdf
• Submission schedule: – May 20, 2014: for data through March 2014
HEN Falls MeasuresInpatient Falls
HEN Falls MeasuresFalls with Injury
High Performing Hospital Highlight… Most Improvement
Inpatient FallsHospital Name
PROVIDENCE SEASIDE HOSPITAL
PARK CITY MEDICAL CENTER
SUTTER TRACY COMMUNITY HOSPITAL
CASSIA REGIONAL MEDICAL CENTER
AMERICAN FORK HOSPITAL
LOGAN REGIONAL HOSPITAL
HEBER VALLEY MEDICAL CENTER
PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL
LINCOLN COUNTY MEDICAL CENTER
SCOTT & WHITE HOSPITAL-ROUND ROCK
High Performing Hospital Highlight… Lowest Rate
Inpatient Falls Hospital Name
SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ
GARFIELD MEMORIAL HOSPITAL
PROVIDENCE SEASIDE HOSPITAL
LOGAN REGIONAL HOSPITAL
SUTTER TRACY COMMUNITY HOSPITAL
PARK CITY MEDICAL CENTER
OREM COMMUNITY HOSPITAL
AMERICAN FORK HOSPITAL
RIVERTON HOSPITAL
CASSIA REGIONAL MEDICAL CENTER
High Performing Hospital Highlight… % Improvement
Hospital Name
UPPER CONNECTICUT VALLEY HOSPITAL
FILLMORE COMMUNITY MEDICAL CENTER
SUTTER TRACY COMMUNITY HOSPITAL
PROVIDENCE MEDFORD MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
BAYLOR HEART AND VASCULAR HOSPITAL
SUTTER LAKESIDE HOSPITAL
SUTTER COAST HOSPITAL
PROVIDENCE NEWBERG MEDICAL CENTER
PROVIDENCE ST VINCENT MEDICAL CENTER
Falls with Injury
High Performing Hospital Highlight… Lowest Rate
Falls with InjuryHospital Name
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
PROVIDENCE MEDFORD MEDICAL CENTER
BAYLOR MEDICAL CENTER AT CARROLLTON
SUTTER TRACY COMMUNITY HOSPITAL
SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ
PROVIDENCE MILWAUKIE HOSPITAL
PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER
GARFIELD MEMORIAL HOSPITAL
BAYLOR HEART AND VASCULAR HOSPITAL
VALLEY VIEW MEDICAL CENTER
Just One Thing MatrixRecommendations
Getting Started Working Harder Ahead of the Curve
Implement standard Assessment tools, protocols and prevention strategies
(high level of evidence)
Appoint “leads” to drive improvement & identify or champion teams that includes unit level nursing, quality, patient safety, physical therapy and pharmacy services. (high level of evidence)
Implement decision algorithms and/or computerized decision support in the electronic medical record to target interventions based on patient specific risk factors
2007 2008 2009 2010 2011 2012 20130.0
0.5
1.0
1.5
2.0
2.5
Falls with InjuryIntermountain System
Average Falls with InjuryLCL UCL
Falls
Rat
e pe
r 100
0 Pa
tient
Day
s
Falls Risk Training
Implimentation
of Safe Patient
Handling
Falls with Injury
Board Goal
Inpatient Falls Savings (CPI+1)Savings
YearFalls w/ Injury
Falls w/out Injury
Patient Days
Injury Rate
No Injury Rate
Fall RateAvoided Injuries
Avoided No Injury Falls
Estimated Improvement from
2006 Fall Rate (Avoided Cases)
Estimated Savings
2006 681 1,102 468,302 0.0015 0.0024 0.0038 0 0 0 $ - 2007 678 1,237 464,720 0.0015 0.0027 0.0041 -2 -143 -145 $ (697,080)2008 694 1,165 527,555 0.0013 0.0022 0.0035 73 76 149 $ 715,809 2009 702 1,166 532,861 0.0013 0.0022 0.0035 73 88 161 $ 773,667 2010 624 1,175 533,255 0.0012 0.0022 0.0034 151 80 231 $ 1,110,151 2011 511 1,198 530,023 0.0010 0.0023 0.0032 260 49 309 $ 1,485,483 2012 383 1,300 523,740 0.0007 0.0025 0.0032 379 -68 311 $ 1,494,136
Per Case 4,805$
YearFalls w/ Injury
Falls w/out Injury
Patient Days
Injury Rate
No Injury Rate
Fall RateAvoided Injuries
Avoided No Injury Falls
Estimated Improvement from
2012 Fall Rate (Avoided Cases)
Estimated CPI+1 Savings
2013 (Through Sept) 276 855 544,854 0.000507 0.001569 0.002076 122 497 620 2,978,547$
Estimated Savings 2,978,547$
Changes in Fall Rates
CPI+1 Calculations
• Set Organizational priority
• Identify Risks and Gaps
• Develop Monitoring Systems
• Designate Champions
• Integrated Nurse Charting and Care Plans
• Repeat Cycles of ‘Plan-Do-study-Act’
Getting Started and Keeping it going!
Fall Prevention Development Team
Region Guidance(Fill in which team or
committee has oversight)
FacilityChampion Team
Nursing Safety Physical Therapy
EducationPharmacy
Fall PreventionAccountability and Communication Diagram
NOTE: Could be Safety or Quality and Patient Safety Committee
Managing Improvement
Development
Identify best practic
e
Blend guideline into work flow
Design outcomes
tracking
Design decisio
n suppor
t
Staff and
patient
education
MaintenanceKeep Care
process
Current
Clinical Learni
ng
Manager
referral clinics
Manage
specialist care manag
ers
PDSA
2014 plans for improvement
• Reach out to low performers to provide assistance.• Collect and share best practices across our network
hospitals & system in a single document
