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February 16, 2011
Quality & Patient Safety at Vanderbilt
Department of Biostatistics
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Crossing the Quality Chasm6 AIMS
S safeT timelyE effectiveE efficientP patient-centeredE equitable
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National Priorities PartnershipConvened by National Quality Forum
National Priorities and Goals:1. Engage patients and families in managing their
health and making decisions about their care2. Improve the health of the population
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3. Improve the safety and reliability of America’s health care system
- infection- adverse events- hospital level mortality rates- 30-day mortality rates post hospitalization
4. Ensure patients receive well-coordinated care within and across ALL healthcare organizations, settings, and levels of care
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5. Guarantee appropriate and compassionate care for patients with life-limiting illnesses
6. Eliminate overuse while ensuring the delivery of appropriate care
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Triple AIM1. Health of the
Population2. Reduced Costs in
Health Care3. Improve Safety,
Reliability, and Experience
- D. Berwick
Dr. Donald Berwick
Quality Pillar We relentlesslypursue and
measureourselves against
the highest qualityperformance in allareas, from patientcare to scholarship
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Quality Pillar: Q2 FY2011 ResultsGoal Q1 FY2011
ResultsQ2 FY2011
ResultsQ3 FY2011
ResultsQ4 FY2011
ResultsFY2010 Results Threshold Target Reach
Reduce O/E Mortality*
0.71* 0.78*Data through
Nov 2010
.73(FY11-0.75)*
0.76* 0.73* 0.71*
Reduce Healthcare Associated Infections
0.82 0.85Data through
Nov 2010
1.21 1.17 1.11 0.98
Reduce Adverse Events
9.24 9.42 9.50 8.08 7.67 7.27
Achieve Top Performance in Clinical Programs
86% 89% 89% 85% 90% 95%
Improve System Reliability
4 10 Not Applicable
6 - 7 8 - 9 10 - 12
Establish Quality Improvement Learning System
Progressing Developing Curriculum
Not Applicable
Develop curriculum
Develop standard tools and methods
Deliver to identified
target group
*Statistics for O/E reflect recalibration in October 2010, resulting in change to FY2011 goal to reflect Top 10, Top 5 and Top 3 of the US World & News Report peer group
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Reduce Healthcare Acquired Infections
GoalQ1 FY2011
ResultsQ2 FY2011
ResultsQ3 FY2011
ResultsQ4 FY2011
ResultsFY2010 Results Threshold Target Reach
Ventilator Associated Pneumonia
1.19 1.11 1.69 1.43 1.26 1.09
Central Line Associated Blood Stream Infections (ICU)
1.01 0.69 1.69 1.45 1.28 0.85
Surgical Site Infection
0.85 0.91Data through
Nov 2010
1.12 1.15 1.09 0.96
Catheter Associated Urinary Tract Infection
0.42 0.53 0.74 0.67 0.63 0.56
Hand Hygiene 79% 80% 77% 85% 90% 95%
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Hand Hygiene
Area
Numerator YTD FY2011
(Jul-Dec)
Denominator YTD FY2011
(Jul-Dec)
Compliance Rate YTD FY2011
(Jul-Dec) Threshold Target Reach
Adult Outpatient 4407 4733 93% 85% 90% 95%
Pediatric Outpatient 1005 1223 82% 85% 90% 95%
VPH 118 118 100% 85% 90% 95%
VCH 4355 6000 73% 85% 90% 95%
VUH 3019 4232 71% 85% 90% 95%
TOTAL 12904 16306 79% 85% 90% 95%14
Overall Historic Trend
y = 1.13x + 65.4R² = 0.58
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55
60
65
70
75
80
85
90
95
100
Jun. 2009 Jan. 2010 Sept. 2010
Com
plia
nce
Rate
Vanderbilt Handwashing Compliance Rate by Month
Rate
Linear (Rate)
Goal: 90% Hospitalwide Hand Hygiene Compliance
March 2011 Improvement Gap per trend
Reduce Adverse Events
GoalQ1 FY2011
ResultsQ2 FY2011
ResultsQ3 FY2011
ResultsQ4 FY2011
ResultsFY2010 Results Threshold Target Reach
Pressure Ulcers (per 1,000 pt days) 0.87 1.08 1.11 0.91 0.86 0.82
Falls (per 1,000 pt days) 3.57 3.75 3.62 3.16 3.00 2.84
Medication Errors (per 1,000 pt days) 4.80 4.59 4.61 4.01 3.81 3.61
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Achieve Top Performance in Clinical Programs
GoalQ1 FY2011
ResultsQ2 FY2011
ResultsQ3 FY2011
ResultsQ4 FY2011
ResultsFY2010 Results Threshold Target Reach
Stroke 85%(Data through
Aug 2010)
89%(Data through
Nov 2010)
91% 86% 91% 95%
Pneumonia 79% 72%(Data through
Nov 2010)
82% 83% 90% 95%
Heart Failure 93% 97%(Data through
Nov 2010)
90% 90% 95% 100%
SCIP 95% Not Available
91% 90% 94% 99%
OPPS 86% Not Available
92% 91% 94% 99%
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Vanderbilt Performs in Top Decile of Leapfrog Hospitals
(1,184 hospitals in 45 States)
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Reliable Process DesignGoal Q1 FY2011
ResultsQ2 FY2011
ResultsQ3 FY2011
ResultsQ4 FY2011
Results Threshold Target Reach
Medication Reconciliation
0 (Progressing)
1Develop
prototype based on admission
Expand prototype to
include discharge
Establish baseline and compliance measures
Blood Management
0 (Progressing)
0 (Progressing)
Build data set for process
Establish internal baseline
Implement monitoring
system
Universal Protocols
2 2Disseminate and spread electronic
process
Implement quantitative
and qualitative analysis of
process
Zero defect in surgical site
Handovers 2 2Finalize
standardized infrastructure
and tools
Disseminate and spread process to 3
areas
Target plus 2 additional
areas
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Building Collaborations to Improve Safety and Quality in Health Care
Challenge: Awards for the best graphical displays of data related to patient safety or quality improvement
Submission: Hang poster in the hall between offices of Frank and Lynda
Deadline: April 15, 2011