Transcript Slide 1

THE LONG & WINDING ROAD
or
How to approach Leadership
and Board reporting
– One Hospital’s Ongoing Journey -
J. Mark Randolph RN, CCM, CPHQ
BSN, MA, Psy.D. (cand)
Director – Quality/Risk Management
Cookeville Regional Medical Center
Cookeville, Tennessee
Cookeville Regional Medical Center
Is a 247- all private bed, national award winning, regional referral
center in the heart of the Upper Cumberland region of Middle
Tennessee. This facility has been serving the surrounding
population since 1950, and has grown over the years to provide
inpatient, outpatient, rehabilitation, and emergency care in
addition to a host of highly recognized specialty services and
programs in both Cardiovascular and Cancer care. With over 140
physicians providing care in 36 specialties, CRMC is dedicated to
bringing the best quality care to our patients and their families.
Awards & Recognition
OBJECTIVES
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Using a Electronic Quality Management system to aid in the collection, management,
and analysis of data.
Using Core Measures and Benchmarking data to build clinical performance feedback
reports.
Using clinical performance data for performance improvement (i.e. improving
outcomes), management decision making, aiding long-term planning, setting strategies,
etc.
Using various techniques to communicate information and data across a organization
to change behaviors and culture.
Showing how Board education & involvement in Quality & Safety makes a difference.
Informatics
The value of a overall Quality Information System (QIS) can’t be overly
emphasized, as the data needed for such detailed reporting requires the use of
Informatics solutions to properly collect, analyze, and report it.
At CRMC we use a system called MIDAS+ Care Management a product of
MIDAS/ACS. This system went live in 1998.
Informatics cont.
The MIDAS+ system has “modules” in use for the following areas (with their respective
databases/repositories).
– Risk Management
– Quality Management
– Performance Improvement
– Patient Relations
– Hospital Case Management
– Infection Control
– Surgery
– Medical Records QA
– Focus Studies
– RCA’s, etc…
And all of this data can be pulled together to produce reports that are very detailed as to
the performance of staff and patient outcomes in our facility.
Education & Training
In 2007 one of our Board of Trustee members – Mr. Richard Grogan
assisted a THA working committee in the development of a training
program for Tennessee Hospital Trustee members that allowed them to
become certified Board Members.
Once this program was established, all of our Board members completed
the necessary training and became certified by THA. To this day, this
training is required of all our new Board members, and our entire board
maintains a certified status.
This gives our Board the knowledge base to provide the oversight for our
organization to continue it’s climb to excellence.
Education & Training cont.
Since training and education for the Board and Leadership is crucial in this
ever changing field of healthcare. CRMC has chosen Estes Park as the
provider of choice for this ongoing, extended training. All Sr. Managers,
Medical Executive members, and Board of Trustee members are sent to a
week long Estes Park training session.
Topics covered include: Reforming the hospital board structure, Using the
hospital board to improve care, Board organization for the future, Payment
reform to encourage more effective care, Advocating health policy that
directs better delivery of care, etc…
Organization
Over the last few years, we have had a complete restructuring of our Performance
Improvement plan and various reporting structures. This was done to stream line both
process and time requirements. As noted in the partial view of the CRMC
Organizational chart below there are now 2 Quality “entities” in our organization: The
Board Quality Committee and the CRMC Quality Council. Both of these allow for Quality
related data and discussion to be held at the highest level of leadership and
management. This along with the information shared with Department directors (and
then with their staff) allow for both bottom up and top down interaction as we proceed
on the course toward a culture of Safety and Quality.
Tools
Also with the restructuring in the PI plan came a variety of new forms and tools that
would allow for reporting PI data and projects, but would avoid unnecessary length and
unwieldy formats which tended to foster tardiness, uncertainty, frustration, and
hesitancy in sharing.
Leadership Reports
On a monthly basis the
“Quality Dashboard” report is
provided to both Sr. and midlevel management during our
regular scheduled directors
meetings.
This report covers key facility
care indicators such as core
measures, mortality rates,
readmits, LOS, Falls, Med
Errors, Return to Surgery, etc.
Leadership Reports cont.
In addition, on a Quarterly
basis the “Quality
Dashboard” report is also
printed in a “stoplight” (red,
yellow, green) format, with
spark line trend graphs.
These are distributed to all
departments for review,
discussion, and posting in
their areas. This allows the
staff to know where we are in
our quality journey, and also
allows them input into the
process.
Facility-wide Committee
On a Quarterly basis the
CRMC Quality Council meets
to review and discuss quality
related matters in the facility.
Departmental PI projects are
reviewed, and data/reports
from key programs &
committees reported.
This group is chaired by the
Director of Quality with the
following members:
•CCO,
•VP Ancillary,
•Dir – Med Rec,
•Dir – Case Mgt,
•Dir – Education,
•Risk Mgr,
•Infection Prevention Mgr,
•Safety Coord,
•Chief of Staff,
•Board Chairperson
Board-level Committee
Also on a Quarterly basis
the CRMC Board Quality
Committee meets (usually
the week after Quality
Council) to review and
discuss high level quality
related activities & matters
in the organization. Topics
covered include items such
as; Medical Staff quality
efforts, National Patient
Safety Goals, TN Patient
Safety Initiative, ACS NSQIP
project, HCAHPS and Core
Measure Public Scores, etc.
This allows the Board
members to keep up to date
on these matters and the
ability to offer oversight.
CRMC Housewide PI Projects for 2008 - 2010
(including CMS 9th SOW)
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Core
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Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Pneumonia (PNEU)
Surgical Care Improvement Program (SCIP)
Others
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IHI Ventilator Associated Pneumonia (VAP)
IHI Rapid Response Teams (RRT’s)
TN Patient Safety Initiative
• Central Line Infections
• MRSA Prevention
• SCIP
ACS NSQIP
Example of Board
Involvement & Support
During a recent Board Quality
Meeting, a dramatic
improvement was reported in
our VAP (ventilator
associated pneumonia)
rate/project in which our rate
dropped 60-70%. After the
meeting, Gail Stearman RN,
FNP – Vice Chairperson
CRMC Board of Trustees
decided that she wanted to
thank our ICU staff for all
their hard work in achieving
this excellent outcome for our
patients. So, she came up to
the unit on her own time, and
brought cookies to celebrate
this achievement with staff
members.
Sometimes it’s just the
simple things that count…
Challenges
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Reliable data abstraction & entry for performance
indicators
Cultural Change – “we must work as a team for
success”
Recognition for Excellence not just negative outliers
Maintain updated Data systems in today’s $$$
environment
Recognition that behavior change will not happen
overnight
Development of staff level involvement and
ownership in Performance Improvement efforts
Exploring the use of other PI methodologies to gain
further improvement in behavior (i.e. Positive
Deviance, etc)
Software Tools Used for
Quality & Safety Reporting
MIDAS+ Care Management
ACS/MIDAS
www.MidasPLUS.com
Microsoft Excel 2003 sp3
Microsoft Corporation
www.microsoft.com
Bissantz SparkMaker Basic v 4.0.4.0
Bissantz & Company GmbH
Nordring 98
D-90409 Nuernberg
Germany
www.bissantz.com/sparkmaker
Contact Information
J. Mark Randolph –
[email protected]
931-783-2481