A New Day In
Quality Care
Table of Contents Executive Message .......................................................................... 2 About Us......................................................................................... 3 Quality Awards............................................................................... 4 Mother Frances Hospital Tyler ....................................................... 5
Core Measures....................................................................... 5 - 6
The Big Dot.......................................................................... 6
AHRQ Patient Safety Indicators........................................... 6 - 7
Hospital Acquired Conditions............................................... 8 - 9
Partnership for Patients Initiative.......................................... 9 - 10
ICU Intensivist Model and CUSP......................................... 10
Readmission Rates................................................................ 10 - 11
Project BOOST.................................................................... 11
Leapfrog................................................................................ 11 - 12
NICU Vermont/Oxford Study............................................... 13
Patient Satisfaction Scores..................................................... 14
Trinity Clinic Outpatient Services................................................... 15
Medical Home...................................................................... 15
ConnectCARE Electronic Health Record........................................ 17 Louis and Peaches Owen Heart Hospital......................................... 18 - 20 Centers of Excellence...................................................................... 21 Spine..................................................................................... 21
Joint Replacement................................................................. 21
Stroke.................................................................................... 22
Bariatric Surgery................................................................... 23
Ross Breast Center.......................................................................... 23 NIH Cancer Genome Atlas Project................................................. 24 Staff Education................................................................................ 24 Other Locations.............................................................................. 25
Tyler ContinueCARE Hospital (LTAC)................................. 25
Trinity Mother Frances Rehabilitation Hospital.................... 26
Trinity Mother Frances Jacksonville ..................................... 26
Trinity Mother Frances Winnsboro....................................... 27 - 28
1
Teamwork is the Key to Our Success
W
e owe our 2011- 2012 successes to the teamwork of dedicated physicians, administrators, nurses, allied health professionals and staff members who strive relentlessly to achieve quality and value – and to our patients, clients and customers, who are our partners in the healthcare decision-making process. We listen to the voices of our patients and believe that the quality of care and quality of caring we provide are inseparable.
Standing from left to right:
As an organization, we are committed to continuous quality improvement, transparency and to providing our patients with award-winning care. That singular dedication resulted in Mother Frances Hospital Tyler’s recognition with the 2013 Healthgrades Distinguished Hospital Award for Clinical Excellence, for the fifth consecutive year, ranking us among the top 5 percent in the nation for clinical performance and one of only 10 hospitals in Texas to receive the award; IMS 2012 Top 100 Integrated Healthcare Network; and designation as a 2012 Thomson Reuters 100 Top Hospital.
Gifford Eckhout, MD Executive Vice President
Sitting from left to right:
Steven P. Keuer, MD
President and Chief Medical Officer
Ray Thompson, FACHE Executive Vice President, Chief Operating Officer
Lindsey Bradley, FACHE President
As the cost of delivering care in the United States comes under even greater scrutiny, you’ll see us finding new ways to ensure that our patients have access to affordable care. It is the right thing to do ethically and financially in today’s world.
Interdisciplinary teamwork has dramatically improved our internal communication and allowed us to move toward even greater standardization of care across our entire organization. With the recently completed implementation of ConnectCARE, our new electronic health record, we are achieving an even higher level of communication and universal access to information across the inpatient and outpatient spectrum of care.
This report on value for 2011-2012 at Trinity Mother Frances Hospitals and Clinics presents quality goals, process improvement initiatives, measures and results in key areas of our organization. We invite you to turn the page and learn more about what we are doing to provide value to our patients, physicians, employees, donors and the communities we serve.
Delivering the highest quality care possible is nothing new to us – we have been doing it for years. As a nationally recognized leader in providing quality healthcare, Trinity Mother Frances Hospitals and Clinics remains focused on improving patient safety and clinical outcomes. At the same time we have adopted cost-efficient measures that ensure value to our patients and payers and align with healthcare reform legislation.
Respectfully,
2
About Us
State-of-the-art, patient-centered facilities
In 1937, Sisters of the Holy Family of the Nazareth recognized the need for a modern hospital in Tyler, Texas. In partnership with physicians and city leaders, the Sisters transformed their vision for a modern medical facility into reality with the opening of Mother Frances Hospital. In 1995, Trinity Clinic and Mother Frances Hospital merged to form one of the nation’s first integrated healthcare systems – Trinity Mother Frances Hospitals and Clinics. Since our beginning more than 75 years ago, we have been faithful to our mission of improving the health of East Texans through service delivered with compassion, excellence and efficiency. Outstanding leadership, successful affiliations and collaborative relationships with regional hospitals have allowed us to provide our patients with convenient access to skilled medical specialists close to home. Trinity Mother Frances was recognized in 2012 as No. 16 in the United States and No. 1 in Texas by IMS as a Top 100 Integrated Healthcare Network (IHN). The IMS IHN Rating System ranks local and regional non-specialty integrated healthcare networks on their performance and level and degree of integration. Mother Frances Hospital Tyler has been designated five consecutive times by Thomson Reuters as one of the nation’s 100 Top Hospitals® and was the only hospital in Texas to receive the recognition in 2012.
Trinity Mother Frances at a Glance • • We serve more than 1.2 million people in a 27-county area. • Trinity Clinic’s more than 200 physicians represent 39 specialties in 36 clinic locations. The clinic has more than 350 healthcare providers • Mother Frances Hospital Tyler is a 404-bed acute care facility that provides highly specialized services, including cardiovascular, critical care, emergency care and trauma, neurosciences and a Level III neonatal intensive care unit • Mother Frances Hospital Jacksonville is a 25-bed critical care access facility • Mother Frances Hospital Winnsboro is a 25-bed critical care access facility • Louis and Peaches Owen Heart Hospital is the region’s first freestanding heart hospital, a 72-bed facility opened in December 2012 3
• Tyler ContinueCARE Hospital is a 51-bed long-term acute care facility • Trinity Mother Frances Rehabilitation Hospital is a 74-bed freestanding rehabilitation hospital affiliated with HEALTHSOUTH, the nation’s largest provider of inpatient rehabilitation services • We partner with Texas Oncology – Tyler, a practice of nationally recognized physicians specializing in oncology, hematology and radiation oncology • Our Access Center offers one-call service for patient transfers and physician-to-physician consults. call (866) 634-7363
Trinity Mother Frances Quality Awards Recognition for Results
• Thomson-Reuters 100 Top Hospital® – 2011, 2012 • CareChex– 2011 – Clinical • CareChex Top 100 Hospital – 2011, 2012, 2013 – Overall Hospital Care (#1 in Texas in 2013) TM
• CareChex Top 100 Hospital – 2011, 2012, 2013 - Overall Medical Care TM
• CareChex Top 100 Hospital – 2013 Overall Surgical Care TM
• CareChex Top 100 Hospital – 2013 Overall Cardiac Care (#1 in Texas in 2013) TM
• CareChex Top 100 Hospital – 2013 Major Cardiac Surgery TM
To view the entire list of CareChex Quality Awards for Mother Frances Hospital Tyler, please visit
carechex.com
• TMF Health Quality Institute Texas Health Care Quality Improvement Award – Mother Frances Hospital Jacksonville – 2012 • Silver Award – TMF Health Quality Institute Texas Health Care Quality Improvement Award – Mother Frances Hospital Tyler – 2012 • Outstanding Achievement and Leadership Award - U.S. Department of Health and Human Services and Critical Care Societies Collaborative • Dallas Morning News Recognized Mother Frances Hospital Tyler as “Best in Texas for Patient Safety” – 2012 • United Healthcare Premium® Cardiac Services Specialty Center • United Healthcare Premium® Surgical Spine Specialty Center
• Healthgrades Distinguished Hospital Award for Patient Safety Excellence – 2007-2012
• STS Three-Star Rating in aortic valve replacement (AVR)
• Healthgrades Distinguished Hospital Award for Clinical Excellence – 2009-2013 – (Ranked Among the Top 5% in the Nation for Overall Clinical Excellence)
• ICANL Nuclear/PET Accreditation
TM
TM
• Healthgrades Mother Frances Hospital Tyler Emergency Medicine Excellence Award™ – 2011 To view the entire list of Healthgrades Quality Awards for Mother Frances Hospital Tyler, please visit healthgrades.com • IMS Top 100 Integrated Healthcare Network – 2007 - 2012 • The Leapfrog Group “A” Hospital Safety Score – Mother Frances Hospital Tyler – 2012, 2011
• ICAEL Echocardiography Accreditation • ACC Foundation’s NCDR® ACTION Registry®-GWTG™ Platinum Performance Achievement Award • Advanced Certification for Primary Stroke Centers – Joint Commission in conjunction with The American Heart Association/ American Stroke Association • Southwest Transplant Alliance Health Resources and Services Administration’s (HRSA) Silver Organ Donation Medal of Honor 4
A
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2
Mother Frances Hospital Tyler
Key Quality and Cost Improvement Initiatives Quality Divided by Cost Equals Value for Our Patients
Creating a Culture of Safety In 1999, the Institute of Medicine published To Err is Human, a study reporting that 3 percent of hospitalized patients will have an adverse event. The study galvanized the medical community and set a national agenda for clinical transformation.
To operate effectively in the new environment shaped by healthcare reform, we monitor performance data and use the data gathered to improve our processes of care. Each of the “small dot” measures pictured in the graphs in the section on Core Measures is significant to patients who undergo certain procedures, and they all contribute to the overarching “big dot” of mortality.
Today, we are challenged with increasing severity of illness in an aging population and consumer demand for transparency in the quality of care we provide. Consumers and payers expect clinical excellence and are no longer willing to pay for care that does not meet the highest standards.
MFH Tyler Performs at High Level on Core Measure Results Core Acute MI All-or-None 100
Mother Frances Hospital
Percentile
Core Acute MI All-or-None Bundle - 2009
Mother Frances Hospital
90
Core Acute MI All-or-None Bundle - 2010
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2011
Mother Frances Hospital
80
Core Acute MI All-or-None Bundle - 2012
January – December
5
Core Pneumonia All-or-None Bundle
Percentile
100
Mother Frances Hospital Core Pneumonia All-or-NoneBundle - 2011
90
Mother Frances Hospital Core Pneumonia All-or-NoneBundle - 2012
80
January – December
Core SCIP All measures All-or-None Bundle
Percentile
100
Mother Frances Hospital Core SCIP All measures All-or-NoneBundle - 2011
90
Mother Frances Hospital Core SCIP All measures All-or-NoneBundle - 2012
80
Percentile
100
Mother Frances Hospital Core Acute MI All-or-NoneBundle - 2011
Mother Frances Hospital Core Acute MI All-or-NoneBundle - 2012
4
We have implemented multiple change strategies to assist our clinicians in meeting the guidelines. As a result, Mother Frances Hospital Tyler was recognized with the 2012 Healthgrades Distinguished Hospital Award for Patient SafetyTM, ranking us among the top 5 percent in the nation for patient safety; IMS Top 100 Integrated Healthcare Network (IHN ), rating No. 1 in Texas and No. 16 in the US; and the 2011, 2012 and 2013 CareChexTM Top 100 Hospital Awards in several categories, including Overall Hospital Care and Overall Medical Care.
Improving survivability, quality of life and preventing patient harm are the ultimate goals of healthcare clinical quality improvement. Over the last 11 years, we have tracked a statistically significant reduction in overall patient mortality at Mother Frances Hospital Tyler.
Core Acute MI All-or-None Bundle
80
Mother Frances Hospital submits data for acute myocardial infarction, congestive heart failure, pneumonia and surgical site infections, among other measures. The all-or-none score in the charts above represents the percentage of patients who received all appropriate care specific to their conditions.
The Big Dot: Mortality Continues on a Downward Trend
January – December
90
Core measures are condition-specific measures that show our compliance with nationally recognized standards of evidence-based care. We report core measures to the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission, a mandatory requirement for acute care hospitals. This focused reporting by hospitals has resulted in reduced morbidity and mortality nationally.
January – December
6
More lives were saved in 2012. We attribute our improved trend to technological advances, evidence-based medical care, implementation of programs designed to reduce risk of injury and strategies for early recognition and intervention.
Continuous Improvement in AHRQ Patient Safety Indicators
Core Heart Failure All-or-None Bundle
Mother Frances Hospital Core Heart Failure All-or-NoneBundle - 2011
90
Mother Frances Hospital Core Heart Failure All-or-NoneBundle - 2012
The United States Department of Health and Human Services’ Agency for Health Research and Quality (AHRQ) has designated 17 patient safety indicators and 28 inpatient quality indicators by which it evaluates a hospital’s performance in the area of prevention of patient harm. These factors contributed to Mother Frances Hospital’s receipt of the Healthgrades Distinguished Hospital Award for Patient Safety™ from 2007 to 2012.
Hospital-Acquired Conditions: Value-Based Purchasing Holds Healthcare Providers Accountable for Cost and Quality of Care
January – December
Core Acute MI All-or-None 100
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2005
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2006
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2007
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2008
90
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2009
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2010
Mother Frances Hospital Core Acute MI All-or-None Bundle - 2011
80
Mother Frances Hospital
January – December
Core Acute MI All-or-None Bundle - 2012
CDB1408 - PSI 90 Patient Safety Indicators Composite, Adults (numerator)
23.0
Mother Frances Hospital
CDB1408 - PSI 90 Patient Safety Indicators Composite, Adults (numerator) - 2010
Percentile
80
Percentile
Percentile
100
Mother Frances Hospital
CDB1408 - PSI 90 Patient Safety Indicators Composite, Adults (numerator) - 2011
16.5
Mother Frances Hospital
CDB1408 - PSI 90 Patient Safety Indicators Composite, Adults (numerator) - 2012
10.0
7
January – December
Hospital Acquired Conditions - Per 1000 Inpatient 2.0 Mother Frances Hospital
Percentile
CDB1335 - Hospital Acquired Conditions - Per 1000 Inpatients - 2010
Mother Frances Hospital CDB1335 - Hospital Acquired Conditions - Per 1000 Inpatients - 2011
1.5
Mother Frances Hospital CDB1335 - Hospital Acquired Conditions - Per 1000 Inpatients - 2012
1.0
January – December
CMS Hospital Acquired Conditions Per 1000 0.4
0.3
Mother Frances Hospital CMS Hospital Acquired Conditions per 1000 ACA - 2011
0.2
Mother Frances Hospital CMS Hospital Acquired Conditions per 1000 ACA - 2012
0.1
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The concept of value-based healthcare purchasing is straightforward: consumers should hold providers of healthcare accountable for both the cost and quality of care. Value-based purchasing (VBP) brings together information on the quality of healthcare, including patient outcomes and health status, with data on the dollar outlays for health. It focuses on managing the use of the healthcare system to reduce inappropriate care and to identify and reward the best-performing providers.
In January 2011, federal officials issued a long-awaited proposal of revised value-based purchasing incentives. The document set forth how hospital quality metrics will affect reimbursement from CMS after October 1, 2012. The CMS proposal incorporates 17 clinical processof-care measures used in five health categories: acute myocardial infarction (AMI), heart failure, pneumonia, healthcare-associated infections and surgical care improvement. It also 8
uses eight measures from the hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which reflects how patients view their care experience. These 25 measures were used to determine hospital diagnosisrelated group (DRG) payments in fiscal year 2013. Based on this data, Mother Frances Hospital Tyler received funds it contributed to the pool plus additional funds for ranking above the national average.
CMS Hospital Acquired Conditions Per 1000 (HACs) Annual Actual vs “Expected” Incidence 40
30
Mother Frances Hospital Actual
20
Mother Frances Hospital “Expected”
10
2009
2010
2011
CMS Defined Hospital Acquired Conditions Trends by Calendar Year: ALL PAYORS
12
9
Mother Frances Hospital 2010
6
Mother Frances Hospital 2011
3
Partnership for Patients Initiative Improves Quality, Safety, Reliability and Cost-Effectiveness of Patient Care Trinity Mother Frances participates in Partnership for Patients, a new initiative sponsored by the United States Department of Health and Human Services to improve the quality, safety and affordability of healthcare for all
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Americans. Mother Frances Hospital Tyler is one of 150 Texas hospitals selected to work with the Texas Center for Quality and Patient Safety to stay competitive and improve the quality, safety, reliability and cost-effectiveness of patient care. The first goal of the Partnership for Patients is to reduce preventable hospitalacquired conditions by 40 percent by 2013 compared to 2010. Achieving this
9
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goal nationally will result in approximately 1.8 million fewer patient injuries and save more than 60,000 lives in just three years. The partnership’s second goal is to reduce the percentage of hospital readmissions by 20 percent by 2013 compared to 2010. Achieving this goal will translate to more than 1.6 million patients recovering from illness without suffering a preventable complication that requires a return to the hospital within 30 days of discharge.
and Quality’s (AHRQ) Comprehensive Unit-Based Safety Program (CUSP) to identify, reduce and eliminate patient safety issues.
The Partnership for Patients is focusing on implementing evidence-based practices that have been proven to reduce 10 preventable hospital-acquired conditions:
CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork and leadership to create and support a culture of patient safety that can prevent errors. The program emphasizes evidence-based safety practices, staff training tools, standards for consistently measuring infection rates, engagement of leadership and tools to improve teamwork among doctors, nurses, and other members of the healthcare team.
• Pressure ulcers • Injuries from falls and immobility • Venous thromboembolism (VTE) • Catheter-associated urinary tract infections (CAUTI)
The CUSP approach can be applied to any patient safety issue, including various types of preventable infections, such as central line-associated blood stream infections (CLABSIs), catheterassociated urinary tract infections (CAUTIs), and ventilatorassociated pneumonia (VAP) in intensive care units (ICUs) and other hospital units.
• Adverse drug events • Surgical site infections • Ventilator-associated pneumonia (VAP) • Central line-associated bloodstream infections (CLABSI)
In recognition of their CUSP work, the staffs of the Mother Frances Hospital Tyler Medical ICU/Surgical ICU and Neuroscience ICU were awarded the 2012 United States Department of Health and Human Services/Critical Care Societies Collaborative’s Award for Outstanding Achievement and Leadership in eliminating central line-associated bloodstream infections.
• Obstetrical adverse events • Preventable readmissions
ICU Intensivist Model and CUSP Lead to an Outstanding Achievement and Leadership Award Clinical outcomes are dramatically better in hospitals with dedicated physician intensivists providing standardized, evidencebased interventions to intensive care patients. Trinity Clinic Critical Care Intensivists are board certified in emergency medicine, internal medicine, anesthesiology, pulmonary medicine or surgery with fellowship training and subspecialty certification in critical care.
Mother Frances Hospital Tyler Maintains Excellent Readmission Rates One in five Medicare patients nationwide is readmitted to the hospital within 30 days. Under provisions of the Patient Protection and Affordable Care Act (PPACA), the Centers for Medicare and Medicaid (CMS) have implemented penalties to hospitals with readmission rates above the norm. The financial take back by CMS is now 1 percent of all Medicare claims. In FY 2015, it will become 1.5%. Mother Frances Hospital Tyler was the only comprehensive acute care hospital in the East Texas region that received money back from CMS under the Value Based Purchasing Plan, which includes evaluation of readmission rates and other metrics, in November 2012.
The care provided by our critical care intensivists is complemented by the work of acute care nurse practitioners (ACNPs) who carry the CCRN certification awarded by the American Association of Critical-Care Nurses. Working with the intensivists and ACNPs to oversee the care of patients who require life-support services and frequent monitoring is a group of registered nurses who have completed a Mother Frances Hospital-based comprehensive program in the management of the critically ill and injured patients. The training uses a blended approach that includes 65 hours of electronic coursework, 60 hours of classroom training and a four-month preceptorship working with an experienced ICU registered nurse caring for critically ill patients.
The rationale behind the penalties is the high number of Medicare readmissions that take place too soon after discharge, which costs the Medicare program an additional $15 billion per year. As part of the PPACA, two-thirds of the 2,200 hospitals in the country have been notified that they will have some amount of reduction in payments in an attempt to reduce the cost of readmission. Beginning October 1, 2013, the maximum penalty will increase to 2 percent; in 2014, the penalty will be 3 percent.
An interdisciplinary team of respiratory therapists, doctoral-level pharmacists, dietitians, rehabilitation specialists, case managers, and laboratory services, radiology and pastoral care professionals supports our critical care nurses and intensivists, ensuring that our patients receive the most advanced evidence-based interventions using a comprehensive team approach to care. The ICU team works together actively, using the Agency for Healthcare Research
The penalties, which will apply to all of our Medicare payments in 2013, are based on the rate of readmission of Medicare patients for heart failure, pneumonia and heart attack conditions. To keep 10
readmission rates low, all clinical disciplines at Mother Frances Hospital Tyler are working together to ensure that patients are well enough for discharge and clearly understand their discharge plan of care, including follow-up appointments with the provider. To that end, we have enhanced our care plans and streamlined followup appointments. Our results demonstrate the value of being part of a truly integrated network with hospital and clinics to support the needs of our patients.
Implemented in February 2011 as a pilot project on 4 Dawson, which serves general medical patients, Project BOOST has shown results in decreased length of stay, decreased readmission rates, improved patient satisfaction and improved staff satisfaction. In January 2011, before the implementation of the project, the average length of stay (ALOS) on 4 Dawson was 6.60. By December 2012, our ALOS had dropped to 5.31. In January 2011, our 30-day readmission rate was 10.77 percent. By August 2011, it was 4.81 percent. Teach-back is one of the one of the most effective tools Project BOOST uses: speak clearly so patients can understand, use words they can fully understand, repeat as often as necessary and ask patients to repeat what they have learned. As a result, our HCAHPS patient satisfaction scores on 4 Dawson related to providing good discharge information moved from 67.1 percent in the fourth quarter of 2012 to 82.5 percent by the third quarter of 2011. Interdisciplinary rounds have added structure to Project BOOST, helping to decrease average length of stay. Conducted at 9 a.m. every morning, rounds include the charge nurse, case manager, social worker, pharmacist, physical therapist and occupational therapist, chaplain, unit director and may also include the attending physician. The need for patient and family conferences is determined based on findings during rounds.
Project BOOST: Reducing Readmissions and Length of Stay Mother Frances Hospital Tyler was among the first 100 hospitals nationwide – and one of the first two sites in Texas – selected by the Society of Hospital Medicine for the implementation of Project BOOST. An acronym for Better Outcomes for Older Adults Through Safe Transitions, Project BOOST includes a focused set of objectives that collectively are improving care for older patients as they transition from hospital to home or another care facility.
The success of the project has led to a rollout on two other units: 5 Dawson (neuroscience and medical/surgical) and 3 Dawson (oncology), 5 Ornelas and 6 Ornelas. How has BOOST affected nursing practice? In the words of Beverly Laskowski, RN, “BOOST is why we wanted to become nurses! To educate people about their health and take care of those who are sick.”
Scoring High in the Leapfrog Hospital Recognition Program
The project is grounded in a team approach to assessing patient risk for re-hospitalization and developing risk-specific discharge plans personalized to each patient. Project BOOST’s objectives are:
Mother Frances Hospital Tyler participates in the Leapfrog Hospital Recognition Program™ (LHRP), a comprehensive hospital pay-for-performance program that focuses on the most important national patient safety, quality and resource use standards. Since The Leapfrog Group’s inception in 2000, its initiatives have been based on the fact that provider performance transparency is critical to the optimal function of the healthcare marketplace.
• To identify high-risk patients when they are admitted and develop interventions that lower the risk of adverse events after discharge • To reduce our 30-day readmission rate for general medicine patients • To reduce length of stay
Through LHRP, a hospital is scored for its performance on each of Leapfrog’s 20-plus standards. Individual scores, which range from 0 to 100, are compared against state and national averages. Scores for each hospital are calculated using the LHRP Scoring Methodology and then rolled up into three composite scores: quality, resource use and value. The three composite scores are used in National Quality and Resource Use comparisons and Value decile rankings.
• To improve patient satisfaction and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores • To improve information flow between inpatient and outpatient providers • To prepare patients and their families for discharge 11
LHRP uses the data collected through the Leapfrog Hospital Survey each year to evaluate hospital performance in numerous clinical focus areas:
Leapfrog Hospital Survey, which determines Hospital Safety Scores. Leapfrog scoring places Mother Frances Hospital Tyler in the 4th decile nationally for quality and resource management. In 2011 and 2012, our overall patient safety ratings fully meet Leapfrog standards in the categories of appropriate ICU staffing, managing serious errors, patient experience of care, heart surgery, bariatric surgery, normal deliveries, esophageal and pancreatic resection for cancer.
• Computerized physician order entry (CPOE) • ICU physician staffing • Outcomes of high-risk procedures (coronary artery bypass graft, percutaneous coronary intervention, abdominal aortic aneurysm repair, aortic valve replacement, bariatric surgery, pancreatectomy, esophagectomy and high-risk deliveries) • Common acute conditions (AMI, pneumonia, normal deliveries) • Hospital-acquired conditions (pressure ulcers, injuries, central-line associated blood stream infections) • Safe practices • Never events To demonstrate our commitment to transparency and quality improvement, we have, for the past six years, participated in the
Quality and Resource Comparison 100 90 Mother Frances Hospital Tyler
Resource Use Score
80 70 60
U.S. Hospitals
50
Texas Hospitals
40
Mother Frances Hospital Tyler
30 20
Mother Frances Hospital Tyler scored among the highest in the nation for quality and safety in the Leapfrog Hospital Survey.
10 0
0
10
20
30
40
50
60
70
80
Quality Score 2011 Leapfrog Data Summary
12
90
100
NICU Vermont/Oxford Study Mother FrancesHospital Tyler opened the only Level III Neonatal Intensive Care Unit (NICU) in November 2008 to provide specialized medical care to infants born as early as 26 weeks or weighing as little as one pound, as well as term infants with breathing difficulties, infections or other health conditions. Since our opening, we have logged more than 1,500 admissions, many of which would have been transferred out of the area before the existence of our unit.
benchmarked against comparisons to the entire network as well as to other NICUs of the same type. Detailed statistical tables of risk-adjusted mortality, morbidity and length of stay with trend data are available.
In January 2009, our NICU became part of the Vermont Oxford Network. Membership in the network provides a range of quality management tools, research and collaborative opportunities that allow neonatal intensive care units to improve quality of care. The network maintains one of the world’s largest databases, including information from more than 800 NICUs from around the world. Reliable, confidential data is available to participating hospitals for use in quality management, process improvement, internal audit and peer review.
Comparative Data For Mother Frances Hospital Tyler NICU and Vermont Oxford Network (Level IIIA)
Our NICU staff includes three full-time neonatologists, 4.3 neonatal nurse practitioners, trained neonatal nurses and respiratory therapists, an occupational therapist, a social worker, a pharmacist and chaplain support. We provide the highest quality evidence-based treatment and environment for our premature and term babies – close to home and their family support network. We performed very well across the network’s benchmarks for the treatment of neonatal patients. Our team is especially proud of our outcomes and length of stay as compared to metrics for similar NICUs.
Established in 1988, the Vermont Oxford Network is a non-profit, voluntary collaboration of healthcare professionals dedicated to improving the quality and safety of medical care for newborn infants and their families. The Network maintains a database of very low birth weight (VLBW) infants and other highrisk newborns cared for by member centers. The membership consists of neonatal intensive care units in the United States and from around the world. It is generally considered to be the best comparison data available in this patient population.
Each member of the network receives extensive statistical reports on their patient data quarterly and annually. This data is
2009 n=398 Any human milk at discharge - VLBW Chronic Lung Disease, <33 wks Extreme length of stay (survivors) Human milk only at discharge - all Intraventricular Hemorrhage Median Length of Stay (days) Mean Length of Stay (days) Mortality (prior to transfer) Necrotizing Enterocolitis Nosocomial infection Pneumothorax Retinopathy of Prematurity Retinopathy of Prematurity - severe
60% 0 4 34% 10 8d 10.8 d 1 1 0.6 4 4 0 13
TMF IIIA 2010 n=428 Mean (%) 83% 14 4 36% 8 8d 11.7 d 2 1 0 5 16 0
2011 n=448
2012 n=410
38% 11 6 33% 17 8d 13.6 d 1 1 0.3 3 8 0
50% 3 5 34% 10 9d 13.4 d 2 0 0.5 3 13 4*
VON IIIA 2011 n=38,915 Mean (%) 53% 11 5 23% 13 14.4 d 15.2 d 2 1 2 3 23 4
NICU continued
Other interesting points about the Mother Frances Hospital Tyler NICU:
• One baby with Stage 3 ROP • Deaths were related to gestational age ≤24 wks, anomalies, and perinatal complications
• Adjusted outcomes are considered the best comparison data. All TMF NICU adjusted outcomes for 2009, 2010, and 2011 were within expected ranges in VON Database. 2012 Adjusted outcomes will be available in August, 2013
• Each year about 150 infants are “transitioned” and not admitted to NICU (not in VON data) • Admitted 30 babies from home with dehydration, apnea, seizures, hypoglycemia, sepsis, jaundice, and/or temperature instability (not in VON data)
• No percutaneous catheter infections to date, and two umbilical line infections in past 4.5 years
Patient Satisfaction Scores: Improving the Hospital Experience
We have instituted processes to improve communication between caregivers, patients and family members, including scripting and rounding on all new patients by nurse leaders. System-wide weekly departmental meetings deliver a common message focused on customer service standards, quality and safety goals.
At Trinity Mother Frances, we have adopted best practices from healthcare facilities across the country and borrowed ideas from leading firms such as Disney and the Ritz Carlton Hotel to move our customer service scores, as reported by Press Ganey, to among the highest in the nation.
We respond to patient concerns individually and review them with managers and our clinical quality committee. Major issues are referred for action to clinical care workgroups or medical peer review, as required.
Customer-service standards have been implemented system-wide, with the support and involvement of our staff and physicians.
Nurse Communication Doctor Communication Hospital Staff Responsiveness Pain Management Medicine Communication Hospital Environment Discharge Information Overall Hospital Rating
1/1/2012 – 12/31/12 77% 80.4% 57.7% 70.3% 63.7% 63.1 83.6% 74.1
Threshold/Benchmark 75.79/84.99% 79.57/88.45% 62.21/78.08% 68.99/77.92% 59.85/71.54% 63.54/78.10% 82.72/89.24% 67.33/82.55%
HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national, standardized survey of hospital patients. HCAHPS was created to publicly report patients’ perspective of hospital care. The survey asks a random sample of recently discharged patients about important aspects of their hospital experience. For more information, please visit hospitalcompare.hhs.gov 14
Trinity Clinic Douglas, one of 36 Trinity Clinic locations
Trinity Clinic Outpatient Services
Trinity Clinic is achieving this change through the following initiatives:
Trinity Clinic is one of the area’s largest multispecialty medical groups, with more than 350 physicians and mid-level providers representing 39 specialties in 36 clinic locations serving the East Texas region. The clinic provides a patient-centered coordinated approach to healthcare – in other words, a medical home.
Provider Alignment Best Practice Clinical Integration. Led by physicians, the PCMH team facilitates quarterly best-practice meetings to focus on improving HEDIS (Healthcare Effectiveness Data and Information Set) quality performance, enhancing primary care access and increasing office efficiencies to transition toward proactive population health management. Since beginning the best-practice initiatives, our HEDIS performance has dramatically improved.
Patient-centered Medical Home The Patient-centered Medical Home (PCMH) is a significant element of emerging healthcare delivery models and is central to the Institute for Healthcare Improvement’s Triple Aim. Designed to provide care that is safe, effective, patient-centered, timely, efficient and equitable, the medical home concept renews focus on primary care in America as the most effective and efficient mechanism for facing the challenges of access, quality and cost. Based on its ability to influence the Triple Aim of enhanced access, high-quality care and sustained lower cost, the medical home makes an enhanced level of data analytics and care management resources available to primary care physicians to help manage highrisk and chronically ill patients. The concept has been associated with a higher quality of care and patient experience.
Patient Registries (Trinity Clinic Prev CARE). To communicate the need for prevention and chronic illness management proactively, Trinity Clinic implemented an automated registry system to query the electronic health record (EHR) for patients overdue for evidence-based preventive and chronic illness care. This outreach encompasses screenings for breast cancer, colon cancer, cervical cancer, diabetes care and care for patients with cardiovascular disease.
Improving the Patient Experience
Trinity Clinic began pursuing clinical transformation toward the medical home model beginning in 2010. Trinity Clinic, the system’s 330-member multispecialty group of specialists and primary care providers, has led this transformation by pursuing NCQA Level 3 recognition for all of its 18 primary care locations. In addition, more than half of Trinity Clinic’s PCPs have achieved NCQA-recognition for excellence in diabetes care management through the NCQA’s Diabetes Physician Recognition Program.
Care Coordination Program. In 2011, the PCMH program piloted two LVN care coordinator roles. The care coordinators serve as prevention and chronic disease specialists for Trinity Clinic primary care patients, providing pre-visit counseling and coaching for prevention and chronic illness management. In addition, the care coordinators provide outreach for patients overdue for recommended evidenced-based care. After piloting these two LVN roles in 2011, Trinity Clinic is expanding the pilot to include a larger population of patients.
Transformation to a Patient-centered Medical Home signifies a fundamental cultural change in the practice of medicine, aiming to transition away from a model of care delivery that is fee-forservice toward one that is based in achieving clinical outcomes. For healthcare providers, this change involves developing a proactive approach to managing population health and chronic disease. 15
Results of Care Coordinator Pilot Manhatton Clinic Category Diabetes Diabetes Diabetes—controlled Diabetes—uncontrolled Coronary Artery Disease Prevention Prevention Prevention Prevention Prevention Prevention Diabetes Management Program. The PCMH has implemented a diabetes management program for members of the TMF and BCBS health plans. The program provides expert care to patients and focuses on learning how to live with and manage diabetes, seeking ultimately to increase quality and reduce cost by lowering hospitalizations. The program is coordinated by a multidisciplinary team of RN nurse navigators and LVN care coordinators who work closely with patients and their primary care physicians. Diabetes Low-Income Copay Waiver Program. To assist patients who have
Measure
Baseline
Final
National Best Practice
LDL < 100 (cholesterol controlled) Eye Exams A1c <7.0% A1c >9.0% (Note: goal is low number) LDL < 100 (cholesterol controlled) Breast Cancer Screening Cervical Cancer Screening Colon Cancer Screening Osteoporosis Screening Flu Vaccine Pneumovax
54%
56%
55%
34% 49% 8%
65% 55% 10%
74% 54% 10%
59%
60%
Not available
74% 41% 67% 82% 54% 78%
76% 50% 72% 84% 58% 83%
80% 82% 71% 82% 57% 82%
limited financial resources, the PCMH team has developed a low-income copaywaiver program for diabetics who cannot afford their prescriptions and supplies, aiming to recoup these subsidies through avoidable hospitalizations and emergency care. These efforts are coordinated through the Medicine Chest, and seed funding has been provided by the TMF Foundation.
Lower Cost of Care Payer Collaboration. Trinity Clinic has pursued value-based contracts with multiple commercial and Medicare Advantage payers to develop new and
innovative strategies for delivering care. These initiatives include medical home collaborations with BCBS, United and Health Spring, with financial models that include per member/per month agreements for increased care coordination, as well as shared savings potential. TMF Employee Health Plan. In addition to managed care initiatives, Trinity Clinic has also taken on responsibilities for implementing a medical home for 7,000 TMF employees and dependents.
Primary Care Medical Home Quality Results 2011-2012 Category Diabetes Diabetes Diabetes—controlled Diabetes—uncontrolled Coronary Artery Disease Prevention Prevention
Measure LDL < 100 (cholesterol controlled) Eye Exams A1c <7.0% A1c >9.0% (Note: goal is low number) LDL < 100 (cholesterol controlled) Breast Cancer Screening Colon Cancer Screening 16
June-Aug, 2011
July-Sept, 2012
Target
59.3%
60.9%
41%
39.8% 43.8%
52.7% 47.9%
52% 39%
11.5%
11.4%
15%
65%
65.3%
50%
65.7% 60%
67.1% 64.6%
65% 59%
ConnectCARE:
Our New Electronic Health Record Improves Access and Efficiency
On May 1, 2011, Mother Frances Hospital Tyler began implementation of an enterprise electronic health record (EHR). ConnectCARE was selected for the name of the enterprise-wide electronic health record, powered by Epic . This name was chosen to communicate the many benefits of the new technology available to patients, physicians and clinicians. Improving access to health information for both providers and patients, ConnectCARE boosts efficiency and engages patients in their healthcare, all of which are vital to improved patient safety and quality of care delivered. TM
Epic is the industry leader providing software for mid-size and large medical groups, hospitals and integrated healthcare organizations – working with customers that include community hospitals, academic facilities, children’s organizations, safety net providers and multi-hospital systems. Their integrated software spans clinical, access and revenue functions and extends into the home. Epic serves over 40% of patients and physicians in the U.S. and is expanding internationally. The new EHR went live at more than 40 Trinity Clinic outpatient sites in September 2012 and at two Mother Frances Hospital locations - Tyler and Jacksonville - the Louis and Peaches Owen Heart Hospital and Tyler ContinueCARE Hospital - in December 2012. On March 22, 2013, the implementation was complete with
the addition of Mother Frances Hospital Winnsboro. ConnectCARE’s MyChart brings connectivity into the patient’s home and offers the patient the opportunity to communicate securely with their Trinity Clinic physician and Trinity Mother Frances. With 20,000 users as of March 2013, MyChart’s many features include messaging, results retrieval, appointment scheduling and preventive care reminders. MyChart also has a smart phone application that allows for access 24/7 from any location. Healthcare systems with electronic health records that meet “meaningful use” criteria will be eligible to earn incentive payments defined by the Centers for Medicare and Medicaid (CMS) Incentive Programs governing the use of electronic health records. 17
The goal of this federal program is to promote patient safety, reduce human error and improve care by emphasizing best clinical practice. The utilization of electronic prescriptions eliminates the need to decipher handwriting and prevents errors by providing an easy to read order. Physicians are encouraged to use electronic order entry which is designed to follow clinical best practices. The EHR provides for a systematic and defined approach to these and other important care elements including reviewing patient problems between providers, assuring the patient’s medication list is complete and their allergies have been reviewed prior to treatment. As of March 2013, approximately 90% of Trinity Clinic physicians and providers have adopted meaningful use.
American College of Cardiology (ACC) to save time and lives by reducing the door-to-balloon times in U.S. hospitals performing primary percutaneous coronary intervention (PCI) (balloon/ stent procedure) of 90 minutes or less.
The Louis and Peaches Owen Heart Hospital at Trinity Mother Frances, the region’s only freestanding heart hospital, is home to the most advanced technology for use in the early detection, diagnosis and treatment of heart disease. The 72bed, 154,000-square-foot facility adjacent to Mother Frances Hospital Tyler includes comprehensive cardiac, thoracic and vascular services, offering all the benefits of a premier hospital dedicated to heart care, plus the safety of immediate access to all acute care medical services at Mother Frances Hospital. As the leader in heart care in East Texas since 1983, LPOHH continues to promote innovative and effective ways of combating heart disease and has performed more than 638,000 cardiac procedures, including more than 60,000 cardiac catheterizations. The first provider of daVinci® robotic heart surgery in Tyler, the Trinity Clinic Cardiothoracic Surgery program is nationally recognized as a leader in
innovative and minimally invasive surgical techniques. Our program is the most experienced in the region at minimally invasive heart valve replacement and repair surgery. Our affiliated specialists are dedicated to saving lives with advanced care and leading-edge technology.
Code STEMI The time between emergency transport of an acute heart attack patient and a lifesaving heart catheterization is critical. In February 2006, Mother Frances Hospital Tyler was the first hospital in the region to implement the Code STEMI (ST-segment Elevation Myocardial Infarction) system to reduce the time between recognition and treatment of acute heart attack victims. We were the first in the area to participate in Door-to-Balloon: An Alliance for Quality™ program launched by the 18
The streamlined Code STEMI processes implemented at LPOHH shorten the time required to open the affected artery during a heart attack. Particular attention is paid to minimizing the steps between diagnosing the heart attack and transporting the patient to the catheterization lab for the procedure. Since 2006, Code STEMI has reduced transport to treatment time of acute heart attack victims from greater than 135 minutes to less than 60 minutes—far better than national standards.
Mean Door-to-PCI Time
Society of Thoracic Surgeons Three-Star Rating in Cardiac Surgical Care
80 70 Time (in minutes)
60
The Society of Thoracic Surgeons (STS) has developed a comprehensive rating system for comparing the quality of cardiac surgery among participating hospitals in the U.S.
50 40
Mother Frances Hospital Mean D2B Time
30 20
In 2012, the Trinity Clinic Cardiothoracic Surgery team at LPOHH received the organization’s three-star rating, the highest STS rating for isolated coronary artery bypass graft (CABG) and aortic valve replacement (AVR). Of the 1,020 hospitals reporting data to the Society of Thoracic Surgeons National Database, 14 percent received a three-star rating for CABG and 3.2 percent for AVR procedures.
10 0
2009
2010
2011
Code STEMI involves collaboration among regional hospitals, including Mother Frances Hospitals Jacksonville and Winnsboro, multiple EMS companies, Flight For Life, and Mother Frances Hospital Tyler, and depends on strong
2012
interdepartmental collaboration between multiple departments at TMF. Significant process improvement efforts at LPOHH continue to improve door-to-balloon times and reduce mortality rates for acute myocardial infarction.
STS CABG Composite Quality Rating Participant 30584 STS Period Ending 12/31/2012
Quality Domain
Participant Score (98% CI)
STS Mean Participant Score
Distribution of Participant Scores • = STS Mean
Participant Rating
Participant Jan 2012 – Dec 2012 Overall
97.4% (96.4 , 98.1)
96.4% Min 89.4
10th 94.7
50th 96.7
90th 97.9
Max 98.9
Participant Jan 2012 – Dec 2012 Absence Of Mortality
98.4% (97.2 , 99.2)
Jan 2012 – Dec 2012 Absence Of Morbidity2
92.1% (88.8 , 94.7)
97.9% Min 93.7
10th 96.9
50th 98.0
90th 98.7
Max 99.4
Participant 86.7% Min 56.4
10th 80.2
50th 87.4
90th 92.2
Max 96.5
Participant Jan 2012 – Dec 2012 Use of 2 IMA
95.5% (92.5 , 97.7)
98.2% 10th 50th 90th Max 96.2 98.8 99.7 99.9
Min 71.9
Participant Jan 2012 – Dec 2012 2 Medications
99.3% (97.9 , 99.9)
88.7% Min 27.1
* Participant performance is significantly lower than the STS mean based on 99% Bayesian probability
19
10th 73.5
50th 90th Max 92.6 98.7 99.9
According to information provided by STS, National Database participants engage in the process of collecting STS data and utilization of database-derived information for the purpose of local and national improvement in the quality of cardiothoracic surgical care. Avoidance of mortality, avoidance of morbidity, use of the internal mammary artery and compliance for recommendation with medication usage are the criteria used to determine a program’s star rating. STS Composite Quality Ratings of one star indicate that the participating hospital’s performance is significantly lower than the STS mean. An STS rating of two stars indicates that performance is not significantly different from the STS mean. The Three-Star STS Rating indicates that performance is significantly higher than the STS mean.
Trinity Clinic Adult and Pediatric Cardiology, Cardiothoracic Surgery, Electrophysiology and Vascular Surgery The expert teams of Trinity Clinic Cardiology and Electrophysiology are committed to prevention, early detection, accurate diagnosis and state-of-the-art
treatment of heart disease. More heart procedures are performed LPOHH than in any other East Texas facility. These medical teams are expert at proven diagnostic tests and treatments, including cardiac catheterization, noninvasive cardiac diagnostic testing, cardiac interventional procedures, arrhythmia services and pediatric cardiology. Our pediatric cardiology team are part of the world-renowned team of specialists on the staff of the Children’s Medical Center of Dallas and are available in Tyler weekly for outpatient diagnostic and followup appointments, as well as providing continuous 24/7 support and consultation for Trinity Clinic neonatolgists and pediatricians. Fetal cardiac evaluations and fetal echocardiography services are also available on-site. The Trinity Clinic Cardiothoracic Surgery team provides superior cardiac and thoracic surgical care using traditional, minimally invasive and robotic-assisted techniques for coronary artery bypass graft, valve procedures and congenital cardiac anomalies, as well as treatment of disease of the lungs, esophagus and aorta. We are known as a national leader in robotic heart and thoracic surgery and minimally
20
invasive valve surgery. We were the first in the region to offer the daVinci® Surgical System and have performed more than 300 robotic-assisted heart procedures. Trinity Clinic Electrophysiology provides evidence-based care in the diagnosis and treatment of atrial fibrillation, offering comprehensive management of all complex heart arrhythmias, including treatment with ablation, medication and devices. Our fellowship-trained specialists have many years of experience in the diagnosis and treatment of patients of all ages for a broad range of atrial and ventricular arrhythmias. Trinity Clinic Vascular Surgery subspecialists diagnose and treat peripheral vascular disease, abdominal aortic aneurysm, varicose veins and other vascular conditions, including minimally invasive venous surgery and cosmetic vein care. Our affiliated physicians are the only group in East Texas who are fellowship-trained in peripheral vascular surgery and whose practice is limited to artery and vein health. They provide comprehensive medical and surgical care, including minimally invasive procedures such as angioplasty, stenting, atherectomy and traditional surgical treatment options.
TMF Centers of Excellence The Trinity Mother Frances Spine Center The Spine Center received The Joint Commission Disease Specific Certification in 2010 and 2012. Awarded to programs that demonstrate excellence in patient care, safety and process improvement, the certification ensures that patients receive clinical care consistent with evidence-based medicine, which is the heart of the Trinity Clinic spine surgery program. With more than 1,000 cases performed each year by highly-skilled and experienced surgeons, patients are assured that our physicians have a high level of experience and expertise.
The spine surgeryâ&#x20AC;&#x2122;s continuous process improvement program has led to a decrease in the average length of stay from 4.0 days in 2009 to 2.5 days in 2012. Infection rates remain consistently less than 1.5 percent, and approximately 85 percent of all spine surgery patients are able to return home immediately following surgery.
Trinity Mother Frances Joint Replacement Center With an emphasis on education and preparation prior to surgery, the Joint Replacement Center offers a healing environment through a collaborative team effort to provide comprehensive care. Our
program is designed to couple a unique care experience for total knee and hip joint replacement patients with a rapid and successful recovery. The JRC has seen an increase in total joint replacement surgeries from 434 in 2006 to 1015 in 2012. Customer satisfaction scores have risen to rank the Trinity Mother Frances Joint Replacement Center in the 99th percentile in the nation. And the JRC has been awarded the Certificate of Distinction by The Joint Commission. The Joint Commission is an independent, not-forprofit, national body that oversees the safety and quality of healthcare and other services provided in certified organizations.
Spine Surgery Length of Stay
4.0 3.5 3.0 2.5 2.0
Spine Surgery Length of Stay
1.5 1.0 0.5 0.0
2009
2010
2011
Joint Replacement Center
2012
Volumes and Yearly Percentage Growth Inception through 2012
1200
7%
1000
40%
4%
4%
800 31%
600
9%
Joint Replacement Center
Volumes and Yearly Percentage Growth Inception through 2012
400 200 0
2006
21
2007
2008
2009
2010
2011
2012
Trinity Mother Frances Stroke Center In addition, the State of Texas has designated Mother Frances Hospital Tyler as a Primary Stroke Center in the East Texas region. Hospitals that receive the designation work in partnership with local emergency medical services to ensure timely care for stroke patients, reduce the burden of stroke and improve survival outcomes.
The Stroke Center has held the Joint Commissionâ&#x20AC;&#x2122;s Disease Specific Certification as a Primary Stroke Center since 2008. This certification is a guarantee to our patients that they will receive a consistently high level of quality, based on effective data-driven performance improvement that reduces the risk of error and improves stroke outcomes.
These designations ensure that patients receive top-quality stroke care from board-certified, fellowship-trained neurologists who are experts in the diagnosis and treatment of stroke and related cerebrovascular disorders. The difference in the quality of care we provide shows in the lives of our former patients and their families.
Our Stroke Program has also received the American Heart Associationâ&#x20AC;&#x2122;s Get With the Guidelines Gold Award, one of the highest recognitions a hospital can achieve for quality improvement programs that show measurable results in stroke outcomes.
Core Measure: STROKE *Inpatients coded with Primary Diagnosis of CVA 3rd Qtr 2012 93.6% 100.0% 100.0% 80.0% 100.0% 96.7% 97.5% 97.9%
Stk 1: Venous Thromboembolism Prophylaxis Stk 2: Discharged on Antithrombotic therapy Stk 3: Anticoagulation Therapy for Atrial Fib/Flutter Stk 4: Thrombolytic Therapy Stk 5: Antithrombotic Therapy By End of Hospital - Day 2 Stk 6: Discharged on Statin Medication Stk 8: Stroke Education Stk 10: Assessed for Rehab 22
4th Qtr 2012 97.3% 100.0% 84.6% 50.0% 97.9% 94.2% 100.0% 100.0%
2012 YTD 94.4% 100.0% 95.5% 87.5% 98.4% 96.6% 96.6% 98.2%
Trinity Mother Frances Bariatric Surgery Center
Bariatric Surgery Volumes
250
The Bariatric Surgery Center has been designated as an American Society for Metabolic and Bariatric Surgery Center of Excellence and a Blue Distinction Center by Blue Cross and Blue Shield of Texas. These designations recognize surgical programs with a demonstrated record of favorable outcomes in bariatric surgery.
200 150 Barictric Surgery Volumes
100
They also confirm our commitment to providing the highest level of care to patients undergoing weight-loss surgery, followed by comprehensive patient care designed to promote weight loss and a healthier lifestyle. The program offers multiple options to patients considering weight-loss surgery, including laparoscopic banding, laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy.
50 0
2008
2009
2010
2011
Volumes/Year
Trinity Mother Frances Ross Breast Center The Ross Breast Center now employs a number of risk estimation computer models to help quantify a woman’s lifetime risk of breast cancer. This information, when combined with an assessment of a woman’s breast density, allows us to make specific and tailored recommendations for supplemental screening. In accordance with American Cancer Society guidelines, women with an estimated lifetime risk that exceeds 20 percent will receive a recommendation to consider adjunctive screening breast MRI. Women with an estimated lifetime risk of 15-20 percent who also have dense breasts will be encouraged to consider adjunctive screening breast ultrasound. For that small subset of women whose personal and/ or family histories are particularly suspicious, recommendations to consider formal genetic counseling may also be made.
In September 2011, Texas became the second state in the nation to pass what is known as Henda’s law, or the Dense Breast Law. The law requires that all mammography facilities in Texas inform women of the significance of radiographically dense breast tissue and the potential benefit of supplemental screening studies. As a consequence of this new law – and our desire to meet a longstanding community need – the Ross Breast Center has launched an innovative new program, known as the RE-Act Program (Risk Evaluation and Action) to help identify and assist women determined to be at elevated risk for breast cancer. While mammography has been consistently shown to decrease diseasespecific mortality by at least 30 percent, many women who are at increased risk for breast cancer may not be effectively screened with mammography alone, due in large part to the masking effects of dense breast tissue. In addition, extreme breast density has now been determined to represent a significant independent risk factor in the development of breast cancer.
Patients are made aware of these recommendations in their mammogram result letter. Our highly skilled team of fellowship-trained, board-certified breast radiologists are dedicated to providing compassionate, quality care to our patients at every stage of their journey. 23
The National Institutes of Health’s Cancer Genome Atlas Project
settings within the first year of practice and the TMF Education has taken serious aim at increasing new nurse confidence and competence utilizing the University Health System Consortium/ American Association of Colleges of Nursing (UHC /AACN) Nurse Residency Program and aligning clinical specialty residencies throughout the first year of nursing practice. Through continuous assessment, planning, evaluation and revising of programs, we have now validated improved quality outcomes.
Through our affiliation with Texas Oncology – Tyler, Mother Frances Hospital Tyler is one of the leading centers promoting advanced cancer research and treatment trials. In 2011, the two organizations announced collaboration with the International Genomics Consortium (IGC) to serve as a critical network tissue source site (TSS). As a TSS, we will provide cancer tissue samples for analysis in the National Institutes of Health’s historic Cancer Genome Atlas (TCGA) project. Texas Oncology – Tyler and Mother Frances Hospital Tyler are one of only 12 sites in the United States for the project.
Our National Database of Nursing Quality Indicators (NDNQI) RN survey results demonstrated significant improvement in the areas of RN-RN interactions, decision-making, autonomy, professional status and professional development. All categories now surpass national benchmarks for hospitals of comparable bed size. We have seen steady improvement in retention of new nurses with each cohort over the past year. We have witnessed significant interest and achievement of clinical specialty certification from our nurses completing the UHC/AACN and clinical specialty residencies. The percentage of RNs holding clinical certification demonstrates commitment to professional development and clinical expertise within the hospital setting.
With a goal of improving our ability to diagnose, treat and prevent cancer, the Cancer Genome Atlas project is one of the largest initiatives to date to analyze a large array of cancers with numerous genomic analyses, ranging from sequencing to methylation studies. The genomic blueprints of each cancer will be available on the Internet, allowing all scientists access to translational discoveries. TCGA expects to analyze 500 tumors from each cancer type studied by the program, and will provide the clinically annotated outcome data along with the complete genomic analysis on the web, free of any intellectual property restrictions. The International Genomics Consortium plans to retain a portion of each sample, if available, to expedite the transfer of translational discoveries to patient care.
The changing healthcare environment, an older work force taking expertise and experience as they retire and a new generation of technically proficient, but inexperienced and extremely mobile, work force will continue to require constant attention and diligence to assure safe, quality patient care outcomes are achieved and sustained at an affordable cost. Retention of our nursing workforce with continuous professional development and education is our best course of action.
The Trinity Mother Frances Cancer Registry collects, analyzes and disseminates information about our cancer patients. Under the supervision of the Trinity Mother Frances Executive Cancer Committee, the registry ensures that the cancer program meets or exceeds all Commission on Cancer program standards related to cancer data management. Our staff members are active members of the National Cancer Registrars Association (NCRA), the Texas Tumor Registrars Association (TxTRA) and the American Cancer Society (ACS). The staff is responsible for the coordination of the weekly General and Thoracic Tumor Conferences for the prospective treatment planning for cancer patients.
Trinity Mother Frances Education and our Staff Trinity Mother Frances Education is dedicated to enhancing student learning opportunities by promoting the system mission and vision for excellence in patient care. Our goal is to provide programs that offer exceptional advancement of staff’s intellectual abilities, and, individual critical thinking directed at enhancing the level of learning while promoting quality patient outcomes. Nursing retention is considered a hallmark of professional nursing organizations and is directly related to quality patient outcomes. Nursing graduates have exhibited a national trend to leave hospital 24
Other Locations Tyler ContinueCARE (LTAC) Tyler ContinueCARE Hospital is a “hospital within a hospital” at Mother Frances Hospital Tyler. Our mission is to enhance community health through service with compassion, caring, accountability, respect and empathy. In 2003, Mother Frances Hospital Tyler and Community Hospital Corporation created a joint venture known as Tyler ContinueCARE and the long-term acute care hospital (LTACH) was successfully launched in 2004. This 51-bed facility is located on the fourth floor of Mother Frances Hospital Tyler for patients who are too ill to be discharged to a rehabilitation hospital, nursing home or similar step-down facility. In the last six years, Tyler ContinueCARE has served thousands of patients from a 100-mile radius of Tyler. As part of our ongoing commitment to excellence, the “Sacred Work” culture program was launched in 2008. Sacred Work is based on the concept that every action needs to be grounded in loving intention and is focused on patients and staff alike. It calls for us to do the right thing. Each new employee receives
education on the program. A Sacred Work Bulletin Board in our break room includes testimonials from patients, families and our staff about the Sacred Work they have experienced in our hospital.
this presentation for one of their breakout sessions. The program was also presented in March 2011 at the 13th Annual East Texas Alumni and Friends Respiratory Symposium.
Each year hospitals and ultimately patients spend thousands of dollars and patients endure longer lengths of stay due to hospital-acquired conditions. In 2007 our clinical director of respiratory therapy, along with other key members of the leadership team, began a ventilatorassociated pneumonia (VAP) focus group. The group began by reviewing current research to develop an evidence-based plan to reduce VAPs based on current and statistically significant research. The VAP focus group continued to make adjustments as necessary until a consistent product was delivered.
The focus of these presentations was the implementation of our program to reduce the number of cases of ventilatorassociated pneumonia (VAP), which decreases the amount of extra resources needed and the cost to the patient, family and facility. An added benefit of this project was increasing the probability of successfully weaning patients from mechanical ventilation. The VAP focus group was instrumental in developing and implementing an oral care and head-of-bed elevation program designed to reduce and prevent VAPs. The programs were based on best practices and evidence-based research.
As a result of these efforts, Tyler ContinueCARE Hospital was chosen to present “Back to Basics: Reducing Ventilator-Associated Pneumonia” at the National Association of Long Term Hospitals 2010 Education Conference – Multidisciplinary Frontiers in Treating the Long Term Acute Care Patient – held in Las Vegas. The 2011 HealthTrust University Conference in Nashville chose
These outcomes demonstrate the effectiveness of a well-defined oral care program and maintaining the patients’ head of bed at 30 to 45 degrees. The data presented show that maintaining a consistent zero or near-zero VAP rate is a task that can be accomplished. We have maintained zero VAP rate for 16 months.
Back to Basics: Reducing Ventilator-Associated Pneumonia Fiscal Year 2010 July 01, 2009 – June 30, 2010
(1) VAP
Ventilator Associated Pneumonia February 2010
Fiscal Year 2011 July 01, 2010 – June 30, 2011
(0) VAP
Ventilator Associated Pneumonia February 2011 25
Fiscal Year 2012 July 01, 2011 – June 30, 2012
(1) VAP
Ventilator Associated Pneumonia February 2012
Trinity Mother Frances Rehabilitation Hospital affiliated with HEALTHSOUTH Trinity Mother Frances Rehabilitation Hospital is a 74-bed facility that provides inpatient and outpatient rehabilitation services and home healthcare services designed to return patients to active and independent lives. Acute rehabilitation hospitals offer distinct advantages in the level of care and services over nursing homes and assisted living centers. We provide a broad range of physical rehabilitation services, a vast network of highly skilled physicians and therapists and the most innovative equipment and rehabilitation technology, ensuring that all patients have access to the highest quality care. Designed with our patients’ care in mind, TMF Rehabilitation Hospital offers semi-private and private rooms with amenities such as telephones, televisions and wireless internet. In addition to caring for general rehabilitation diagnoses such as orthopedics, cardiac and generalized weakness, TMF Rehabilitation Hospital has specialized inpatient programs for stroke, brain injury, spinal cord injury, trauma and neurological disorders. Other services offered include outpatient and home health for a continuation of rehabilitation after an inpatient stay. Since 2007, we have ranked in the 99th or 100th percentile nationally for our patients’ clinical outcomes, making us a national leader in rehabilitative care. The ranking is based on Uniform Data
Systems for Medical Rehabilitation, a not-for-profit organization affiliated with the University of Buffalo, The State University of New York. The UDS Functional Independence Measure details severity of patient disability and the results of medical rehabilitation. More than 1,400 facilities make up the world’s largest database for medical rehabilitation outcomes. Performance criteria include discharge to community rate, discharge to skilled nursing rate, discharge to acute care rate, gain in function and independence and length of stay efficiency.
Trinity Mother Frances Jacksonville Serving Cherokee County and surrounding areas, Mother Frances Hospital Jacksonville is a modern 96,000-square-foot medical complex with 25 beds, a 24-hour Emergency Care Center, laboratory, radiology and pharmacy services, as well as adjacent outpatient medical and fitness services. The hospital offers spacious patient rooms and advanced surgical equipment for both inpatient and outpatient procedures. The Women’s Center includes the services of the Ross Breast Center, offering digital mammography, bone densitometry and other diagnostic services in a dedicated women’s area. Trinity Clinic primary care physicians and specialists are available for outpatient visits, including orthopedic surgery, cardiology, gastroenterology, sleep medicine, urology, ear 26
nose and throat, and other specialties. An adjacent Health and Fitness Center houses a 14,000-square-foot facility, upgraded in 2009 with state-of-the-art fitness equipment. Mother Frances Hospital Jacksonville received the 2011 Top Performers on Key Quality Measures™ from the Joint Commission. The award recognizes accredited hospitals that attain and sustain excellence in accountability measure performance. Mother Frances Hospital Jacksonville is among 620 hospitals recognized in 2011, representing the top 18 percent of Joint Commissionaccredited hospitals reporting core measure performance data for 2011. We were recognized for the pneumonia and surgical care measure sets. We also received the Texas Health Care Quality Improvement Silver Award from TMF Health Quality Institute, the Medicare quality improvement organization for Texas. The award honors Texas hospitals engaged in quality initiatives aimed at improving outcomes in patient care by recognizing hospitals that have improved their performance on specific national quality measures.
We were evaluated on 10 appropriate care measures based on 10 quality indicators, including four for heart and six for pneumonia. To earn the Silver Award, hospital must achieve or maintain performance between 90 and 100 percent on the Appropriate Care Measure and have met all other award requirements.
Areas of Quality Success Mortality: The overall mortality rate for fiscal year 2012 was 0.68 percent, compared to the benchmark of 1.78 percent Readmissions: Our overall acute care 30-day readmission rate for fiscal year 2012 was 7.10 percent, compared to the national benchmark of 10.98 percent Core Measures: Congestive heart failure, 100 percent; pneumonia, 96.9 percent; surgical care improvement, 93.8 percent. Our core measure composite score was 98.63 percent Medication Errors: There were 3.65 medication errors per 1,000 patient days, compared to the benchmark of 5.59 Foley Catheter Infections: None in fiscal year 2012 Customer Service: Our Emergency Care Center scored in the 85th percentile for customer service, the centerâ&#x20AC;&#x2122;s highest score ever. Door-to-Physician Time: The time from arrival in our Emergency Care Center (ECC) to triage was 5.2 minutes. The time from arrival to a bed in the ECC was 14.31 minutes, and the time from arrival to seeing an emergency physician was 33.9 minutes
Trinity Mother Frances Winnsboro Mother Frances Hospital Winnsboro is a 25-bed, full-service hospital serving Camp, Franklin, Hopkins, Rains and Wood counties and surrounding areas. Highly skilled primary care physicians and specialists offer services that include emergency medicine, cardiology, pain management, gastroenterology, general surgery, physical therapy, sleep medicine, vascular surgery, hyperbaric therapy and wound care. Our patients also benefit from access to diabetes education and state-of-the-art diagnostic imaging, including mammography and bone densitometry. In 2011, Mother Frances Hospital Winnsboro received a commendation from TMF Health Quality Institute, the quality improvement organization for the State of Texas for hospitals that are Medicare funded. We were recognized for participating in the national Surgical Care Improvement Project and Heart Failure Collaborative from August 2008 to July 2011. The recognition honors Texas hospitals that play a significant role in enhancing the wellbeing and safety of patients in Texas.
27
Our hospital received and has maintained a Level IV Trauma Designation since 1998. Our six-bed Emergency Care Center was remodeled and expanded in late 2006, and a helicopter landing zone can accommodate most of the larger air ambulances. Beginning in March 2012, we implemented Straight-Back Triage for our patients to decrease patient-to-physician wait times and improve the quality of care. To date, our time from door to physician has remained at 24 minutes. In September 2011 we opened a Pain Management Clinic to service patients in Winnsboro and the tri-county area of Wood, Hopkins and Franklin Counties. The Joint Commission Triennial Survey was completed in December 2012 with no deficiencies requiring Measures of Success follow up.
Areas of Quality Success Mortality: The overall mortality rate for 2011 was 1.13 percent, compared to the national benchmark of 1.78 percent Infection Rate: There were no urinary catheter infections in 2011. Our surgical site infection rate was 0.4 percent, compared to an expected rate of 1.15 percent. We had no ventilator-associated pneumonia cases or central line-acquired blood stream infections
Trinity Mother Frances Winnsboro Continued
Core Measure All-or-None Bundle AMI
Heart Failure
CAP
SCIP
100
Composit Score
80
60
40
20
0
1st 2nd QTR QTR
3rd QTR
1st 2nd QTR QTR
3rd QTR
4th QTR
1st 2nd QTR QTR
Customer Service: The Emergency Care Center scored in the 50th percentile for customer service in 2011. As of August 30, 2012, the score had increased to the 80th percentile with the implementation of Straight-Back Triage
3rd QTR
4th QTR
1st 2nd QTR QTR
3rd QTR
4th QTR
Advantage, which sets the benchmark for days to heal at 56. The score is based on data from Verdugo Hills Hospital in Glendale, California. Our days to heal rate for 2012 to date is 32.75, which remains well below the benchmark. This rate also remains consistent with our 2011 rate
Fall Rate: Our overall fall rate for 2011, was 5.1 with an expected rate of 4.6. Although our rate was 0.5 over expected, our patients have sustained zero to only minor injuries due to nursing staff dedication to implementing fall prevention measures. As a result of our fall prevention measures, our fall rate for calendar year 2012 is 3.28
Readmission Information: Using data from calendar year 2010, the Centers for Medicare and Medicaid Services (CMS) reported on readmission rates. The National Crude Rate for the CMS Dry Run Hospital-Specific Report for Hospital-Wide All-Cause Unplanned Readmission Measure is 16.8 percent. The rate for the state of Texas is 16.3 percent. Our facilityâ&#x20AC;&#x2122;s rate is 16.1 percent, which is considered no different than the U.S. national rate
WoundCARE: In 2011 our expected rate for median time to heal was 28 days, and just over expected at 31.75 days was realized. In January 2012, we changed management company to Wound Care
28
Trinity Mother Frances Hospitals and Clinics Region at a glance
HOPKINS
Locations Sulphur Springs Emory Quitman Winnsboro Mineola Canton Holly Lake, Hawkins Lindale Tyler Kilgore Chandler Whitehouse Lake Palestine Athens Henderson Jacksonville
RAINS WOOD
GREGG
VAN ZANDT SMITH
RUSK
HENDERSON
Mother Frances Hospital
Trinity Clinic
CHEROKEE
13-0891
tmf hc.org