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Denni McColm, CIO Renee Whitman-Teeter, Director of Performance Improvement

Denni McColm, CIO Renee Whitman-Teeter, Director of Performance Improvement Citizens Memorial Healthcare. Quality – What is it?. Patient outcomes, did they get well? Short term? Long term? Patient perceptions? How often we followed evidence based protocols? Survival rates?

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Denni McColm, CIO Renee Whitman-Teeter, Director of Performance Improvement

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  1. Denni McColm, CIO Renee Whitman-Teeter, Director of Performance Improvement Citizens Memorial Healthcare

  2. Quality – What is it? • Patient outcomes, did they get well? • Short term? • Long term? • Patient perceptions? • How often we followed evidence based protocols? • Survival rates? • Readmissions rates? • Is it safe, error-free care?

  3. CMS

  4. HealthGrades

  5. Leapfrog Group

  6. JCAHO

  7. How are they using that quality data? • Publicizing it on the Internet • Paying us for it

  8. Deployment of Rapid Response Teams…at the first sign of patient decline • Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack • Prevention of Adverse Drug Events (ADEs)…by implementing medication reconciliation • Prevention of Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle” • Prevention of Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time • Prevention of Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps called the “Ventilator Bundle”

  9. CMH Strategic Initiatives • Core/Regulatory Measures • Pain • Turnaround Times

  10. Using IT to Improve Quality • EMR • CPOE • eMAR • Reduce errors of transcription/illegibility • Give physicians more information with which to make care decisions • Alert drug/drug interactions and allergies • Improve the timeliness of results

  11. Order prompting in the ED • Order prompting in PCS • Required fields • Documentation templates for physicians • OE Rules • Evidenced based order sets • Clinical alerts

  12. FROM ONE AT A TIME CHART REVIEWS AFTER THE FACT TO: NPR Reports Required Fields Reporting Daily, end of shift BUILDING IN QUALITY & MONITOR IT CONCURRENTLY Changing our thinking . . .

  13. But, • Where should we focus our effort? • Where are we doing the worst? • We could write an NPR for every one of those measures (Core, ORYX, 100K Lives . . . . . . . . . .) • How many people would it take to write an NPR report for every quality measure out there? • Just to determine where to focus . . . And then, • How would we adjust for severity and compare to benchmarks?

  14. The Institute for Health Metrics (IHM) is: • A non-profit that helps us leverage our electronic systems for quality improvement • Extracting data from MEDITECH for use in: • Quality of Care Reporting & Benchmarking • Physician Performance Analysis & Reporting • A MEDITECH Strategic Ally

  15. Recognizing that we need . . . • Quality management tools to help us: • Identify • Analyze • Target • Track • Tools that are: • Automated • Timely • Use sophisticated analytics • Give us a graphical presentation • Case/provider drill downs and • Trend analysis

  16. AIESTM & PQMSTM

  17. IHM: Clean Normalize Map Report Hospital HCIS Web Based Monthly Reports IHM VPN Extract Data Directly from Meditech

  18. AIES: Quality Dashboard by Indicator

  19. Total Case Matrix

  20. Graphs for Trending

  21. Resource Definitions & Links

  22. Download Data to Excel for Analysis

  23. Drill Down Into Text

  24. What comes with AIES?

  25. PQMS: Dashboards by Specialty or Physician

  26. PQMS: Drill Down

  27. Benefits • Automates Data Extraction and Analysis • Eliminates manual data collection, analysis and reporting • Gives us an unbelievable number of measures • Extracted • Severity adjusted • Benchmarked • Presents and Analyzes Data in a Usable and Actionable Format • Focuses Efforts on the True Causes & Drivers of Performance • Supports timely Interventions and Improvement Strategies • Helps Clinical Staff Focus on Improving the Quality of Care

  28. Upcoming Releases • Concurrent Case Management System (CCMS) • Identification and scoring for high risk patients • Daily reports for Core Measure case tracking • Daily reports for concurrent quality improvement efforts • Financial Analysis System • Nursing Quality Management System

  29. Thanks! Questions: Denni McColm, denni.mccolm@citizensmemorial.com Renee Whitman-Teeter, rwhitm@citizensmemorial.com Jeff Borkowski, jborkowski@healthmetrics.org

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