Strategies and Tools for Patient Safety/Quality ImprovementDonald Crandall, MDPhysician Informatics ConsultantTrinity Health, Novi, MI.

Trinity Health – Our Communities

• Fourth-largest Catholic health system in the United States

• Operating revenues of $5.7billion

• 44,950 FTEs• 7,315 physicians – 95% private

practice community hospital based

• 25 Ministry Organizations, 44 hospitals (29 owned and 15 managed), 379 outpatient clinics/facilities, numerous long-term care facilities, home health and hospice programs, and senior housing communities in seven states

The Scale of Change

• How big is Genesis?

• Project Genesis will involve:– Implementation of 20+ information systems – Across 17 Member Organizations and 23 hospitals– Redesign of 300+ business and clinical processes

Scope: Applications Installed

• CLINICAL (Cerner/Millenium)– Power Chart - Orders and results– Clin Doc - Clinical documentation– PharmNet - Pharmacy – FirstNet: Emergency Dept.– RadNet: Radiology Dept.– SurgiNet: Operating Room – Inet: ICU– Profile - HIM application– EMPI– Standard Orders– Electronic Record - Clinical functions by pt. type - Current clinical documentation forms

Copyright © 2006 Trinity Health, Novi, Michigan

Trinity Health Genesis Clin/Rev Schedule as of June 2007

MuskegonJuly 2004

Sioux CitySept 2005

F03/05

Grand RapidsOct 2004

FY06

Mason CityJuly 2005

FY07

Battle CreekFeb 2005

CompletedIn ProcessNot Started

Key:

OaklandMarch 2007

MacombApril 2005

ClintonOct 2007

DubuqueFeb 2006

LivoniaMarch 2006

FY08 FY09

BoiseJan 2009

FY10

Ann ArborJune 2009

ColumbusTB ConfirmedLate Fall 2009

HQ UpgradeAug 2006

FresnoOct 2008

South BendApril 2008

Silver SpringJuly 2008

Domain SplitJan 2007

CTTACS & CHF

Cerner UpgradeMay 2006

MC-Network Phase I

July 2007

MC-NetworkJuly 2008

MC-NetworkSept 2008

CernerUpgrade Alpha

Sept 2007

LivoniaOrtho Tot Joint

PI Pilot

ACS/CHFPI Pilot-Oakland

Mar 2007

CernerUpgrade Main

Jan 2008

FY08 Genesis Doc MngBundle

Genesis Accomplishments

• 10 ministry organizations live on in-patient system as of 7/2007• Three ambulatory clinics live on PowerChart Office• Avg. # of physicians placing orders per day (actually doing it themselves)

is >850• Orders processed per day > 300,000• Avg. chart openings per day > 160,000• Avg. HQ-Cerner ADT transactions per day > 50,000• Avg. concurrent users per day during peak hours • (08:00-16:59) > 1200• Peak concurrent users > 1500• Simultaneous synchronization to 2 data sites

Trinity CPOE Saturation – previous 13 months

CPOE Saturation % = physician entered orders + protocol orders + AHP orders / total orders

QUALITY MONITORING

The objective of I²S² is to create information from data in order to measure and improve clinical and operational performance.

  AMI

Site ASPIRIN w/in 24h ASPIRIN @ DC Adult Smoking Cessation BETA @ DC BETA w/in 24h PCI w/in 120

min

Ann Arbor 97% 99% 98% 99% 93% 90% FAV

Battle Creek 86% 83% 75% 97% 86%  

Boise 100% 98% 94% 93% 92% 71% FAV

Cadillac 100% 100% 82% 100% 100%  

Clinton, IA 94% 93% 24% 79% 86%  

Columbus East 95% UNF 99% 68% FAV 98% 98% UNF 91%

Columbus West 97% 96% UNF 86% FAV 96% UNF 99% 90%

Des Moines 98% 99% 100% 99% 99% 91% FAV

Dubuque 95% 99% FAV 89% 100% FAV 94% 63%

Fresno 97% 96% 74% 96% FAV 99% 92%

Grand Rapids 95% 93% 91% 100% 99%  

Grayling 88% 100% 0 patients 90% 82%  

Livingston 98% 95% 67% 100% 90%  

Livonia 96% 94% 75% 93% 95%  

Macomb 97% 97% 84% UNF 99% 97% 53%

Mason City 100% 98% 100% 97% 100%  

Mishawaka 95% 97% 93% 100% 88% UNF 63%

Muskegon 99% 99% 86% 97% 99% 56%

Oakland 94% 96% 84% 93% 83% 78%

Plymouth 92% 100% 100% 100% 91%  

Port Huron 90% 94% 100% 100% 88%  

Saline            

Silver Spring 99% 93% 75% 98% 93% 75%

Sioux City 100% 99% 95% 96% 90% 100%

South Bend 94% 99% 89% 94% 92% 63%

Westerville 88% 91% 20% 95% 94%  

Trinity Health 96% 97% 87% FAV 97% 94% 78% FAV

Date of Data Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04 Mar 04 - Aug 04CMS Top Decile 100% 99% na 98% 98% na

Green Top 25% 98% 99% 93% 98% 97%  

Yellow 25-75% 97-92% 98-93% 92-73% 97-87% 96-83%  

Red <25% <92% <93% <73% <87% <83%  

Blue cells indicate less than 30 cases            

Trinity Quality Dashboard 2004

Trinity Quality Dashboard 2007

AMI Indicators

Site Aspirin w/in 24 hrs AMI-1 Aspirin at discharge

AMI-2ACEI/ ARB at discharge

AMI-3Adult Smoking Cessation Counseling

AMI-4Beta blockers at discharge

AMI-5Beta blockers w/in 24 hrs

AMI-6 PCI w/in 90 min

AMI-8

AMI Composite

Ann Arbor 100% EP 99% 99% 99% 99% 94% 57% DNS

Battle Creek 89% 93% 100% 100% 91% 100%   84%

Boise 99% 99% 100% 100% EP 99% 99% 55% 90%

Cadillac 98% 88% 100% 100% 100% 100%   94%

Clinton, IA 94% 92% 67% 89% 87% 88% 50% 81%

Columbus East 100% EP 99% 97% 100% EP 100% EP 99% 97% EP 97% EP

Columbus West 100% EP 100% EP 97% FAV 100% EP 99% FAV 98% 76% 95%

Columbus St. Anns100% 100% 100%

100%100% 100%   100%

Des Moines 99% 100% EP 99% 100% EP 99% 98% 98% EP 97% EP

Dubuque 99% 99% 97% 100% EP 95% 94% 42% 84%

Fresno 99% 99% 100% EP 100% EP 99% 100% EP 63% 97% EP

Grand Rapids 95% 97% 93% 100% 97% 97% 50% 81%

Grayling 100% 100% 100% 100% 91% 81% 82%

Livingston 100% 100% 100% 0 pts 100% 80%   DNSLivonia 98% UNF 99% 94% 100% 100% EP 97% 71% 90%

Macomb 98% 99% 100% 100% EP 99% 98% 86% 93%

Mason City 96% 99% 94% UNF 100% EP 99% 97% 64% 91%

Mishawaka 96% 100% 67% 89% 100% 100% 73% 87%

Muskegon 100% EP 100% EP 97% 100% EP 99% 100% EP 25% 89%

Oakland 100% EP 100% EP 100% EP 100% EP 99% 98% 83% 98% EP

Plymouth 100% 100% 100% 100% 100% 94%   95%

Port Huron 88% 93% 86% 100% 94% 96%   75%

Saline 100% 100% 0 pts 0 pts 100% 100%   DNSSilver Spring 94% 88% UNF 100% 67% 85% UNF 86% UNF 13% 65%

Sioux City 99% 98% 92% 100% EP 99% 100% EP 81% 97% EP

South Bend 97% 99% 78% 96% 98% 93% 80% 90%

Trinity Health 98% 99% 97% 99% 98% 97% 71% 93%

Date of Data April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06 April-Sept 06

Exceptional Performance 100% 100% 100% 100% 100% 100% 86% 97%Target 100% 100% 100% 99% 100% 100% 70% 94%Above Median 99 - 96% 99 - 95% 99 - 85% 98 - 92% 99 - 95% 99 - 93% 69 - 60% 93 - 84%Median <96% <95% <85% <92% <95% <93% <60% <84%

Less than 30 cases

Targets developed from CMS data for FY 2005. When CMS data not available, other vendor data used.

FAV = Favorable 12 month regression (p<.05). UNF = Unfavorable 12 month regression (p<.05).

• We are successful with the technology.• Are we achieving our clinician goals?

6 3 3 6 6

Indicator Before

Go-Live

Disruption Pre Go-

Live

Disruption Post Go-

LiveDisruption Combined

After Go-Live

P value-Before

and After

Sig Improveme

nt Combined

Sig Improvem

ent PH

Sig Improvement Musk

Sig Improvem

ent GR

Sig Improvem

ent BCAMI-1 Aspirin on admission 95% 96% 96% 96% 94% 0.76AMI-2 Aspirin at discharge 97% 95% 98% 96% 97% 0.89AMI-3 ACEI / ARB at discharge 86% 88% 89% 89% 86% 0.99AMI-4 Smoking cessation 90% 90% 93% 91% 99% 0.02 Y yAMI-5 Beta at discharge 98% 97% 99% 98% 98% 0.77AMI-6 Beta on admission 96% 96% 96% 96% 97% 0.47AMI-8 PCI in 120 minutesHF-1 Discharge instructions 50% 45% 64% 54% 63% 0.00 Y y yHF-2 LVF assessment 93% 93% 94% 94% 96% 0.07 yHF-3 ACEI / ARB at discharge 81% 81% 84% 83% 90% 0.03 Y yHF-4 Smoking cessation 90% 86% 88% 87% 88% 0.69 yCAP - Antibiotics w/in 4 hours 71% 66% 67% 66% 77% 0.06 yCAP - Smoking Cessation 72% 80% 92% 86% 93% 0.00 Y y y yCAP - Blood C/S 82% 75% 77% 76% 77% 0.07 yCAP - Pneumococcal vaccine 47% 50% 53% 52% 58% 0.02 Y y

Chi Square Chi Square

Lessons Learned from Live Sites

CARE TRANSFORMATION

Moving from Utilization to Standardization

Copyright © 2006 Trinity Health, Novi, Michigan

Data Standards

Medication Cycle

Decision Support

ED ICU ACUTE SURG CATH

Governance

Oversight

Acute Coronary Syndrome

Congestive Heart Failure

Care Area Improvement Teams

Transformation Structure

Copyright © 2006 Trinity Health, Novi, Michigan

Decision Making TeamsPatient Centric – Zero Defects

• Care Area Improvement TeamsVenue Specific, Interdisciplinary, Workflow BasedED, Acute Care, Critical Care, Surgical, others…

• Clinical Transformation TeamsLean process, Interdisciplinary, Outcomes, Evidence Coronary, CHF, Pneumonia, Diabetes, SIP, others…

• Clinical Oversight TeamCross Venue, architecture, cross venue, and system decision making.

•Improve consistency in quality performance on key clinical indicators •Enhance the patient experience•Increase value and decrease risk in Genesis as noted in PGVA

• Evidence-based clinical practice is not embedded in many of the order sets.

• The workflow pattern has not changed much. For example even though a STAT ORDER is now instantly processed, it DOES NOT mean that the nurse sees it any earlier to do anything about it.

• We still have MO specific formularies. This means we have different ways of approaching even the highest risk drugs.

• We will embed evidence into workflow, order sets, rules, etc.

• Workflow will be optimized by embedding evidence--enhancing the overall clinical experience and care outcomes.

• Communication and efficiency improvements between all care providers and patients.

• Medication cycle and formulary will reflect evidence based use.

Current Future

Clinical Transformation

Care Transformation is a comprehensive approach to:Improve quality and safety of care, the patient care experience and improve financial stewardship Achieve zero defects by embedding evidence throughout the care processSupport acceleration of change and rapid replicationMaximize value from Genesis technology

Trinity Health’s brand name for Care Transformation is Genesis CareExperience (Genesis CareEx on second reference).

Key attributes of Genesis CareEx are:Patient focused – studies the end-to-end patient experienceDisease specific – e.g. heart failure, acute coronary syndrome, diabetesInformation and evidence driven – versus consensus opinion drivenHolistic – examines all elements of cost and quality Measurable – produces quantifiable benefitsIterative – we never stop looking for new opportunities

Care Transformation Definition Reaching a Higher Standard of Care

Genesis CareExperience Design Objectives

• Establish enterprise workflows that are actionable, flexible, patient focused and incorporates evidence throughout the care delivery process

• Ensure consideration and elimination to current provider and patient dissatisfiers• Ensure avoidance of all avoidable and predictable errors• Establish process, productivity and functional indicators• Ensure required documentation meets applicable standards• Will deliver outstanding care within financial parameters of CMS reimbursement

while maintaining alignment with our Mission • Support Genesis CareEx teams to support evolution towards system formulary• “Hardwire” into Genesis systems• Improve the patient experience

Acute MI Example Order Set from Zynx on Nexus

Best Practice EmbeddingTransformational Order Set

Designing the “Quality Heath Record”

Threats:– High cost of dictation & transcription, storage & retrieval/release of information – Fragmentation & Case Mix (lower productivity)– Continuity of Care, Handoffs, & Communication

Ongoing “Quality Health Record” projects:– Concurrent quality documentation review & dialogue with physicians, coding

and DRG assignment– Structured physician documentation templates (PN2G), including diagnosis – Standard terminology definitions for documentation and coding classification– Voice recognition & medical documentation quality review– Document management (Scanning) and Imaging– “Virtual” environment - working remote & load balancing

QUESTIONS?