# Presentation: 718574

## Strategies and Tools for Patient Safety/Quality Improvement

- Donald Crandall, MD
- Physician Informatics Consultant
- Trinity 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

**Notes:**
THIS IS TECHNICAL COMPONENT: MASSIVE IMPLEMENTATION EFFORT
 COORDINATION AND INTEGRATION CRITICAL
 MUST TIE TO REDESIGNED PROCESS OR UNLIKELY TO WORK: TOO COMPLEX

## Trinity Health Genesis Clin/Rev Schedule as of  June 2007

- Muskegon
- July 2004

- Sioux City
- Sept 2005

_**F03/05**_

- Grand Rapids
- Oct 2004

_**FY06 **_

- Mason City
- July 2005

_**FY07**_

- Battle Creek
- Feb 2005

- Completed

- In Process

- Not Started

_***Key:***_

- Oakland
- March 2007

- Macomb
- April 2005

- Clinton
- Oct 2007

- Dubuque
- Feb 2006

- Livonia
- March 2006

_**FY08**_

_**FY09**_

- Boise
- Jan 2009

_**FY10**_

- Ann Arbor
- June 2009

- Columbus
- TB Confirmed
- Late Fall 2009

- HQ Upgrade
- Aug 2006

- Fresno
- Oct 2008

- South Bend
- April 2008

- Silver Spring
- July 2008

- Domain Split
- Jan 2007

- CTT
- ACS & CHF

- Cerner Upgrade
- May 2006

- MC-Network
- Phase I
- July 2007

- MC-Network
- July 2008

- MC-Network
- Sept 2008

- Cerner
- Upgrade Alpha
- Sept 2007

- Livonia
- Ortho Tot Joint
-  PI Pilot

**ACS/CHF**
**PI Pilot-Oakland**
**Mar 2007**

- Cerner
- Upgrade Main
- Jan 2008

- FY08 Genesis
- Doc Mng
- Bundle

## 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 

## 	We embrace evidenced-based measures to monitor and improve our own performance:
Tracking performance on 29 inpatient indicators for heart failure, acute myocardial infarction, pneumonia, maternal child care, patient satisfaction and patient identification on our core indicator report card.
Detailed patient satisfaction measures
All indicators are evidenced based and benchmarked against published national performance levels
There is vertical integration of the indicators
All levels of the organization
Accountability for performance 
Transparency of performance using Clinical Quality Indicator Report Card.  

**	****We embrace evidenced-based measures to monitor and improve our own performance:**
- Tracking performance on 29 inpatient indicators for heart failure, acute myocardial infarction, pneumonia, maternal child care, patient satisfaction and patient identification on our core indicator report card.
- Detailed patient satisfaction measures
- All indicators are evidenced based and benchmarked against published national performance levels
- There is vertical integration of the indicators
- All levels of the organization
- Accountability for performance
- Transparency of performance using Clinical Quality Indicator Report Card.

- Evidence-based Performance Measures

**Notes:**
Slide for notes only

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

## Trinity Quality Dashboard 2004

|   | 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 04 |
| CMS 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 2007

|  | AMI Indicators |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Site  | Aspirin w/in 24 hrs AMI-1 |   Aspirin at discharge               AMI-2 | ACEI/ ARB at discharge               AMI-3 | Adult Smoking Cessation Counseling                         AMI-4 | Beta blockers at discharge AMI-5 | Beta 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. Anns | 100% | 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% |   | DNS |
| Livonia | 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% |   | DNS |
| Silver 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).  |  |  |  |  |  |

## Lessons Learned from Live Sites

- Are we achieving our clinician goals?

## CARE TRANSFORMATION 

**Moving from Utilization to Standardization **

## Transformation Structure

*Data Standards*
*Medication Cycle*
*Decision Support*

- ED     ICU      ACUTE    SURG  CATH

- Governance
- Oversight

- Acute Coronary Syndrome
- Congestive Heart Failure

- Care Area Improvement Teams

## Decision Making TeamsPatient Centric – Zero Defects

- 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.

## Clinical Transformation

**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**

## Care Transformation Definition           Reaching a Higher Standard of Care

- Improve quality and safety of care, the patient care experience and improve financial stewardship
- Achieve zero defects by embedding evidence throughout the care process
- Support acceleration of change and rapid replication
- Maximize 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 experience
**Disease specific** – e.g. heart failure, acute coronary syndrome, diabetes
**Information and evidence driven** – versus consensus opinion driven
**Holistic** – examines all elements of cost and quality
**Measurable **– produces quantifiable benefits
**Iterative** – 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

## Best Practice Embedding

- _[Acute MI Example Order Set from Zynx on Nexus](file:///Acute%20MI%20Example%20Order%20Set%20from%20Zynx%20on%20Nexus)_

**Best Practice Embedding**
**Transformational 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?