marlyn conti –patient safety initiatives manager and eric crawford, data manager

Intermountain-led CMS Hospital Engagement Network

Falls and ImmobilityApril 11, 2014

Affinity Call

Marlyn Conti –Patient Safety Initiatives Manager and

Eric Crawford, Data Manager Intermountain Quality and Patient Safety

Outline for Discussion

• Review of 2013 data through Q4• ‘High performers’ – Identify and ask what

they are doing?• Falls recommended metrics• “Just-one-thing” – updated document• 2014 plans for improvement:

– Reach out to low performers to provide assistance– Continue Webinars for sharing

Overall Progress Through 2013

Intermountain HEN 2012-13 submitting Hospitals Falls with Injury

Intermountain HEN 2012-13 submitting Hospitals

Falls with Injury

Intermountain HEN 2012-13 submitting Hospitals Inpatient Falls

Intermountain HEN 2012-13 submitting Hospitals

Inpatient Falls

HEN Falls Measures

• Metric specification resource manual http://www.henlearner.org/wp-content/uploads/2012/03/HEN_measure_Feb5.pdf

• Submission schedule: – May 20, 2014: for data through March 2014

HEN Falls MeasuresInpatient Falls

HEN Falls MeasuresFalls with Injury

High Performing Hospital Highlight… Most Improvement

Inpatient FallsHospital Name

PROVIDENCE SEASIDE HOSPITAL

PARK CITY MEDICAL CENTER

SUTTER TRACY COMMUNITY HOSPITAL

CASSIA REGIONAL MEDICAL CENTER

AMERICAN FORK HOSPITAL

LOGAN REGIONAL HOSPITAL

HEBER VALLEY MEDICAL CENTER

PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL

LINCOLN COUNTY MEDICAL CENTER

SCOTT & WHITE HOSPITAL-ROUND ROCK

High Performing Hospital Highlight… Lowest Rate

Inpatient Falls Hospital Name

SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ

GARFIELD MEMORIAL HOSPITAL

PROVIDENCE SEASIDE HOSPITAL

LOGAN REGIONAL HOSPITAL

SUTTER TRACY COMMUNITY HOSPITAL

PARK CITY MEDICAL CENTER

OREM COMMUNITY HOSPITAL

AMERICAN FORK HOSPITAL

RIVERTON HOSPITAL

CASSIA REGIONAL MEDICAL CENTER

High Performing Hospital Highlight… % Improvement

Hospital Name

UPPER CONNECTICUT VALLEY HOSPITAL

FILLMORE COMMUNITY MEDICAL CENTER

SUTTER TRACY COMMUNITY HOSPITAL

PROVIDENCE MEDFORD MEDICAL CENTER

VALLEY VIEW MEDICAL CENTER

BAYLOR HEART AND VASCULAR HOSPITAL

SUTTER LAKESIDE HOSPITAL

SUTTER COAST HOSPITAL

PROVIDENCE NEWBERG MEDICAL CENTER

PROVIDENCE ST VINCENT MEDICAL CENTER

Falls with Injury

High Performing Hospital Highlight… Lowest Rate

Falls with InjuryHospital Name

BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE

PROVIDENCE MEDFORD MEDICAL CENTER

BAYLOR MEDICAL CENTER AT CARROLLTON

SUTTER TRACY COMMUNITY HOSPITAL

SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ

PROVIDENCE MILWAUKIE HOSPITAL

PROVIDENCE WILLAMETTE FALLS MEDICAL CENTER

GARFIELD MEMORIAL HOSPITAL

BAYLOR HEART AND VASCULAR HOSPITAL

VALLEY VIEW MEDICAL CENTER

Just One Thing MatrixRecommendations

Getting Started Working Harder Ahead of the Curve

Implement standard Assessment tools, protocols and prevention strategies

(high level of evidence)

Appoint “leads” to drive improvement & identify or champion teams that includes unit level nursing, quality, patient safety, physical therapy and pharmacy services. (high level of evidence)

Implement decision algorithms and/or computerized decision support in the electronic medical record to target interventions based on patient specific risk factors

2007 2008 2009 2010 2011 2012 20130.0

0.5

1.0

1.5

2.0

2.5

Falls with InjuryIntermountain System

Average Falls with InjuryLCL UCL

Falls

Rat

e pe

r 100

0 Pa

tient

Day

s

Falls Risk Training

Implimentation

of Safe Patient

Handling

Falls with Injury

Board Goal

Inpatient Falls Savings (CPI+1)Savings

YearFalls w/ Injury

Falls w/out Injury

Patient Days

Injury Rate

No Injury Rate

Fall RateAvoided Injuries

Avoided No Injury Falls

Estimated Improvement from

2006 Fall Rate (Avoided Cases)

Estimated Savings

2006 681 1,102 468,302 0.0015 0.0024 0.0038 0 0 0 $ - 2007 678 1,237 464,720 0.0015 0.0027 0.0041 -2 -143 -145 $ (697,080)2008 694 1,165 527,555 0.0013 0.0022 0.0035 73 76 149 $ 715,809 2009 702 1,166 532,861 0.0013 0.0022 0.0035 73 88 161 $ 773,667 2010 624 1,175 533,255 0.0012 0.0022 0.0034 151 80 231 $ 1,110,151 2011 511 1,198 530,023 0.0010 0.0023 0.0032 260 49 309 $ 1,485,483 2012 383 1,300 523,740 0.0007 0.0025 0.0032 379 -68 311 $ 1,494,136

Per Case 4,805$

YearFalls w/ Injury

Falls w/out Injury

Patient Days

Injury Rate

No Injury Rate

Fall RateAvoided Injuries

Avoided No Injury Falls

Estimated Improvement from

2012 Fall Rate (Avoided Cases)

Estimated CPI+1 Savings

2013 (Through Sept) 276 855 544,854 0.000507 0.001569 0.002076 122 497 620 2,978,547$

Estimated Savings 2,978,547$

Changes in Fall Rates

CPI+1 Calculations

• Set Organizational priority

• Identify Risks and Gaps

• Develop Monitoring Systems

• Designate Champions

• Integrated Nurse Charting and Care Plans

• Repeat Cycles of ‘Plan-Do-study-Act’

Getting Started and Keeping it going!

Fall Prevention Development Team

Region Guidance(Fill in which team or

committee has oversight)

FacilityChampion Team

Nursing Safety Physical Therapy

EducationPharmacy

Fall PreventionAccountability and Communication Diagram

NOTE: Could be Safety or Quality and Patient Safety Committee

Managing Improvement

Development

Identify best practic

e

Blend guideline into work flow

Design outcomes

tracking

Design decisio

n suppor

t

Staff and

patient

education

MaintenanceKeep Care

process

Current

Clinical Learni

ng

Manager

referral clinics

Manage

specialist care manag

ers

PDSA

2014 plans for improvement

• Reach out to low performers to provide assistance.• Collect and share best practices across our network

hospitals & system in a single document