1. Information provided by: Yvette Mansion-Whittaker
Quality Improvement-Change Management, Core Measures & Patient Safety Education, 2014
Information provided by: Yvette Mansion-Whittaker

2. Quality Improvement – Education, 2014.
Objectives- The participant will be able to:
Define Quality
Name 2 quality approaches
Name 2 quality tools used at CHSB
Define Value Based Purchasing
Recognize at least 2 Core Measures
Identify 2 of the new core measures

3. What is Quality?
MEETING OR EXCEEDING YOUR
CUSTOMER EXPECTATIONS.

4. QUALITY APPROACHES FOCUS-PDCA(Plan, Do, Check, Act). SIX SIGMA LEAN
LEAN SIX SIGMA
TRANFORMATIONAL
TQM (Total Quality
Management)

5. CHSB APPROACH TO QUALITY
FOCUS PDCA(plan, do, check & act)
TRANSFORMATIONAL
CARE
CORE MEASURES

6. FOCUS PDCA Based on scientific method known as Shewhart Cycle.
Planned approach to process or problem resolution.
Team focused
Reporting intervals

7. TRANSFORMATIONAL CARE
Change management process
Based on lean principles
Team Focused
Rapid cycle improvement

8. Performance Improvement Monitoring Summary ( PIMS).
Currently used to measure compliance with standards or identified opportunities
Maintained in Quality Management Department
Reported to Quality Council, Medical Executive Committee and Board of Directors

9. TRANSFORMATIONAL CARE REPORTING TOOLS
Daily Report Huddles
PMT –electronic intranet
Progress monitoring tool
Newsletters

10. Projects can be department specific driven for opportunities or regulatory based.
Examples
Emergency Dept. Patient Flow
Patient Satisfaction
Sepsis
Timely Discharge
Early Recognition of Pediatric Sepsis
Readmission Reduction
Emergency Collaborative
ICU Collaborative

11. VALUE BASED PURCHASING CORE MEASURES
Infection Prevention for Surgical Patients (SCIP)
Congestive Heart Failure
Acute Myocardial Infarction
“Heart Attack” (AMI)
Pneumonia

12. VALUE BASED PURCHASING
Core Measures= key measures of care and outcomes for patients who have had surgery or have been discharged with a diagnosis of:
Infection Prevention for Surgical Patients(SCIP)
Congestive Heart Failure
Acute Myocardial Infarction “ heart attack” (AMI)
Pneumonia

13. Infection Prevention for Surgical Patients ( SCIP)
CORE MEASURES FOR CHSB
Infection Prevention for Surgical Patients ( SCIP)
Congestive Heart Failure
Acute Myocardial Infarction
“heart attack” (AMI)
Pneumonia ( PN)

14. CORE MEASURES FOR CHSB CONT’D.
Children with asthma (CAC)
Blood Clot Prevention (VTE)
Emergency Department ( ED)
Behavioral Health ( HBIPS- or Hospital Based In-Pt Psych.)
Influenza and Pneumococcal Immunization Program (IMM)
Stroke ( STK)

15. VALUE BASED PURCHASING
Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS)= Patient Satisfaction
8 key categories that measure the patient
and family perceptions of care and services
Points are given based on performance at or above the 50 percentile.
Weighted reward -70%- core measures and 30% HCAHPS

16. WHY PATIENT SAFETY QUALITY CARE SAFE WORK ENVIRONMENT
CENTER OF EXCELLENCE

17. CORE MEASURE FOCUS Timeliness of care Antibiotics given within 1 hr.
Antibiotics given within six hours of arrival to the hospital.
EKG completed within 15 minutes of arrival to hospital

18. CORE MEASURE FOCUS Appropriateness of care
Blood cultures are drawn before antibiotics given
Evaluation of the heart for heart failure patients

19. CORE MEASURE FOCUS Medical practice supported by evidence and research
Cholesterol lowering medication for patients who had a heart attack
Early interventions to prevent blood clot formation such as medication or special stockings
Aspirin use for heart attack
Immunizations for influenza and pneumonia
Continuance of medication (beta blockers) for patients who have surgery

20. CORE MEASURE FOCUS Prevention of Infection
Preparation of the patient for self care at home
Patient education and discharge instructions related to current disease state, activity, diet, symptoms of worsening condition and follow up care
Prevention of Infection
Removal of urinary catheters within first two days after surgery
Discontinuance of antibiotics within hours of surgery
Outcomes
Readmission Rates
Mortality or death rates

21. CORE MEASURE FOCUS
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
8 key categories that measure the patient and family perceptions of care and services
Communication with nurses
Communication with doctors
Communication about medications
Discharge information
Pain Management
Responsiveness of hospital staff
Overall hospital rating

22. WHO DO WE REPORT THEM TO
CMS-Center for Medicare and Medicaid Services (Medi-Cal)
Monitoring and payment of services ( Medicare)
Medi-Cal is Medicaid in California
TJC- The Joint Commission
Private Entity
Provides accreditation triennially
Provides deemed status on behalf of CMS
CDPH- California Department of Public Health
State Entity
Local Agent for CMS
Monitoring and payment of services ( Medi-Cal)

23. WHERE – PUBLIC REPORTING
CMS initiated voluntary reporting requirements with a financial incentive in 2003 Hospitalcompare.cms.gov maintains 1 year of performance data (information) for all hospitals and public view. Currently, reporting is required and key measures with substantial performance will be rewarded.

24. WHAT IS OUR RESPONSIBILITY AT CHSB
Work as a team to ensure we meet our customers needs Know how our work affects the results both positively and negatively Communicate to our patients and families Achieve our goals Celebrate our successes