Perficio by Mindstorm Communications Group, Inc.

Volume I • Spring 2013

A note from Dr. Jack Cox INSIDE

Welcome to the first edition of Perficio, Premier’s newsletter updating you on our organization’s commitment to performance improvement. More than ever, quality and performance improvement are taking center stage in healthcare. News stories about wrong-site surgeries, heightened awareness of medical errors, and public demands for greater scrutiny of healthcare professionals have placed new stresses on the healthcare system.

PAGE 2 Clinical performance initiative: Atrial fibrillation

PAGE 4 Performance Improvement Goal 2004: Executive summary

Compounding these issues is the need to remain competitive in the marketplace. I have been asked on many occasions, “How can I get into the Top 100?” While there is no silver bullet for achieving that industry accomplishment, being proactive in creating performance improvement solutions is certainly a step in the right direction. That’s why Premier has launched its “Performance Improvement 2004” initiative. It’s our way of helping our valued members leverage the resources and skill sets contained in the alliance that can help accomplish healthcare breakthroughs. Hence the title of this newsletter, Perficio, which in Latin means “to achieve” or “accomplish.” We’re homing in on 11 clinical areas – areas that reflect the clinical priorities of Premier’s Clinical Performance Initiatives. Based on our research, these areas present the greatest opportunities to reduce practice variation, improve outcomes, and decrease costs. These clinical areas also are of major interest to external groups such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Leapfrog Group. A list of Premier’s focus areas, along with corresponding metrics and Premier PI resources, is found on page 5. Why are we doing this? To assist in your commitment to provide the best healthcare delivery in your community. The more your improvements are documented, the more you can leverage those activities to enhance your position with the Joint Commission and local quality panels.

PAGE 6 Fusing together teams for spine care at Mission St. Joseph’s

What do you have to do? For now, all you have to do is pick one to three clinical areas from the list and sign up with your relationship management vice president. Signing up means you are making a two-year commitment to make clinical performance improvement a part of your performance improvement plan, which should align with your overall strategic plan. But the real work won’t start until after June 30, 2002. That’s when the clock starts ticking toward 2004. Many hospitals have already joined. If you’re one of them, welcome aboard. If you haven’t, I encourage you to contact either your Premier representative or one of the participating hospitals. Find out what’s in it for them, and find out if there’s something in it for you. Look forward to more updates, anecdotes, and success stories in future issues of Perficio. Jack Cox, M.D., M.M.M., is senior vice president of Premier's Clinical Innovations group. He is responsible for Premier's quality initiatives.

MORE INFORMATION A note from Dr. Jack Cox . . 1 Participating hospitals . . . . 5

Clinical performance initiatives:

Atrial fibrillation W

hen representatives from the Medical Center at Bowling Green attended a Premier Clinical Performance Initiative conference on atrial fibrillation following coronary artery bypass graft surgery in 1999, they weren’t sure their organization had any problems in this area.

The Medical Center already used betablockers before and after surgery, as recommended by the American College of Cardiology, but staff made a renewed effort to ensure that every eligible patient received the medication. As a result, the post-surgical use of beta blockers rose from 86 percent in 1999 to 93 percent in 2000.

By the time the conference was over, the clinicians from Bowling Green were sure – sure they didn’t have a problem. "People were asking us what we were doing there, because our numbers were already so good,’" said Don Johnson, R.N., cardiac nurse liaison at The Medical Center. "The national average for new onset a-fib at that time was 20 percent to 50 percent. It turned out our rate was 5 percent to 10 percent." But Bowling Green is committed to performance improvement. So Johnson and others looked deeper for reasons to participate in the initiative. They found that Bowling Green’s length of stay for patients experiencing post-surgical atrial fibrillation was higher than it should be, at 8.29 days. So they decided to focus on reducing that key measure.

The medical center also implemented a protocol that required a faster response to post-surgical atrial fibrillation when it did occur. By talking to representatives of other facilities involved in the Clinical Performance Initiative, Bowling Green learned that a protocol-driven quick response is not the norm everywhere. 2

“At some facilities we’ve talked to, patients are in a-fib for 24 hours before the cardiologist sees them. Our surgeons manage all follow-up post-operative care, so there’s no delay,” Johnson said. “We found that the more quickly you respond, the better the results. As soon as we see someone go into post-operative atrial fibrillation, we put them on a Cardizem drip until we attain normal sinus rhythm. The majority of people convert with chemical management alone.” These are the lessons Bowling Green learned through its improvement efforts and its participation in the CPI: • Emphasize early detection and aggressive treatment. • Implement a standard protocol that requires immediate response. • Use beta-blockers before and after surgery. • Perform all anastamosies – proximals and distals – in cross clamp using antegrade and retrograde cardioplegia. “The nice thing about the CPI is we get the different ideas of people across the country,” Johnson says. “If you do have a

Standing orders problem, there are people who have tried different things and can speak from experience. In that respect, it really works.” One important thing about Bowling Green’s experience is that the hospital didn’t rest on its laurels, says Leslie McCombs, R.N., Ph.D., project director in Premier’s Clinical Performance Initiatives unit and leader of the atrial fibrillation CPI. Rather, it showed an unusual degree of commitment to the performance improvement process. “Bowling Green’s CEO, Connie Smith, came to all three CPI meetings, which just shows extraordinary organizational commitment,” says McCombs. “That’s an organization that really believes in performance improvement and understands what it takes to make a difference.” The heart program at Bowling Green is always looking for ways to improve, according to Randy Carter, M.D., a thoracic and cardiovascular surgeon who is participating in the atrial fibrillation performance initiative. It takes continuous work. “We want to meet with other people to find out what they’re doing out there on the cutting edge. I think just meeting with other groups of people in healthcare and working through Premier has been a great benefit to us. It’s not like we just automatically got a post-operative a-fib rate of five percent. This is something we’ve been working on over the past few years.” Despite its excellent results, Bowling Green continues to learn from its

involvement in the Clinical Performance Initiative. For example, the heart team thought it was doing well with extubations, completing most of them within eight hours of surgery. Based on what they learned from other collaborators, the Bowling Green team has now gotten 50 percent of its extubations down to the four-hour range, and about 90 percent of them occur within six hours. In the year ahead, Bowling Green is going to focus on reducing blood and is gearing up to submit data to the Society of Thoracic Surgeons (STS) and the American College of Cardiology (ACC) registries for benchmarking. Through Premier’s relationship with the American College of Cardiology, owner hospitals such as Bowling Green can combine data from Premier’s Perspective Online with ACC data for an even more powerful benchmarking tool. “This is all part of an ongoing effort in our heart program to look at how we can improve outcomes, reduce costs, and improve the quality of care, making it better all the way around,” Johnson says. “We’re not

Atrial fibrillation by the numbers A-fib average length of stay

Percent of patients receiving beta-blockers

SOURCE: The Medical Center, Bowling Green, KY

• Check blood pressure, heart rate, and O2 saturation. • Begin supplemental O2 to get saturation to > 90 percent. • If systolic BP is < 90 percent or heart rate > 150, call cardiac surgeon and transfer patient to OHR. • If systolic BP is > 90 percent and heart rate is > 120, begin Cardizem drip. • Bolus 0.25 mg/kg over 30 minutes. • Begin infusion after bolus of Cardizem drip at 10 mg/hr and titrate up to 15 mg/hr to achieve heart rate control if necessary. • Monitor BP Q five minutes during bolus of Cardizem.

Performance Improvement Goal 2004 Executive summary Background Premier’s core purpose is to improve the health of communities. Our vision calls for member hospitals to operate in the top quartiles of quality, safety, and cost. Premier’s tools can assist hospitals in improving clinical performance. Premier believes its success is directly related to the success of its hospitals. Therefore, our goal is to partner with our hospitals and support them in reaching top clinical performance. The performance improvement goal Premier is seeking interested hospitals to engage in a relationship whereby Premier shares in the responsibility and accountability for the success of the hospital’s performance improvement efforts between now and June 30, 2004. There is no cost to join. Why? Premier’s board of directors has adopted a strategic priority – Align and adapt resources to support hospitals’ improvement of core clinical processes leading to breakthroughs along the dimensions of quality, safety, and cost.

Program summary Goals

Next steps

• June 30, 2002: 250 hospitals have agreed to participate, selected one to three clinical focus areas and agreed to PI targets and plans. • June 30, 2003: 50 percent of those participating have met their targets. • June 30, 2004: 80 percent have met their goals.

• Obtain other information and resources the hospital needs to evaluate this goal. • Get executive team approval to participate. • Select one to three clinical focus areas in which to collaborate. • Identify performance improvement champion(s) for each clinical focus area. • Complete sign-up process with RMVP (must be done by May 31, 2002). • Set improvement targets for each clinical focus area by May 31, 2002. • Implement ongoing collaborative efforts with the performance improvement team(s).

Hospital agrees to: • Participate in one to three clinical focus areas*. • Submit data to Perspective™ database on a scheduled basis. • Set specific improvement targets, including the quality and cost indicators that Premier monitors. • Involve Premier field staff (as appropriate) in your PI process for those clinical focus areas. • Integrate the chosen clinical focus areas and improvement targets in your JCAHO PI plan. • Attend regional PI meetings.

Sample resources available • Safety Institute • Clinical Performance Reports (CPRs) • Supply chain resources • Partnerships (Zynx, IHI, ACC, Bridges) • Performance consulting • Networking • Baseline and progress reports • Idea database (read-only access)

Premier agrees to: • Make resources* available to four PI teams (as appropriate). • Provide recognized and regular comparative data and other proven metrics (JCAHO, Leapfrog, etc.). • Serve as a facilitator for networking. • Provide best practices, tool kits, and lessons learned. • Provide regional PI meetings. • Share accountability for cost and quality improvement targets. * See list of clinical focus areas and resources on next page.

• Perspective data • JCAHO Core Measures • New clinical performance initiatives (CPIs) • Completed CPI Toolkits • New tools and resources as developed • Performance Engineering • Regional PI meetings

Clinical focus areas Focus area

Cost indicator

Quality indicator

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