Donald D. Wolff Jr. Center for Quality, Safety, and Innovation at Upmc
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DONALD D. WOLFF JR. CENTER FOR QUALITY, SAFETY, AND INNOVATION AT UPMC Ensuring the right patient gets the right care, at the right time, in the right way…every time Annual Report | Fiscal Year 2013 Dear UPMC patients, families, and colleagues: Amid the ever-present national and local health care transformation and its accompanying challenges, the Donald D. Wolff Jr. Center for Quality, Safety, and Innovation at UPMC remains focused and dedicated to achieving high-quality, reliable patient care. For more than seven years, the center has collaborated with system leadership and local sites to provide education, propel innovation, and foster dissemination of evidence-based practices that save lives, reduce harm, and lower costs. Guiding our efforts is a data-driven analytic strategy that enables us to detect meaningful differences, which, in turn, allow providers, patients, and families to make more objective health care decisions with greater confidence. Shepherding that quantitative strategy is a principle of caring, one that spans our patients, our members, their loved ones, and each other. This second annual report builds on our previous work and details projects and outcomes in Fiscal Year 2013. As you read further, you will discover the wide range of our nearly 90 initiatives, a testament to our unwavering commitment to quality of care and patient safety at UPMC. Thank you to all who diligently contribute to the work of the center and the entire system to place UPMC health care among the best in the country. We do this for our patients who trust and rely on us every day. Sincerely, Tamra E. Minnier, RN, MSN, FACHE Chief Quality Officer, UPMC TABLE OF CONTENTS PAGE 3 EXECUTIVE SUMMARY PROJECTS, GOALS, AND OUTCOMES PAGE 5 PATIENT SAFETY A Just Culture Magee-Womens Hospital of UPMC Triggers /International Bloodborne Pathogen Safety Task Force Normalized Ratio (INR) Triggers: Smart Room Catheter-Associated Urinary Tract Infection (CAUTI) Reduction Multidose Medication (MDM) at Discharge Project Campaign Preventing Alaris Pump Alarm Triggers Video Culture of Safety Survey & Steering Committee Reducing Duplicate Patient Records in Registration/Scheduling Fall Harm Prevention Data Flow Hand Hygiene Campaign Richard L. Simmons, MD, Speak Up for Patient Safety Award Hillman Cancer Center Guardrail Compliance Improvement Risk and Safety Management Alert System (RASMAS) Project Spotlight on Safety Home Intravenous (IV) Antibiotic Discharge Plan of Care Standardized Invasive Procedure Universal Protocol Form Hospital and Health System Association of Pennsylvania (HAP) Standardized Process for Anesthesia Blocks and Hospital Engagement Network (HEN) Project Surgical Care Improvement Project (SCIP) Hospital-Acquired Pressure Ulcer Prevention: Interrater The Joint Commission Support Reliability Pilot Theradoc® Oversight Infection Control Forum UPMC Flu Task Force Infection Control UPMC Senior Communities UPMC Presbyterian Line Safety Video Infection Control System Committee UPMC Safe Discharge Report Infusion Best Practice Initiative Wrong-Site Surgery Prevention PAGE 13 PERFORMANCE MEASUREMENT AND REPORTING: ACCELERATING IMPROVEMENT American College of Surgeons - National Surgical Quality International Cardiac Surgery Databas (ISMETT and Improvement Program (NSQIP) UPMC Beacon Hospital) Cardiology and Cardiac Surgery Abstraction and Reporting International Data Quality and Metrics Centers for Medicare and Medicaid Services (CMS) and The International ISMETT/UPMC Presbyterian Specialty Specific Joint Commission (TJC) Public Reporting International Quality Benchmarking Centers for Medicare and Medicaid Services (CMS) Reduce Lean Medical Record Secure Email to Non-UPMC Skilled Avoidable Hospitalization Using Evidence-Based Interventions Nursing Facilities (SNFs) Chief Nursing Officer (CNO) Portal Page Manual Abstraction Elimination Clinical Data Quality Team Palliative and Supportive Care Highmark Quality Blue FY13 Pennsylvania Health Care Cost Containment Council (PHC4) Home Health Face to Face Forms Implementation Physician Documentation Improvement Hospital-Acquired Condition (HAC)/Patient Safety Indicator Physician Incentives (PSI) Project Quality and Safety Wednesday Intensive Care Unit (ICU) Dashboard UPMC Health Plan Hospital Partners Program (P4P) UPMC Virtual Pre-op Chart PAGE 18 IMPROVING PATIENT AND FAMILY CARE EXPERIENCES Day of Conversation Patient Experience Surveying Emergency Medical Treatment and Active Labor Act (EMTALA) Patient Experience Telemedicine Survey Institute for Healthcare Improvement Conversation Project Section 504, the Americans with Disabilities Act, and PARTNER Program Education Reform Patient Experience Discharge Phone Calls at UPMC McKeesport UPMC Heart and Vascular Institute (HVI) Patient Education and UPMC St. Margaret UPMC ‘Your Care. Our Commitment.’ Patient Experience Patient Experience HCAHPS Telephone Surveys at UPMC Symposium Northwest PAGE 20 INNOVATIVE CARE MODELS FOR IMPROVEMENT Care Coordination and Transitions Model Reliable Rounder/Variable Rounder Care Model Emergency Department (ED) U-Turn Program PAGE 21 PROMOTING EFFECTIVE AND EFFICIENT, EVIDENCE-BASED CARE AND APPROPRIATE RESOURCE UTILIZATION Cardiovascular Optimization Program (CVOP) Reducing Hospital Readmissions Children’s Hospital of Pittsburgh of UPMC Magnetic Resonance The Patient Blood Management Program Imaging (MRI) Total Joint Replacement Clinical Pathway Contract Management UPMC East Assessment Crimson UPMC McKeesport Congestive Heart Failure (CHF) Hysterectomy Clinical Pathway Readmissions Pilot Lung Transplant Retreat UPMC Passavant Emergency Department/Lab Flow Magee-Womens Hospital of UPMC Radiology Inpatient Add-On UPMC Seneca Place Optimizing Rehabilitation Services Management PAGE 26 QUALITY EDUCATION Just-In-Time Classes Quality Education Series Nurse Planner Quality Symposium Quality Board Member Education Series UPMC Passavant Emergency Department Legos PAGE 28 PATIENT CARE INNOVATION AND SHARED DECISION MAKING: THE BECKWITH INSTITUTE The Beckwith Institute PAGE 29 OUR TEAM Quality information, resources, and educational tools can be found on UPMC Infonet at Infonet.UPMC.com/QualityEducation. EXECUTIVE SUMMARY MISSION AIM/STRUCTURE The Donald D. Wolff Jr. Center for Quality, Safety, This report provides a review of the work of the and Innovation at UPMC is an enterprisewide Quality Center during FY13. Projects are resource that supports the transformation and presented by goals and outcomes and organized improvement of patient care delivery and by core content areas, including Patient Safety; outcomes utilizing patient-centered cost, quality, Performance Measurement and Reporting: and service metrics. We provide quality Accelerating Improvement; Improving Patient improvement leadership, education, and a support and Family Care Experiences; Innovative Care infrastructure to health professionals across Models for Improvement; Promoting Effective UPMC. The center strives to achieve high and Efficient, Evidence-Based Care and reliability in all aspects of patient care by Appropriate Resource Utilization; Quality increasing the pace of improvement in quality Education; and Patient Care Innovation and and disseminating best practices throughout the Shared Decision Making: The Beckwith Institute. organization. Our quality vision is creating an Interspersed throughout the content areas, you environment in which the right patient gets the will find both systemwide and local (denoted by right care, at the right time, in the right way… ) projects. Driven by national quality goals, every time. In addition, this environment supports our systemwide initiatives are characterized by a culture of safety in which individuals feel free a willingness of many different stakeholders to to speak up about errors or near misses to keep come together in partnerships to achieve our patients safe. improvement. In complement, our local projects support the uniqueness of our varied settings, thereby acknowledging the value of individually OUR TEAM tailored interventions and change, while at the The Quality Center is staffed by 50 trained same time recognizing the potential for the professionals who provide expertise and spread of excellence and best practices. leadership for assessing, developing, implementing, and improving care-delivery processes. In collaboration with hospital PRODUCTIVITY leadership and staff, they identify tools and FY13 has emerged as productive and rewarding. techniques that can help solve the problems The Quality Center team actively engaged inherent in today’s health care delivery in 88 projects with notable strides in the areas environments. of patient safety, blood management, patient satisfaction, data analytics, care coordination, and implementation of local change initiatives through The Beckwith Institute. This work spanned our hospitals, senior communities, international sites, Physician Services Division, and UPMC Health Plan. [ 3 ] PERSPECTIVES Across the enterprise, individuals hold varied As a member of the Ticket to Ride team, I was experiences and perspectives on what we do and immediately“ impressed, not only with the Quality the differences we make. The Quality Center has Center’s commitment to the well-being of the grown in size, maturity, and impact over the past patient but also their thorough knowledge of how seven years, and our team is most grateful for the UPMC systems, outside of their own, operate. opportunity to serve the UPMC community. Because of that, in the Ticket to Ride, we created