Affordable Care ActPolicy and Reimbursement Status

• Authorized by the Affordable Care Act, which added Section 1886(o) to the Social Security Act.

• Quality incentive program built on the Hospital Inpatient Quality Reporting (IQR) measure reporting infrastructure.

• Pays for care that rewards better value, patient outcomes, and innovations, instead of just volume of services.

Recognized as a “high performing” hospital by the Centers for Medicare & Medicaid Services (CMS) National Coordinating Center for Value Based Purchasing (VBP) and Hospital Quality Reporting.

Hospital Value Based Purchasing

FY 2015 Finalized Domains and Measures/Dimensions

12 Clinical Process of Care Measures Overall 2012 Inpatient Core Measure compliance was 99.3%. Overall 2012 Outpatient Core Measure compliance was 98.3%. Received recognition from the Joint Commission as a Top Performer on four key quality

measures for 2011 that included: Heart Attack, Heart Failure, Pneumonia and Surgical Care. Named to the Georgia Hospital Association’s (GHA) Partnership for Health and Accountability

(PHA) Core Measures Honor Roll in the Chairman’s category (99.02% to 100% score).

Evidence based practice protocols/orders in place for the following:• AMI (Acute Myocardial Infarction)• PN (Pneumonia)• VTE • SCIP (Surgical Care Improvement Project)• Stroke• HF (Heart failure)• Early elective deliveries

Universal Protocol Indicators• Patient identity & procedure to be performed, physician site marking, informed

consent, current H&P, available diagnostic studies & equipment, time out, and confirmation of supplies and sterile instrumentation.

• Maintained 100% compliance in 2012

12 Clinical Process of Care Measures ContinuedMedication Management

• Implemented a barcoding system for medication distribution which reduced Medication Variances by 20% compared to CY 2011.

• PharmD rounding on patients to ensure patients understand medications.Emergency Department

• Radiologists are notified upon decision for CT Head on suspected stroke patients to ensure results within 45 minutes of presentation.

• Early recognition process for Sepsis in ED • Average 66 minutes for door-to-balloon time against the national benchmark of 90

minutes.Monitoring and Review

• Concurrent Rounds• Rounds are done 7 days a week to ensure all processes and protocols are in place

based on diagnosis and condition.• Patient Discharge

• Timeout at discharge to review point of care and protocols.

8 Patient Experience and Care Dimensions Ranked 6th out of 20 in the small hospitals category by Georgia Trend. Pink Ribbon Facility ASMBS Bariatric Surgery Center of Excellence

High Reliability Initiative• From the top to the bottom – both staff and physicians• Patient Safety Organization provides framework for implementation

• Safety first on all agendas (regardless of meeting topic)• Reward and recognize safety success• Reinforce safety behaviors and Error Prevention Tools

• 2013 Error Prevention Tools• Support the Team• Ask Questions• Focus on the Task• Effective Communication Every Time

• AIDET is always practiced to keep the patient informed.• Hourly Rounding

• Pain, Potty, Position and Possessions• Nurse Manager Rounding• Discharge Call Backs

• Identifying Trends

8 Patient Experience and Care Dimensions Continued Inpatient Units

• Patient Communication Boards• Questions for your caregivers• Bedside shift reporting• Personalized Discharge folders• Handouts to patient and caregivers regarding medication side effects for new medications

Emergency Department• Implemented 30-minute or less “Door to Doc” ER Pledge with average wait time of 21

minutes.• Designated as Level III Trauma Center

• Physicians and staff trained to provide prompt assessment, resuscitation and stabilization of acutely injured patients.

Elevated NICU to Level II • Specially trained NICU Medical Director, RN’s and ancillary staff in caring for critically ill

neonates.• Prevents separation of mom and baby.

Specially trained staff• Central Line Management• Wound Care• NICHE

8 Patient Experience and Care Dimensions Continued Fatigue Awareness

• Implemented a policy in response to The Joint Commissions Sentinel Event Alert on Worker Fatigue.

• Incorporated into staff roundingHousekeeping Checklist

• Completed at patient discharge with automatic work orders generated for identified issues.Patient Satisfaction Surveys

• Conducted quarterly on sample of patients.• Monitored to identify trends, process improvements and recognize staff.

Comprehensive Risk Assessment• Every department, every year with continual compliance monitoring.

Campus-wide ADA project to better accommodate persons with disabilities.

5 Outcome Measures Honored with an “A” Hospital Safety Score by The Leapfrog Group using publicly available

data on patient injuries, medical and medication errors, and infections. In 2012 achieved zero hospital-acquired central line infections, ventilator-associated

pneumonia, or catheter-associated urinary tract infections in the ICU and zero catheter-associated urinary tract infections on the general nursing units.

• Daily Safety Huddle and Daily Departmental Huddles• Starts with Safety Success.• Addresses safety issues and/or anticipated safety issues.• Includes input from each department.• Addresses days since SSE, last fall with injury and days since lost time injury.

• Any incident or event scored using the SSER nomenclature.• Implementation of Skin Team

• Monitors patients to prevent pressure ulcers• Mortality Reduction Tactics

• First recognized RRT team in area• SBAR Communication (situation, background, assessment, & recommendation)• Early Warning Scoring System

5 Outcome Measures ContinuedEducation regarding fire safety in invasive procedure areas

• Physicians, staff, clinical contract providers & vendors.• Conducted fire drills in all invasive procedure areas.

Implementation of Fall Team • Performs a root cause analysis on every fall. • Reduced Inpatient fall rate to 1.39% compared to 1.70 for CY 2011.

Surgical Site Infection Surveillance• Hip replacements• Knee replacements• Colon surgeries• Abdominal hysterectomies• Lap gastric bypass

Bundles• Practices put together to achieve best outcome.

• VTE• Sepsis• Central Line Insertion• VAP

5 Outcome Measures ContinuedEnvironment of Care Rounds

• Conducted by Infection Control and the EOC committee.Implementation of SurgiCount process in OR and FFCB

• No unintentional retained foreign bodies.• Investment in patient outcomes.

Fetal Monitoring• Competency modules completed by all physicians and staff.

EVS staff education “Saving Lives”• Role of surfaces in the transmission of infections, disinfection and isolation. • Work practice controls and safe handling of sharps.

100% testing of Hospitalized patients who met the criteria for MRSA screening.

1 Efficiency Measure 2012 Blue Cross Blue Shield QHIP rewarded Trinity with $174,593.00 for Quality scores. Achieved "Exemplary" status for NICHE program.

NICHE Certified Facility • Geriatric RN’s on all units who are specifically trained to address the needs of elderly

patients.Discharge Call Back System

• CNO and designated staff members call back all ED patients, inpatients and physician practice patients to ensures patients needs are met and to determine that follow up is taking place with home health, prescription drugs, etc.

Case Management/Social Worker Involvement• Schedule follow-up appointments after hospitalization as ordered by attending physician.• Assist indigent or under-insured patients with medications, services, DME, etc. that they may

need when retuning home.• Focus on specific medications that may be expensive for the patient to ensure the patient has

adequate insurance coverage and/or is able to afford their copay prior to the patient being discharged to prevent patient being from being readmitted.

• Special CHF patient education is reviewed with patient and signed discussing medications, daily weights, avoiding tobacco, etc.

Patient Education regarding opioid use, anticoagulants, and stroke awareness.

Build a Shared Vision Expect 100% Performance

Create a Culture (Linking Performance to Purpose)

Treat the care as if it is your child, spouse or your

mother

Implement Effective Processes / Systems

Create a Fail-Safe Process (Ensure the highest

likelihood of success)

Establish Accountability We all own the result!

Empower Staff’s Performance to Achieve

Desired Outcomes

Teams / Training / Tools / Knowledge

Recognize Results Showtime, Nightmare or Dreams

Keys to Organization Change

Financial Impact of Value Based Purchasing

African American Impact

Employee Mix • 35% of Trinity Hospital employees are African American who utilize our hospital’s

services on a regular basisPatient Population

• No unintentional retained foreign bodies.• Investment in patient outcomes.

What really matters…

Meeting your highest s andards.t