Our Stories: Joint Commission preparedness

Team, 

As you know, we’re preparing to soon welcome a group of Joint Commission surveyors between now and September. I hear a lot from different groups about being “Joint Commission ready.” While this is absolutely important—as their survey provides us with a benchmark of our hospitals and clinics’ quality and safety standards—the real question we should ask ourselves is, “Are we patient ready?” 

Our protocols and policies are not in place for the Joint Commission. They exist—and we follow them—because it’s the right thing to do for our patients and visitors to keep them safe. If we’re diligent and mindful of maintaining a safe environment day in and day out, a visit from the Joint Commission becomes just another week. 

With that in mind, we should all be taking a proactive approach to patient-readiness, each and every day.  

How do we do this? I encourage you to review the host of resources available to us from our Quality and Safety teams. Resources—from quick tips to downloadable fact sheets—can be found on The Loop to help us all be patient (and Joint Commission) ready.  

Thank you for all you do. 

Theresa Brennan, MD, FACC 
Chief Medical Officer 

Our Stories: Reducing falls

This blog is part of an ongoing series focused on introducing the current quality initiatives. This month, we are featuring the work being done to reduce injuries resulting from falls. Thank you to the Quality Improvement Program team for sharing their important work with us and thank you for taking the time to learn more about the vital work that goes on to improve the care we provide to our patients.   

Patient falls are a challenging problem to solve since there is no one-size-fits-all approach to reducing falls and preventing injuries. All health care team members (e.g., provider, nursing, therapy, transport teams, etc.) have the ability—and responsibility—to make a difference in the safety of our patients. A fall event typically occurs unexpectedly, but many of these falls can also be anticipated through the completion of a thorough fall risk assessment. 

 What risk factors are patients assessed for? 

The fall risk assessment is completed to assess for multiple risk factors including:  

  • Elimination: Most common activity contributing to falls 
  • Mobility/Ambulation: Gait, unsteadiness, weakness, assistive devices, etc. 
  • Mental Status: Delirium is a major risk factor for falling and is preventable. 
  • Sensory/Communication Deficit: Neuropathy, vision, hearing, etc.  
  • Medications: Cardiac and central nervous system medications 
  • Last fall: Including admission due to a fall or a fall during hospitalization 
  • Age-related risk 
  • Nursing judgment: Alcohol withdrawal, encephalopathy, impulsivity, impaired judgment, etc. 

Fall prevention interventions are multifactorial and individualized. Recognizing what makes your specific patient population unique and using the information obtained from the fall risk assessment to understand your patient’s fall risk factors will aid in initiating appropriate fall prevention strategies.  

 What is a fall with injury? 

We have standard definitions that are provided to us by the National Database of Nursing Quality Indicators (NDNQI) to ensure a standard process in defining a patient fall and the level of injury. A patient fall event is defined as a “sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can).” The NDNQI further defines the injury levels by providing a framework of examples including but not limited to: 

  •  No injury: Resulted in no signs or symptoms of injury as determined by post-fall
  • Minor injury: Resulted in application of ice or dressing, cleaning of a wound, limb elevation, topical medication, pain, bruise or abrasion 
  • Moderate injury: Resulted in suturing, application of steri-strips or skin glue, splinting, or muscle/joint strain 
  • Major injury: Resulted in surgery, casting, traction, required consultation for neurological (e.g., basilar skull fracture, small subdural hematoma) or internal injury (e.g., rib fracture, small liver laceration), or patients with any type of fracture regardless of treatment, or patients who have coagulopathy who receive blood products as a result of a fall 
  • Death: The patient died as a result of injuries sustained from the fall (not from the physiological events causing the fall) evaluation” 

 Core Team: 

There is a monthly multidisciplinary Fall Prevention Committee that consists of nursing leaders, staff nurses, nursing assistants, physical therapists, occupational therapists, a pharmacist, and a provider. We are also developing a task force consisting of a smaller core team that will review the data on current themes with opportunities for patient falls and quick decision-making for opportunities in fall prevention, as well as the correlation of other patient factors to their fall risk.   

 Metrics being tracked: 

In addition to the total number of patient falls each month, we also monitor the number of assisted falls and falls that result in an injury within Tableau. Each quarter, we also submit our data on total patient falls and falls with injury to the NDNQI. We use this data from the NDNQI to benchmark against other academic medical centers and other comparative units (down to the unit level), allowing for fair comparison for each unit/clinic that submits data to the NDNQI. Inpatient and ambulatory/non-inpatient falls and falls with injury are monitored and shared each month (data is through the month of May 2022). 

What is the team doing to improve metrics? 

Generally, patient falls are multifactorial, which is why a thorough fall risk assessment and understanding of how each risk factor impacts the patient’s risk of falling is important. In some instances, the fall risk assessment may have been completed just to “check the box,” ultimately missing the correlation between risk factors and the appropriate fall prevention interventions. 

Reinstituting post-fall huddles is one way UI Health Care is working to improve metrics. Additionally, the post-fall huddle form was redone, including the development of an electronic version. The updated form is broken down by risk factor to assist staff with making the connections and linking appropriate interventions with the patients identified risk factors. The team is continuing to work with various departments to assist staff with making the connections between risk factors, interventions, and hardwiring practices that will promote routine use of patient-specific strategies for fall prevention.  

Patient fall events have been an ongoing national concern that has resulted in The Joint Commission’s sentinel event definition in January 2021. Any patient fall that results in a major injury or death (as defined above) is now reported to the Joint Commission as a sentinel event.  

So, as we continue our work reducing falls and preventing injuries for our patients, it’s important to remember that change doesn’t happen overnight. We encourage you to make short-term attainable goals that are specific for your area that include realistic components that will help you hit those milestones. Understand what the top three risk factors/causes are for patient falls in your area, build a plan with your team with realistic interventions, and implement those interventions to  minimize those identified risks. A good rule of thumb is to start with the primary risk factor and continue to build as you make progress.  

Focus areas for improvements 

  • Education for thorough and accurate fall risk assessment 
  • Education on connecting risk factors with appropriate interventions 
  • Complete a multidisciplinary post fall huddle (paper or electronic version) after every fall to learn from fall event 

Our Stories: Central-Line Associated Blood Stream Infections (CLABSIs)

This blog is part of an ongoing series focused on introducing the current quality initiatives. This month we are featuring the work being done to improve Central-Line Associated Blood Stream Infections (CLABSIs). Thank you to the Quality Improvement Program (QuIP) team for sharing your important work with us and thank you to our readers for taking the time to learn more about the vital work that goes on to improve care for our patients here within UI Health Care. To learn more about the other initiatives please check out the introduction and previous topics

—Theresa Brennan, MD 

Why do some patients need central lines? 

Reliable vascular access is necessary for the safe and effective care of hospitalized patients. Central lines are often necessary for many patients requiring acute or long-term venous access treatments. Central lines have many benefits and are indicated for longer dwell times when compared to peripheral vascular access. When determining appropriate venous access, expert teams use evidence-based practice guidelines to aid in decision making for vascular access devices. Key clinical indications must be considered, which include length of treatment, indication for vascular access, need for vessel preservation, and the nature of the infusate. Although central lines provide many patient benefits, there are also associated risks. Due to these risks, central lines should be removed as soon as the benefits no longer outweigh the risks.  

What causes a Central-Line Associated Bloodstream Infection (CLABSI)? 

CLABSI is a bloodstream infection where germs enter the blood through a central line. It occurs when the patient’s line becomes contaminated. This can happen at the time the line is being placed and the skin is not adequately cleaned. It can happen when dirty health care worker’s hands (or gloves) contact the line. Or it can occur when medications are being introduced through contaminated lumens.  

CLABSI is the most expensive hospital-acquired infection and adds approximately $46,000 per event. Furthermore, it impacts length of stay by 10.4 days, and mortality can be high, with approximately 1 in 4 patients (23.8%) dying as compared to similar patients without a CLABSI. CLABSIs occur less frequently than they used to but nationwide, they still impact 41,000 patients annually.  

How do we prevent CLABSIs?  

At the most basic level, CLABSIs are prevented by ensuring correct and sterile insertion of a central line, proper care of the line, and prompt removal when no longer needed. Accessing and maintaining the line requires health care workers to interact with the device, dressings, and patient’s skin around the line, and each interaction comes with some risk of infection. Reducing the amount of time that a patient has a central line decreases the risk of contamination. All members of the care team have a role in maintaining sterility of the device and site and in reducing the amount of time a patient has a line inserted. 

Foundational practices by care team members actively caring for a patient’s central line make a significant difference in keeping the device and site clean. Implementing effective hand hygiene and following best practices for insertion, removal, dressing changes, and blood culture collection are important in preventing contamination. Further, bathing with chlorhexidine gluconate soap keeps the bacterial load on a patient’s skin to a minimum.  

Members of the patient’s care team who do not directly interact with their central lines also have a role in preventing CLABSIs. For example, when a patient is admitted with a previously placed central line, documenting the insertion date enables accurate calculation of line days. Epic reporting can then display this timeframe, prompting the care team to review whether that line is still needed. Additionally, when a patient’s environment is contaminated, it is more likely that the contamination will spread to their central line. This is most notable in pediatric patients who are smaller and more active. Further, if a patient is experiencing signs of a CLABSI, timely, properly obtained cultures will allow clinical and epidemiology experts to identify the bacteria and better understand the circumstances to improve in the future. 

CLABSI reduction initiative 

In December 2020, an interprofessional CLABSI committee was formed to reduce CLABSIs across adult and pediatric units within UI Health Care. Currently co-chaired by Karen Brust, MD, hospital epidemiologist, and John Swenning, BSN, RN, MBA, CENP, director of ISS Nursing, this initiative team monitors CLABSI trends in our institution, investigates changes needed to align with best practices, and implements proven CLABSI reduction strategies.  

Upon review of UI Hospitals & Clinics CLABSI trends, a significant number of CLABSIs were found to be associated with peripherally inserted central catheters (PICCs). After researching evidence-based recommendations, the team pilot and implement chlorhexidine-coated PICCs for all eligible adult patients. Chlorhexidine is an antimicrobial that provides another layer of protection in preventing line contamination. During the trial period, more than 550 coated PICCs were placed in eligible adult patients. This trial included extensive data tracking, educational content development, and policy expansion. Combined with basic infection prevention bundle elements, the introduction of chlorhexidine-coated PICCs has significantly decreased PICC CLABSIs. In patients who are not immunocompromised, only one patient in the trial developed a CLABSI from September 2021 to February 2022. Comparatively, the institution averaged three adult CLABSIs per month prior to this trial. With organizational recognition of trial success, the team has begun a similar process to implement chlorhexidine-coated central venous catheters (CVCs). 

Another identified opportunity to reduce CLABSIs, was to improve compliance with scheduled central line care and maintenance bundle elements. This includes routine dressing changes, tubing changes, and needleless access device changes. A small workgroup was tasked to build a dashboard that gives frontline staff and unit leadership real-time information about patients with central lines that require those bundle elements to be completed. With quick access to this information, they are in the best position to call out missed bundle elements and concerns during rounding. “Nurse-first” rounding is being used in many areas, and this workbench report will be an asset to all participants.  

The central line dashboard will be rolled out in the coming weeks starting with units that have the highest utilization of central lines and then continuing to remaining areas. Look for more information regarding house-wide implementation by the end of this fiscal year. 

Everyone can help prevent CLABSIs by focusing on proper insertion, appropriate care and maintenance of central lines, and early removal.   

Blog contributors:
-Kathryn Trautman, MSN, RN, CMSRN, Nursing Practice Leader, Adult Vascular Access
-Mary Beth Hovda Davis, MSN, RN, VA-BC, Nursing Practice Leader, Pediatric Vascular Access
-Karen Brust, MD, Hospital Epidemiologist
-Jill Furgason, MPH, PMP, CPHQ, Sr. Project Manager
-Dominica Rehbein, MHA, MPH, PMP, Sr. Project Manager

Our Stories: Discharge planning

This month I wanted to write about our work on modifying the discharge huddle process and the purpose. 

I like to think of the patient’s hospitalization as a journey, similar to any road trip you would plan. You would pack your car with your bags and fill the tank with gas. Your bags would have clothes and shoes for all weather conditions, just in case. You may plan to stop along the way to see different sites, pick up souvenirs, take pictures and eat at a restaurant you have heard so much about. Armed with a spare tire in the trunk, extra cash, and maybe an umbrella, you hope for a smooth trip, but are prepared for the unexpected. You have an expectation of the day and potentially time that you will arrive at your destination. Most of the time, this journey is uneventful, but occasionally, things come up. As you are driving, on your way, your “check engine” light comes on and you have to find a service station. With this detour, how do you get back on track?  

This journey is analogous to the patient’s journey through their hospitalization. We prepare for the patient’s need by having the right people available to care for them, the right testing and procedural access, the right meds, etc.—all of these we have at the ready for that patient and their potential needs, just as we have done to pack our car. All patients have an expected length of stay for the diagnosis for which they present. Many of us, including the patient, do not know what that expected date of discharge should be, and that date may change based on the diagnoses that patient comes in with and acquires during their hospitalization. However, the unexpected may occur: they have a complication, their course is slower or faster than expected, they need help when going home, etc. What do we do as health care providers to make sure this patient gets back on track and discharged on time, as expected, safely?  

The first is to make sure everyone on the team knows what is going on and what to expect. This communication should result in the team working together better and should eliminate some duplication of efforts. This need for this communication is the purpose of the discharge huddle. We know not everything goes as planned, so we prepare the best we can for each patient during their hospitalization. We schedule procedures, order consults, labs and imaging ahead of time. We prepare them for post-acute treatment needs, like skilled care and rehab and home health care, and schedule any follow-up appointments as necessary. We send prescriptions for their medications to the patient’s pharmacy. We do all of this to have a safe and efficient discharge for the patient. 

Communicating and planning with our teams each and every day about each of our patients makes the journey through the hospitalization more effective, more satisfying, and safer. And when unexpected delays occur, we can quickly resolve them and get our patients back on track by working together as a great team.  

Discharge planning truly begins at admission. It is important to discuss the discharge plan each day of hospitalization to ensure timely discharge. 

—Theresa Brennan, MD, Chief Medical Officer

Our Stories: Hospital Acquired Pressure Injury (HAPI)

We all have a role to play in preventing hospital acquired pressure injuries, or “HAPI.” These injuries harm patients, prolong the hospital stay, and are costly. With teamwork and attention to proven strategies, nearly all HAPIs can be prevented. 

How does a HAPI impact our patients? In addition to an extended length of stay, HAPI’s can lead to sepsis and may require surgical intervention. 

HAPI definition and stage descriptions: Pressure injuries are damage to the skin and/or underlying soft tissue related to positional pressure on a bony prominence or external pressure from a medical device. Medical device related pressure injuries often take on the shape of the device. Pressure injuries can occur due to a high amount of pressure over a short period of time or a low amount of pressure over a long period of time. They can range from an area of redness on intact skin to deep cavernous wounds with exposed bone and are often painful. 

How are HAPIs monitored at UI Hospitals & Clinics? Our performance is monitored through two primary methods. Our PSI-03 CMS reportable event is captured exclusively through physician documentation. The staging and determination of present on admission (POA) status are both required documentation per coding guidelines. Effective Feb. 15, 2022, providers are now able to use the dot phrase .PRESSUREINJLIP in their note to incorporate wound nursing documentation. Providers then have an attestation statement to complete.  

This change will help to standardize and accurately reflect the correct stage of HAPI. Additionally, the wound and ostomy nursing team completes Riskonnect events to monitor HAPI performance. 

Fiscal year 2022 HAPI reduction initiative 

Beginning in July 2021, Greg Schmidt, MD, professor of internal medicine, associate chief quality officer, and Nick Poch, DNP, RN, MBA, VA-BC, interim director of Centralized Function, Interim associate chief quality officer, have been co-chairing the organizational HAPI reduction initiative for UI Hospitals & Clinics. During the past nine months, much work has focused on improving documentation tools in Epic, reporting tools for frontline staff and leaders to proactively identify high-risk HAPI patients, and identification of HAPI reduction tools such as the HoverTech Q2 Roller designed to provide consistent and adequate sacral pressure relief. Additionally, effective March 1, 2022, all VoalteOne nursing phones have the Rover application capable of uploading images directly into the patient’s medical record. 

Stages of pressure ulcers  

  • Stage 1 Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. 
  • Stage 2 Partial thickness skin loss with exposed dermis: The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible.  
  • Stage 3 (PSI-03 reportable event to CMS): Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, or bone are not exposed. 
  • Stage 4 (PSI-03 reportable event to CMS): Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. 
  • Unstageable (PSI-03 reportable event to CMS): Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. 
  • Deep tissue injury: Persistent non-blanchable deep red, maroon, or purple discoloration; Intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precedes skin color changes. Discoloration may appear differently in darkly pigmented skin. 

You can see further information on the staging system for pressure injuries in this guide with definitions and illustrations. Stage 3, 4 and unstageable pressure injuries determined by physician documentation coding are reported to CMS for the PSI-03 Quality Performance Metric. 

Plans for future improvements  

  • Organization-wide use of four eyes skin assessment on admission and transfer 
  • Education on device-related pressure injuries 
  • Education and monitoring of consistent and effective turning  

Key Points 

  • Everyone on the health care team has a role in pressure injury prevention 
  • When documenting in a note, use .PRESSUREINJLIP 
  • Consult wound ostomy care nurses (Inpatient Consult Wound Ostomy Nurse – Adult) when you are concerned about any skin breakdown  
  • Complete and document a full body skin assessment with a colleague (four eyes skin assessment) upon admission and transfer 
  • Use the Rover application on the VoalteOne phones to capture and upload images when any skin injury is identified 
  • Refer to this guide for further information on the NPIAP staging system for pressure injuries 

Blog contributors:
– Julia Langin, MSN, RN, CMSRN, CWON, Nursing Practice Leader, Adult Wound and Ostomy/Quality, Nursing Centralized Functions
– Nick Poch, DNP, RN, MBA, VA-BC, Interim Director of Centralized Function, Interim Associate Chief Quality Officer, Department of Nursing
– Greg Schmidt, MD, Professor of Internal Medicine, Associate Chief Quality Officer

Our Stories: An introduction to health care quality

It has been more than 20 years since the Institute of Medicine—now known as the National Academy of Medicine, published “To Err is Human: Building a Safety Health System1” and “Crossing the Quality Chasm: A New Health System for the 21st Century2.” These seminal “call to action” reports brought significant and much needed attention to the issues of patient safety and health care quality in the United States. One of the most important and enduring contributions of “Crossing the Quality Chasm” was the identification of six specific aims that have since become the essentials of health care quality. Health care should be safe, timely, effective, efficient, equitable, and patient-centered.   

  • Safe: Avoiding harm to people for whom care is intended. 
  • Timely: Reducing wait times and eliminating delays that do not provide information or allow time to heal.   
  • Effective: Providing evidence-based health care services to all patients who could benefit. This also refers to refraining from providing services to those unlikely to benefit from them.  
  • Efficient: Maximizing the benefit of available resources and avoiding waste. 
  • Equitable: Providing care that does not vary in quality on account of gender, ethnicity, geographic location, or socioeconomic status.  
  • Patient-Centered: Providing care that is respectful of and responsive to individual preferences, needs, and values.   

These aims are well represented in the mission, vision and core values of UI Health Care. They also serve as an important and consistent framework for all of us as we engage in ways to make our health care system better.     

Each year, the Quality Improvement Program (QuIP) identifies several issues that are deserving of focused quality improvement efforts. For fiscal year 2022, we chose to continue efforts on reducing hospital acquired conditions and improving our end-of-life care services. The rationale for focusing on these two areas is that it both aligns with a goal of delivering STEEEP care (i.e., health care that is safe, timely, effective, efficient, equitable, and patient-centered) and may also have a high impact on our publicly reported metrics and pay-for-performance programs.   

QuIP has engaged multidisciplinary performance improvement teams that are working to reduce surgical site infections (SSI) related to colon procedures (colon SSI), surgical site infections related to cesarean sections (cesarean section SSI), central line-associated bloodstream infections (CLABSI) and hospital-acquired pressure injuries (HAPI). We also have a team focused on improving the ways we identify patients with serious illnesses and patients who are potentially near the end-of-life who may benefit from supportive care, palliative care and/or hospice care services so that we can offer those services sooner.   

In each of the subsequent Quest monthly newsletters, we are going to highlight one of the FY22 Quality & Safety Initiative Projects so you can learn in greater detail what we have been doing to improve the quality of care we deliver here at UI Health Care.  

— Derek Zhorne, MD, Interim Chief Quality Officer 

References 

1  Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human: Building a Safer Health System. National Academies Press (US). 

2  Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US). 

Our Stories: Focusing on Wellness

First, I want to say thank you. Thank you for your continued commitment and effort after another challenging month. Thank you for being there for our patients and for each other. 

After a stressful and at times chaotic January, we’re not out of the omicron surge just yet, but numbers are moving in the right direction. That’s good news. 

I know it hasn’t been easy to prioritize wellness during an ongoing pandemic that doesn’t seem to give any reprieve. That’s why this month’s message is focused on wellness. You may think, “How does wellness fit in a quality and safety newsletter?” I actually see the two as deeply connected. When you feel strong, both physically and mentally, you’re better able to care for your patients, support your coworkers, and just be your best self.  

There are so many resources available to us right now for support. I encourage you to learn more about the COPE Team. Another opportunity is an upcoming forum on health and well-being, held by liveWELL, our university partner. I also encourage you to bookmark this page, which is full of resources to support employee well-being with everything from physical health, emotional support, and resiliency tools. 

Did you know there is only about a month and a half to go until the sun sets after 7 p.m.? It may seem like a small thing, but for me, something as simple as having a bit more daylight is giving me something to look forward to and keep me going through these long winter days and freezing temperatures. 

Stay safe, stay healthy, and be well. Thank you, again, for all you’re doing to support the safety of our patients and others.

—Theresa Brennan, MD

Our Stories: New year, new variant, revitalized focus on safety and our commitment to each other

As we start anew in 2022, I know that there are likely many things on your mind, including the omicron variant. Omicron is now the dominant variant in the U.S. and in Iowa and is more contagious compared to previous COVID-19 variants.  

Although we all hoped that 2022 would be a time we would call “post pandemic”, the new year does bring a fresh start and a chance to revitalize our commitment to safety.  

Here’s what we can do to get through these challenges together: 

Recommit ourselves to diligently follow our safety standards both at work and in the community.  

This includes wearing medical-grade face masks, social distancing, avoiding large gatherings (including congregating in areas such as break rooms), and most of all, getting vaccinated and boosted.   

We know that these safety standards are effective when we use them consistently. 

Finally, I encourage you all to lead the way with kindness. The days to come will require sacrifice, compassion, and empathy. We can’t always change the situation we’re in, but we each have the power to control how we respond. With this new year, it is a chance to remember that throughout this pandemic, we have committed to these safety practices for ourselves and our patients, but also for our families—both those at home and for our UI Health Care family. As Suresh and Dr. Jackson shared in yesterday’s message: “Together, we will get through this”. 

Thank you for all that you do, happy new year, and please stay safe. 

—Theresa Brennan, MD, Chief Medical Officer

Our Stories: Vizient quality and accountability scorecard

Hospital quality metrics are a set of standards developed by the Centers for Medicare & Medicaid Services (CMS) to quantify health care processes, patient outcomes, and organizational structures. You are likely familiar with some of these key metrics such as length of stay, 30-day readmission rates, or mortality rates which may be reviewed at a clinical service line, department, or hospital-wide level.

Hospital-acquired conditions such as central line-associated blood stream infections (CLABSI), catheter-associated urinary tract infection (CAUTI), or surgical site infections (SSIs) are also key quality metrics for a health care organization to track and monitor because preventing these from occurring in our patients is central to the goal of ensuring that every patient receives safe, effective, and high-quality care that is free of all preventable harm. 

CMS spearheads dozens of initiatives with publicly reported data aimed at reducing overall health care costs and improving care quality, including programs such as the Hospital Outpatient Quality Reporting Program, the Hospital Inpatient Quality Reporting Program, the Hospital Value-Based Purchasing Program, and the Hospital-Acquired Condition Reduction Program. 

Although the focus and metrics differ among these programs, the underlying premise of performance measurement and improvement is something that we can certainly all support. 

Derek Zhorne, MD, Interim Chief Quality Officer

The Vizient Quality and Accountability scorecard is a tool that measures academic medical centers (AMCs) clinical performance year over year focusing on quality and safety in comparison with similar hospitals while targeting specific opportunities for improvement. The Q&A provides scoring and ranking across the cohort group of AMCs to identify structures and best practices across a variety of patient populations divided into six weighted domains. 

Vizient also provides a quarterly calculator reports with the same metrics within the six domains and allows quarterly ranking to track progress throughout the year. Within the calculator, a member can perform “what if” analyses to identify projected rankings and how scores with improved metrics will impact rankings.

CMS have developed a methodology to calculate and display overall hospital-level quality using a Star Rating system. An individual hospital is assigned a summary Star Rating of between 1 to 5 stars (more is better) based on the hospital’s performance across a variety of quality measures. The most recent CMS Star Rating included forty-nine individual quality measures among the five measure groups of mortality, readmission, safety of care, patient experience, and timely and effective care. The intent of the CMS Star Rating is to improve the usability and interpretability of information posted on Care Compare, which is a website designed for consumers to use along with their health care provider to make decisions on where to receive care. The CMS Star Rating is usually updated each year.

  • What are these data sources?
    • Data sources for the Vizient Q&A scorecard is provided at the encounter level that we submit monthly to Vizient. It is based on our EPIC billing data.
    • CMS gets the data from two sources: 1) claims submitted to CMS for delivered care; and 2) information collected from patient medical records.
  • How is the data for each collected?
    • UI Hospitals & Clinics submits encounter level data to Vizient monthly by using an extraction process from Clarity (EPICs data warehouse). The extraction process from Clarity begins as soon as the previous completed month reaches at least 90% “Coded Complete” in EPIC. We submit both Inpatient and Outpatient encounters in our Clinical data submission files. We utilize a rolling three-month period with every monthly submission to Vizient so we have the opportunity to pick up any late coded, changes, edits, etc. from a specific month, three different times. We also resubmit every fiscal year to catch any late changes prior to the deadline for the annual Q&A scorecard.
    • In general, the CMS rating is calculated through a complex process of grouping measures, calculating group scores, weighting summary scores, and dividing hospitals into appropriate peer groups for comparison purposes. The details of the methodology have changed over time.
  • Where does the scorecard live?
    • Our Vizient Q&A data and scorecard lives within the Vizient Clinical Database. Vizient also offers an online query tool to run routine and ad hoc reports to track performance throughout the year. Our analytics team downloads encounter level data from the Clinical Database and stores the data both in HEDI Data warehouse as well as on Tableau Server for end users to easily access.

  • Who manages the data?
    • Currently HCIS, and Hospital Decision Support manage the Vizient data. The CMO office manages the Q&A scorecard as well as providing analysis and presentation of the scorecard. The analysts in the CMO office are also responsible for validating and overseeing the entire cycle from data submission to extraction of the data.  
    • The Quality Improvement Program (QuIP) manages the evaluation and submission of the CMS quality measures. A team in Health Information Management collaborates with QuIP to abstract the data from the medical records according to measure specifications. Both teams leverage subject matter experts to improve performance on the measures and validate the data prior to submission.
  • Why are these important in terms of quality work and how they directly affect the hospital?
    • The Q&A is important to see how well we are providing quality and patient safety to our patients. The metrics within the Q&A look at hospital acquired conditions as well as clinical metrics such as mortality, length of stay, and direct cost. When compared against other academic medical centers, we can identify where we have the largest opportunities to become better performers, whether it be in documentation, coding, or processes. It also is important as it gives us an idea on how satisfied our patients are with their care and where we can improve satisfaction across the institution.
    • The CMS Star Rating is publicly available on CMS’s Care Compare website along with UI Hospitals & Clinic’s performance on each quality measure. The quality measures within the CMS Star Rating are also included in CMS’s Pay-for-Performance Programs.
  • What are the similarities and differences/variations in these data sources?
    • Similarities: Both use our hospital encounters to identify our performance across quality, safety, and patient satisfaction.
    • Differences: Vizient utilizes all inpatient and outpatient payors, including Medicare, Medicaid, and private insurances. Vizient also looks at all patients ages. CMS Star Rating only looks at Medicare Payors and patients 65 and older.
  • How do they overlap?
    • Many of the metrics within the two reports are the same in regards to quality and safety.
  • Why you might see that we are ranked high in one versus the other?
    • The Q&A only uses comprehensive academic medical centers. All patient ages and all insurance payors. The category/domains are weighted differently.
  • What about the difference in time frames?
    • CMS Star Rating looks at older data when its calculating rankings, currently the Star Rating is based on fiscal year 2017 to fiscal year 2019 data. Vizient annual scorecard includes the previous fiscal year performance released in the fall of each year, currently July 2020 to June 2021.
  • How do individuals access the data?
    • The Vizient Q&A is available to view and download directly from the Vizient Clinical Database site. Regarding our internal reports, the majority of the Vizient data and reports are available on Tableau Server.
  • Who to work with to better understand the data:
    • Vizient Benchmarking:
      Kelly Noel-Roszell, Quality and Operational Improvement Engineer, Vizient Analyst, Vizient CDB Coordinator

Kelly Noel-Roszell
Quality and Operational Improvement Engineer, Vizient Data Analyst, Vizient CDB Coordinator

Jennifer McDanel
Quality & Operations Improvement Engineer

Our Stories: Delta is different, our goals are the same

If you’ve been following the news or watching the COVID-19 numbers reported in Noon News, you’ve likely seen a noticeable difference in the status of the pandemic in the U.S. as compared to just a month ago. Unfortunately, the evolution of the pandemic is not trending in a positive direction. However, there is still positive news to share.  

We’re equipped with the resources we need to focus on safety.  

COVID-19 vaccinations 

If you haven’t yet received your COVID-19 vaccine, it’s as easy as a call to our Employee Health Clinic at 319-356-3631 to ask your questions and get your vaccination scheduled. 

Wondering how to encourage your patients, family members, or friends to get vaccinated? 

  • According to the Kaiser Family Foundation, eight in 10 people look to their health care providers when deciding whether to receive the COVID-19 vaccination. Check out our guide for addressing vaccine hesitancy with your patients. 
  • Did you know we have fact-based vaccine information you can share with family and friends? View more at uihc.org/covid-vaccine

Safety resources 

  • As a reminder, you can find our own safety guidelines, tips, and information on The Loop.  
  • Pediatric resources are available on uichildrens.org. This includes tips for helping remind kids to wash their hands, a Q&A video with pediatrician Hao Tran, MD, on keeping kids safe as they return to school, among many other resources for families. 
  • Looking for general safety resources? Our COVID-19 hub on uihc.org has information about COVID-19 testing for patients, what to do if someone in your home is sick, and more. 

The delta variant, which is now causing the vast majority of COVID-19 cases in the U.S., is fundamentally different than the earlier versions of the virus. It spreads more easily, but the way out of this pandemic is the same. We work together, we stick to what we know works when times are tough, and we share the word about how we can all do a little to make a big difference.  

Thank you for all that you do, seen and unseen, each and every day. 

—Theresa Brennan, MD, Chief Medical Officer