Introduction to Quality at University Hospital



Introduction to Quality at University Hospital

Neither individuals nor institutions drift into Excellence. The commitment to excellence requires purposeful intent, aggressive goals and standards, and strong leadership support. The physician leaders, the Administration and the Board of University Hospital have a stated commitment to compare favorably with the best facilities anywhere, to be in the top tier on any measure of excellence.

We participate in voluntary reporting of the Medicare / Joint Commission “core measures” of quality in the current and upcoming publicly available information. Early on, we became participants in all six of the topics addressed in the Institute for Healthcare Improvement’s 100,000 Lives Campaign and later in its 5 Million Lives expansion. University Hospital efforts have been recognized in multiple regional and national forums, including I H I, Voluntary Hospitals of America (VHA) at state and national levels, the National Patient Safety Foundation, Magnet Hospital national forums, Infection Control & Epidemiology Association, and others.

Tools available to physicians and physicians-in-training include standard order sets for most of the common conditions requiring hospitalization. These sets may be found at the “M D Orders” site on the hospital Intranet, and may be printed off as needed. They provide a level of decision support as prompts for the usual elements of care for each diagnosis. However, they are not “cookbook” medicine and thus require intentional editing for the individual needs of each individual patient. Feel free to use them.

Core measure items are noted in the first table below. We seek to meet these content-of-care measures in a highly reliable and consistent manner, with a goal of at least 95% performance of the whole bundle (“perfect care score”) for each of the areas. Achieving high levels of “perfect score” patients requires giving attention to detail to evaluate each patient for each of the key components, ordering and delivering the care for which the patient is eligible, and documenting in the record any exclusionary reasons for omission of key components (e.g., active bronchospasm for beta blockers). The second table below demonstrates the poor performance that an inconsistent pattern of meeting expectations creates.

We also focus on a number of safety issues that impact care and outcomes. Outcomes include complications, such as potentially avoidable adverse events, death, injury and length of stay. Research has shown that risk of adverse events is about 1 in 6 for each day of critical care unit stay and about 1 in 24 for each day of general unit stay. Thus, the more quickly we can attend to the specific needs of the patient according to a well designed and communicated plan, the more likely an uncomplicated stay in our facility.

Adverse events of concern include

• ventilator associated pneumonia in ICUs (addressed through a “vent bundle” of attention to prophylaxis for DVT, prophylaxis for stress ulcer, attention to position – at least 30 degrees of elevation of head of bed, and aggressive weaning strategies)

• Central line associated blood stream infections (addressed through careful assessment of need for central line in the first place and for continuation of the line on frequent basis, sterile technique in insertions, avoiding femoral lines whenever possible, favoring enteral feedings over TPN whenever possible, avoiding unnecessary blood draws from lines, optimizing blood sugar control and antibiotic appropriateness).

• Surgical site infections (addressed through optimal use of perioperative prophylactic antibiotics, clipping rather than shaving operative field, optimal temperature and oxygenation, seeking good blood sugar control).

• DVT / P E prophylaxis in appropriate patients based on risk. Standard orders for prophylaxis provide decision support regarding risk scoring and regimen choices.

• Clinical deterioration. A rapid response team (at University, the “MET”, or medical emergency team) responds to calls from front line caregivers for acute changes in status of the patient. Our goal is to avoid codes on the general units by heading off potential “rescue vs. failure to rescue” situations through early recognition of sepsis, fluid overload, respiratory failure and similar emergencies. Early intervention and, where necessary, transfer to a critical care unit can often avert a code situation. The response team (nursing supervisor, lead respiratory therapist, ACLS trained resource nurse and IV team member) has available an approved set of orders they can initiate to stabilize and begin evaluation, and notifying the physician is a key part of the process.

• Safe medication use. Reconciliation of medications upon admission, upon transfer to another level of care, and upon discharge from the hospital is a key element of safe care. Home medications may need adjusting or changing on admission; home medications need to be considered at every level of care, including discharge to the next care setting. Our forms on admission, in the hospital and at discharge provide a uniform way to achieve physician intent regarding medications.

• Unsafe practices to be avoided include

• poorly legible handwriting in notes and orders

• untimed and undated entries in the chart

• unsafe abbreviations to be avoided (see other orientation material)

• incomplete information at “handoffs” between care givers

• poor communication with other physicians, members of the care team, the patient and family.

Resources available to you in your learning experience here include, of course, your attending physician. Nursing leaders on each unit are a great resource to clarify how various processes work and help define the resources available to you. The Administrative Nursing Supervisor, in charge of the house at all times, is a tremendous asset to all and can be reached at 774-7051 should a need arise. Other key information is available in the other orientation material.

Table 1. Core measures + 90th and 50th percentile thresholds among JCAHO hospitals.

| |Executive Summary - University Health Care Systems |Top 10% |Top 50% |

| | |JCAHO** |JCAHO** |

| | | | |

|AMI |# patients | | |

|P |Aspirin with in 24 hours of arrival |100% |97% |

|P |Aspirin at discharge |100% |97% |

|P |Beta-blocker on arrival within 24 hrs. of arrival |100% |94% |

|P |Beta-blocker at discharge |100% |96% |

|P |ACEI/ARB at discharge with LVEF ................
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