New Lung Cancer Screening at JSCC

Provider Focus March 2015

New Lung Cancer Screening at JSCC Lung cancer is the leading cause of cancer death in the United States, yet more than 80 percent of lung cancers have a chance to be cured if detected early. Approximately 85 percent of lung cancer occurs in current or former cigarette smokers. It is estimated that there are more than 9 million current and former smokers in the United States, many of whom are at high risk of developing the disease.

Lung Cancer Screening Computerized tomography (CT) screening uses special X-ray technology to obtain image data and then uses computer processing of the data to show a cross section of the body tissues and organs.

What is the goal of LDCT lung screening? The goal of LDCT (low dose CT) lung screening is to save lives. Without LDCT lung screening, lung cancer is usually not found until a person develops symptoms. At that time, the cancer is much harder to treat and most are not curable.

How effective is LDCT lung screening at preventing death from lung cancer? Studies have shown that LDCT lung screening can lower the risk of death from lung cancer by 20 percent in people who are at high risk. It has also been shown that with screening, 4 out of 5 cancers detected may potentially be curable.

How is the exam performed? LDCT lung screening is one of the easiest exams you can have. The exam takes less than seconds, no medications are given, and no needles are used. You can eat before and after the exam. You do not even need to get changed as long as the clothing on your chest does not contain metal. One must, however, be able to hold their breath for at least 6 seconds while the chest scan is being taken.

How often will I be screened? LDCT screening is an ongoing process and you may undergo yearly screening for several years.

How many people will be found to have lung cancer? For every 100 people screened, only 1 will be found to have lung cancer.

What are the risks of screening? The risk of finding an abnormality on the CT screening is 1 in 4. Ninety-six percent of these abnormalities will not be cancer. If an abnormality is found, one may have to undergo further testing to determine the exact nature of the abnormality. Most of the testing will be in the form of other imaging tests. Very few people will require an invasive (needle biopsy) test. Radiation exposure from the test is minimal. The amount of radiation you will receive is less than six months of natural background radiation. Some cancers that are found may never have become a problem and would not have affected the person's longevity. This is called "over diagnosis," and we do not know how often this occurs.

Qualifications for Lung Cancer Screening The United States Preventative Services Task Force (USPSTF) is now recommending annual low dose computed tomography (LDCT) scans for high risk individuals. A person is considered high risk if they meet all of the following criteria:  Adults 55-74 years  Asymptomatic (no signs or symptoms of lung cancer)  Greater than 30-pack per year history (one pack year smoking one pack per day for one year, 1 pack = 20 cigarettes)  Current smoker, or have quit within the past 15 years A written order must be received from your health care provider for LDCT. For the initial screen one must receive a written order during a face to face lung cancer screening, counseling and shared decision making visit. For subsequent screens, one must receive a written order, which can be obtained during any subsequent health care visit.

Insurance Coverage The Affordable Care Act mandates that private insurances cover all screening exams with a grade B evidence or greater (LDCT lung cancer screening meets this). Medicare will also cover the cost. If a person does not have insurance, then the screening will cost $199.

How to schedule a screening All that's needed is a health care provider's written order as outlined above. For additional information, talk to your doctor or call UnityPoint Health - Des Moines Radiology at (515) 263-5370.

DMU Foot and Ankle, a Proud UnityPoint ACO Partner

Members of the podiatric physician group at Des Moines University are committed to providing the best possible care to UnityPoint patients. DMU Foot and Ankle is one of the largest and most experienced groups of foot and ankle specialists in the state. All are board certified by the American Board of Foot and Ankle Surgery. The practice is located in the easily accessible, on-campus Des Moines University Clinic (Grand Avenue and 31st Street).

Collectively, our six clinicians treat the entire spectrum of foot and ankle conditions with a patient management emphasis on prevention and using non-operative measures prior to recommending surgical intervention. Areas of interest include but are not limited to prevention and treatment of diabetic foot complications, treatment of occupational and athletic overuse injuries, surgical correction of developmental foot conditions when conservative measures are unsuccessful, treatment of acute soft tissue and bone/joint injuries, fracture management and providing basic foot care to help seniors maintain an active lifestyle.

We work closely with the patient’s primary care physician and other specialists to create a team approach with the goal of achieving the best outcome for each patient in a cost-effective manner. The DMU Foot and Ankle clinicians provide consultations and patient care at all UnityPoint Health – Des Moines medical centers.

Affiliated with an academic health science center, DMU Foot and Ankle offers the latest technology in clinical and diagnostic services. Examples include the Human Performance Lab used for gait analysis, bone density testing, 3-D digital scanning technology in prescribing orthotics and digital x-rays. As one of the largest podiatric groups in Des Moines, we make available quick scheduling and prompt appointments. Our hours are Monday-Friday. 8:00 a.m. - 5:00 p.m. with Friday afternoons reserved for urgent care and minor office-based procedures.

At DMU Foot and Ankle we believe that ambulatory health contributes to a person’s overall health and well-being. As such, we offer comprehensive medical and surgical care of the foot and ankle. Quality in Action

Quality Consultation: Fall Prevention for Community Dwelling Older Adults

By Lisa Baumhover, Geriatric CNS

Starting this month, Quality in Action will begin to publish quality consultations sub-mitted by our Clinical Nurse Specialists (CNS) at UnityPoint Health Des Moines. These advanced practice nurses are clinical experts with graduate education at the master’s or doctorate level and are Board Certified in specific specialty areas. CNSs are focused on continuous improvement of patient outcomes and nursing care based on evidence-based nursing interventions. The goal for these articles is to enhance your clinical knowledge. We are pleased to be able to offer you this new venue of information. – The Editors

The Iowa Department of Public Health reports that unintentional falls are the leading cause of emergency room visits, hospitalizations and deaths for Iowans 65 years of age and older. Those over age 85 are seven times more likely to die from a fall as their younger counterparts, the 65-84 year olds. With Iowa’s aging population, the number of unintentional falls continues to increase each year resulting in more than 430 reported fall-related deaths in 2012. These unintentional falls add up to more than 135 million dollars in hospital costs each year.

In an effort to decrease the numbers of unintentional falls for this population in our community, UnityPoint Health Des Moines is sending our two Gerontological CNSs to the Stepping On Leader Training. Cheryl Lillegraven and Lisa Baumhover, advance practice nurses specializing in gerontology, have been accepted to attend the three day workshop in Johnston. Two sessions of the Stepping On program have already been scheduled for 2015. There will be a spring session on the Iowa Methodist campus and a session in the fall on the Iowa Lutheran campus. Stepping On will dovetail nicely with the Matter of Balance program already being facilitated three times per year by Karen Jones, RN Trauma Coordinator at UPHDM.

Stepping On is an evidence-based fall prevention program that empowers older adults to carry out health behaviors that reducethe risk of falls. The workshop is offered once a week for seven weeks using adult learning and self-efficacy principles. The program will have a variety of guest speakers throughout the seven weeks including a physical therapist, occupational therapist and a pharmacist. Participants will learn balance exercises and specific skills to prevent falls. Other topics to be covered are home and environmental safety, vision, and medication review. The goal of the seven week work-shop is to build older adults’ confidence in their ability to manage their health behaviors to reduce the risk of falls and to maintain active and fulfilling lives.

Stay tuned for ongoing information about this program and others from our CNS’s. Quality Through Documentation: Transferring Patients in Epic

By Sandy Petersen & Kelley Blackburn, Clinical Quality

Patients going to the following procedural areas MUST be transferred in EPIC:

 Periop (Operating Room)  Cath Lab  Endoscopy  Interventional Services Radiology Unit Clerks will now be responsible for transferring patients when they leave the floor to go to these areas. When a Unit Clerk is not available, this responsibility falls to the patient’s RN or Charge RN. Patient Transporters will notify the Unit Clerk prior to physically leaving the floor with the patient so the patient can be transferred in Epic immediately. Why is this important?

• A recent patient safety issue (related to a patient getting inappropriate medications) was identified as a result of the patient not being transferred appropriately in Epic. • Not only does this assist with Phase of Care, it ensures correct documentation timing in the procedural areas. • Any medications ordered during the procedure will be delivered to the correct area. • Procedural medications given to the patient there are automatically discontinued upon the patients return to the floor. Epic Process: How Can You help*?

1) Go to “Unit manager” or “Unit Census”; 2) highlight the patient’s name; 3) select “Transfer”.

4) Select area/unit patient going to; 5) select transfer. NOTE: “Hold Bed” must be selected if patient will return to your unit.

6) Once “Transfer” is selected and hold old bed is checked, this moves patient from Current tab to expected tab.

7) When patient returns to floor, select transfer to bring patient back to “Current Census”. *If your area has a different process to transfer patients – please contact your manager/supervisor to ensure your patients are getting transferred correctly. Quality in Action: UnityPoint Health Des Moines Quality Agenda/Plan – 4th Quarter 2014 Results

By Kathie Nessa, Clinical Quality

Please find results of the 2014 progress report of the UnityPoint Heath Des Moines Quality Agenda/ Plan on the following pages.

OBJECTIVE 1: Reduce Acute Hospital Readmissions

Statu s Tactics

√ Plan & Implement the ED Consistent Care Program LEGEND

Status of √ Plan & Implement the Emergency Department Observation Unit Objectives

Establish a COPD workgroup to implement the GOLD standard across the DM ___ Not started √ region

√ Implement a High Risk readmission assessment in Epic S – Started

S Further develop the role of the PCF including multidisciplinary discharge planning √ - Completed

S Implement the use of Case Management, Social Service and Home Care in the ED

S Improve the communication/transition with SNF

Measures of Success

Not Met: Achieve an acute hospital 30 day all cause readmissions rate of 10.9% or less

 YTD 11.2% (Rolling 12 months including discharges through Nov); 2013 rate was 11.35%

OBJECTIVE 2: Improve Patient Care & Support Service Processes

Tactics Statu Tactics Status s

√ Implement the Drug Assist Program √ COPD Continuum Care Best Practice Initiative- Phase I

√ Implement Safe Patient Handling (Diligent) S Tracheostomy Care

√ HIM Release of Information Process √ Wound Healing Center

√ Behavioral Health Clinic Workflow √ Endoscopy Process Improvement

√ Behavioral Health Gap Analysis S Infusion Pharmacy

S Outpatient Scheduling √ HEICS to HICS Conversion √ Hospitalist Efficiency √ Ebola Response Process Development

√ Linen Project Consultation with CCU at Methodist to complete BEACON √ √ Pediatric Gen Peds Workflow application

√ Lymphedema Clinic Project S Vascular Access

√ Pediatric Gown Project S Patient Transfers to Procedural Areas

√ Phlebotomist Allocation S IMMC Maternal Services 5S Supplies

S ED/ICU remodel project S Cardiovascular Pts 6am CXR

√ Specimen Collection Process √ Therapy Scheduling Program

S Radiology CT Scheduling and Utilization S Courier Project

S OR Scheduling S Pharmacy Order Verification

S Nursing Dashboard Development S Translation Services Dashboard

S Develop & Implement a PI Internship Program S Denial Letters Workflow

Develop plan & curriculum to spread Adaptive Design S Pharmacy Layout/workflow S to the Ancillary/Outpatient Areas S Analysis of C-Arm Resources in IMMC OR

Retool the Patient Service Excellence Team to S Home Health Care Consistency of Nursing Resources S provide greater focus on outpatient services S Reducing Denials for Radiology Observation Patients

Measures of Success

Met: Measures of Success for PI projects will be predetermined for each initiative as it is implemented

Met: Four new units/departments will be trained in the process and tools of Adaptive Design

 IMMC and MWH Surgery Departments, Blank Endo, Hematology, Infusion clinics, and Integrated Services Directors completed training Met: At least 6 boot camps will be provided for leadership training in Adaptive Design

 6 Boot Camps were completed in 2014 with a total of 82 participants

OBJECTIVE 3: Improve the Efficiency of the Patient Stay

Status Tactics

√ Establish a COPD workgroup to implement the GOLD standard across the DM region S Determine gaps in meeting Heart Failure Accreditation Standards & implement measures to obtain accreditation

S Analyze the Renal, HF, Pneumonia, Diabetes & Respiratory DX w Ventilation to determine opportunities to reduce cost

Develop tactics on how to address Greater than 7 Day LOS Patients

Measures of Success

Reduce the cost/case to the target or below for the following patient populations:

Met: COPD < $4,231; Actual $4,107 $124

Not Met: Renal < $3,655 Actual $5,152 ($1,497)

Met: Heart Failure < $4,447; Actual $4,108 $339

Not Met: Pneumonia < $3,805; Actual $3,877 ($72)

Not Met: Diabetes < $3,127; Actual $3,252 ($125)

Met: Respiratory DX with Ventilation < $27,123; Actual $14,968 $12,155

Adjusted Baseline reflects case mix through Nov. YTD

OBJECTIVE 4: Improve Coordination of Care to support ACO work

Statu Tactics s

S Further develop the role of the PCF including multidisciplinary discharge planning

S Expand bedside reporting & white board use to all nursing units

 Develop capability to provide analytics using Medicare claims data (use of InfoMed & Exploris)

S Support system work focused on High Risk patients

S Improve handoffs from inpatient to the outpatient setting

Implement use of Post-Acute Algorithm

Increase resources devoted to medication reconciliation at transition points

S Implement IHA’s ChimeMaps to help focus opportunities

S Expand Epic Care Link to partner organizations

S Implement automatic call to PCP to schedule the post discharge visit

Measures of Success Met: Reduce Medicare PMPM inpatient cost by $9.37 or more from 2013

 PMPM reduced $13.79; $239.29 to $225.50 as of Sept 2014 data Not Met: Reduce the all cause readmission rate to 10.9

 YTD 11.2% (Rolling 12 months including discharges through Nov); 2013 rate was 11.35% Not Met: Increase the HCAHPS Transitions of Care domain to 83.8 (Stat. sig. increase from 2013 score of 83.3)

 83.4 YTD (69th percentile); has improved 0.1 from last year.

OBJECTIVE 5: Eliminate preventable complications and unnecessary care to improve quality and support sustainability

Status Tactics

√ Identify Hospital Acquired Conditions to target: -VTE -HAPU -Falls -Sepsis -CAUTI

S Implement Nurse driven CAUTI protocol

S Implement skin standards

S Spread NICHE program to additional nursing units

S Provide reeducation on the Beers criteria

S Develop & Implement a Sleep Apnea Protocol

S Develop Epic report for blood utilization & provide ongoing feedback to physicians

S Establish physician feedback loop for NSQIP data

S Implement Sentri7 software (Pharmacy clinical decision support system & Infection Prevention Surveillance system)

√ Implement CAUTI surveillance on the Med/Surg units (including feedback to units re: rates)

√ Develop a NetLearning Module on Sepsis with all E.D. & direct care RN’s & PCTs completing the module

√ Implement a new Sepsis Screening tool

Rollout the revised standardized order set for glycemic management

Measures of Success

Not Met: Decrease CAUTIs in Critical Care to a SIR < 0.5

 IMMC SIR= 0.66; ILH SIR= 1.65; PICU= 0 CAUTIs Met: Increase the surgery patients who received appropriate VTE prophylaxis within 24 hrs. pre/post-surgery to 98%  100% for IMMC/MWH and ILH (Data through September) Partially Met: Increase the stroke patients who received VTE prophylaxis to 95%

 97% for IMMC/MWH and 90% for ILH (Data through November) Not Met: At least 90% of sampled cases receive VTE prophylaxis per CMS definition (VTE1 &VTE2)

 VTE1 IMMC 85.7% & ILH 84.9%; VTE2 IMMC 93.9% & ILH 88.4% Met: Reduce falls with harm (level 3 & above) to 0.07/1,000 patient days or less

 UPHDM rate is .069/1,000 patient days Not Met: No hospital acquired stage 3 or 4 pressure ulcers

 There have been three stage 3 HAPUs (IMMC-2; ILH-1) Not Met: 80% or more RBC transfusions have a pre transfusion Hgb < 8

 74% adult inpatients at UPHDM

OBJECTIVE 6: Strengthen the UPHDM Culture of Quality & Safety

Statu Tactics s

√ Implement the Diligent safe patient handling programs

√ Integrate the Safe Patient Handling Program and the Mobility work into one initiative

√ Implement new Occurrence Reporting system including initial and ongoing training

S Administer AHRQ’s Culture of Safety Survey

Establish mechanism for feedback/analysis re: reported occurrences & near misses including those S reported by the residency programs

Implement a Nursing Peer Review process to identify best practices and improvement opportunities

S Implement TeamSTEPPS in the IMMC ED

Leverage the use of the Simulation Lab to improve interprofessional communication skills and assist in S principals of patient safety

Leverage the use of the Simulation Lab for credentialing and privileging providers

Measures of Success

Not Met: Increase the GPTW Survey question “This is physically a safe place to work” to 90 (previously at 88)

 88 UPHDM score Not Met: Increase the participation rate for the Culture of Safety Survey to 50% or greater.

 34.4% Response rate Not Met: Increase the % positive responses for the composite score for “Hospital handoffs & Transitions” in the

Culture of Safety Survey to 50% or greater (past score at 37%)

 42.2% for UPHDM Met: Increase the Resident Culture of Safety Survey % positive responses to the question “Important pt. care

information is often lost during shift changes” to 50% or greater (previously at 35%)

 56.6% for combined residency program score Not Met: Increase the Resident Culture of Safety Survey % positive responses to the question “When a mistake is

made, but has no potential to harm the pt., how often is it reported” to 60% or greater (previously at 44%)

 38.2% for combined residency program score

OBJECTIVE 7: Optimize the use of our electronic medical record

Status Tactics

√ Implement EpicCare Link

√ Expand EpicCare Link to partner organizations

√ Assist in the training & implementation of Epic at our rural affiliates

√ Optimize the Epic system by sharing records between transferring hospitals (rural/urban)

S Reduce the use of cut and paste in the Medical Record

S Implement the recommendations developed by the Care Plan workgroup & develop a mechanism to measure/audit the compliance

S Implement the Work list

√ Implement the use of a Continuous Flow sheet Note

Measures of Success

Not Met: Increase Medication Bar Code scanning compliance to 95%

 IMMC= 93% ; ILH = 94%; MWH= 93% Partially Met: Obtain a 90% compliance rate per the care plan audit/measurement tool

 Two out of the six measures in the audit reached 90% compliance - 99% Was the care plan initiated within 24 hrs. of admission? - 87% Does the nursing care plan show interventions which include other disciplines when appropriate? - 93% Does the RN verbalize how the pt’s. care plan is updated based on ongoing assessment of pt. needs and the pt’s. response to interventions? - 67% Is there evidence the pt. Care Plan was reviewed with every change in nursing assignment? - 76% Was the care plan updated to reflect the change - 57% Of the pt’s. who have a preexisting condition or a psychosocial need impacting their current hospitalization, is it reflected in the care plan? Met: Meet or exceed Meaningful Use stage I and II metrics

Quality in Motion: Healthwise: Patient Education Materials

By Carla Orr, Nurse Champion, Healthwise Implementation Team

UnityPoint Health has chosen Healthwise to be the standard platform for all patient education materials across affiliates. The Healthwise product meets the goals of delivering consistent health content and patient education across the entire organization.

The emergency departments will go-live with Healthwise on April 30th when the contract expires with ExitCare, the current patient information platform. Training for the emergency departments begins April 24th. The remaining areas, including Home Health Care and the UPH Clinics, begin training June 17 with a go-live date of June 23.

Healthwise can be accessed in several ways. Clinicians will be able to access Healthwise for patient instructions from within Epic. Suggested patient education will automatically be generated from the problem list and added to the After Visit Summary. Patients will be able to access the Healthwise knowledgebase through the MyUnityPoint patient portal as well as through the UnityPoint Health’s external website. A video library will also be available for patient use. The knowledge-base contains more than 8,000 health topics including health conditions, symptoms, medications, medical tests, and wellness and prevention.

Patient education materials from Healthwise are evidence based, written at a 4th-6th grade reading level, and usually 1 to 3 pages in length. Education materials are available in both English and Spanish. Healthwise also offers patient instruct-tions for the most common diagnoses in 10 additional languages.

This is a great time for departments, providers, etc. to review any “home grown” educational materials or smart text/free text that is entered into the patient education section of Epic. The UPH-DM Patient Education Committee is completing a gap analysis to identify what we have that are “home grown” versus what is available in Healthwise. Please notify Cheri Miller at [email protected]. you or your area has any “home grown” patient education information or materials you are currently using as soon as possible (ASAP)! Be sure to list the name, any form numbers, where it may be located, i.e., Print Center, DocuCenter, etc. for follow up. CardioMEMSTM HF Monitoring Iowa Lutheran Hospital is the first Iowa hospital to offer CardioMEMS HF™ System, the first and only FDA-approved heart failure monitoring device that has been proven to significantly reduce hospital admissions when used by physicians to manage heart failure. Read the Des Moines Register article here. Younker Rehab Accreditation

We are pleased to share that Younker Rehabilitation’s accreditation survey by the Commission on Accreditation of Rehab Facilities (CARF) has confirmed our 3-year accreditation. This reaffirms the exceptional care Younker Rehabilitation is providing to individuals in our community with disability. A few of the strengths highlighted by the surveyors were: a team passion for patient care, knowledgeable staff, and medical leadership who continually strive for technology learn. This is a testament to our team at Younker Rehab who help assure the best outcome for every patient every time. Problem List as a step in Medication Reconciliation The problem list will be available to you as a step in medication reconciliation for quick access. You can skip this step in Med Rec if you have already addressed the problems elsewhere. This will be added to All Physician Medication Reconciliation steps including the surgeon navigators.

Dr. Nath Recognized by American Heart Association Dr. Amar Nath recently received the From the Heart award from the American Heart Association at their annual Heart Ball on February 14. Dr. Nath is from UnityPoint Clinic – Cardiology. Congratulations to him on this well-deserved award!