Improving Quality/Safety

Every new patient care model proposed in health care reform requires doctors, hospitals, nursing homes, and home care agencies to compete on the basis of value. To prevail, the best health care systems must offer the best possible outcomes and service at the lowest possible cost.  The Centers for Medicare and Medicaid plan to use this “Value-Based Purchasing” equation to rank – and effectively steer patients toward – those systems that deliver the best value.  Never before has improving quality been so critical.  At URMC, this meant installing new electronic tools and sharpening our focus on reducing the number of errors, infections, falls, and the harm they cause.

One Patient, One Record

erecord logoTo create health care that’s more efficient, safer, and of higher quality, providers must be able to communicate and share information across settings. That’s why health care reform has always included a requirement and financial inducements for providers to implement an electronic medical record and use the technology to make “meaningful” improvements. 

In 2011, URMC installed the industry-leading Epic product as its new inpatient electronic health record, first at Strong Memorial Hospital and then at Highland.  The $79 million investment represents the single largest component of URMC’s strategic plan and is the linchpin in our effort to both improve care and capture federal funding available for reform initiatives. 

Over the course of 47 days, 60 trainers taught 10,000 URMC faculty members and staff the basics of using the new eRecord system through both classroom and on-line training.  In a painstakingly choreographed move, Strong Memorial “cut over” to a paperless environment on March 5, with Highland Hospital following on June 11.  To support the units through our most ambitious information technology deployment ever, hundreds of “super users,” highly proficient staff with intensive training, ensured that patient care was not interrupted as eRecord went live.  Almost immediately, staff began reporting medication administration errors averted thanks to eRecord’s barcode technology.  Lab turn-around times dropped by 10 to 12 percent and the number of lab tests was down 17 percent, indicating more efficient ordering practices. Because they no longer spend time searching for paper charts or toggling between computer programs, users found that they are able to review patient data faster – which means quicker, smarter care decisions.   

In the weeks that followed, the eRecord team received and acted on many of the hundreds of suggestions on how to optimize the system further, and it continues to evaluate recommendations with an eye toward further safety and efficiency improvements. 

In May, URMC also launched MyChart, an online portal that allows patients to conveniently and securely view portions of their URMC outpatient electronic record, including their health summary, current medications, test results, and dates of upcoming and past appointments.  Although MyChart is currently only available to oncology patients, all patients can use the tool once the rest of URMC outpatient clinics go live on eRecord.

With the vast majority of patient care now provided in an outpatient setting, the next major milestone in URMC’s move to paperless health care is the deployment of eRecord in the system’s 130 ambulatory clinics, which manage 1.75 million patient visits per year in 64 distinct specialties.  The effort is well under way to bring all practices onto eRecord by May 10, 2012. 

Grant Expands Telehealth

VNS’ successful Telehealth project got a major shot in the arm this year in the form of a half-million-dollar grant from the Greater Rochester Health Foundation.  With the additional funding, VNS expects to serve more than 1,500 chronically ill patients with in-home monitoring, including those with heart disease, hypertension, diabetes, or chronic obstructive pulmonary disease.  The in-home devices monitor patients’ vital signs and symptoms, alerting professionals to status changes. Early intervention by VNS staff can thwart unnecessary Emergency Department visits and hospitalizations.  VNS’ Telehealth program has compiled an impressive track record, showing that telemedicine patients are half as likely to go to the hospital as those not enrolled in the program. 

Central Line Infections Fall

Strong Memorial has been a pioneer in the national movement to eliminate infections contracted by patients who are on ventilators for long periods of time.  In fact, it has been well over a year since even a single Ventilator-Associated Pneumonia (VAP) has been reported on any of the hospital’s Intensive Care Units (ICU).  Using the same approach of developing effective care bundles, the hospital turned its attention in 2011 to eliminating infections linked to the use of central lines or catheters.  These dangerous infections plague hospitals nationwide, not only affecting the bottom line (they carry a cost of about $40,000 per infection, between lengthened stays and antibiotics), but worse – they put patients at risk for potentially avoidable pain, distress and even death. 

The Central Line Infection Improvement Project, or CLIIP for short, studied the literature and then developed two simple, best-practice checklists that revolutionized the way that central lines are both inserted and cared for over time in our ICUs.  Once staff was retrained with a more careful, consistent approach that empowers every team member to halt the process if they doubt the procedure’s sterility, Strong Memorial saw incredible results.  In just 18 months, infections were cut in half, bringing the hospital’s rates below the national average.  Encouraged by these advances, teams implemented the same checklist in non-ICU areas, reducing infection rates among those patients as well.  URMC hospitals’ efforts are being mirrored at hospitals across Rochester.   

Community vs. Infection

In 2011, infection preventionists, hospital epidemiologists and safety experts from Excellus and four area hospitals (Strong Memorial, Highland, Rochester General and Unity) formed the new Rochester Patient Safety Collaborative – a city-wide effort to fight Clostridium difficile, or C. diff, a bacterial infection that vexes hospitals, long-term care facilities and communities nationwide. Efforts are being driven by faculty at the Center for Community Health.

C. diff infections can causepotentially life-threatening illness, delaying a patient’s discharge by days, and pushing complete recovery back by months. What’s more, these infections can addtens of thousands of dollars to an admission cost – and a patient affected by C. diff has a 20 percent chance for recurrent infection. The new city-wide collaborative aims to cut Rochester’s burden of hospital C. diff infections by 30 percent in just a few years –  first by focusing on hospitals, then tackling infection rates in long-term care facilities and, finally, in the general community. Hospitals will adopt more rigorous environmental cleaning, including testing the use of powerful ultraviolet lights, more consistent antibiotic stewardship, and more careful adherence to infection prevention procedures. 

Reducing Harm

Whether it’s triggered by a new medication, an unfamiliar setting, or simply by being debilitated, patients who fall can suffer life-changing injuries, even death.  For many years, staff at URMC hospitals has pulled out all the stops to prevent patients from falling, but in 2011, they started to think differently:  continue working to prevent falls in general, but layer on new efforts to minimize injury in those who do fall. 

Since head injuries are one of the most deadly complications of falls, staff on the 6-3400 Hematology/Oncology unit introduced protective helmets for those patients who, because of treatment, have lower platelet counts, and are at greater risk of bleeding.  Staff explains the increased risk and the consequences of a potential head injury, then offers patients the option of wearing a helmet.  So far, roughly half of the patients on the unit have been eligible and willing to wear the helmets; of these, there have been no patients who’ve fallen and suffered a head bleed since the program began in September.  Helmets are now being offered in other areas, like the 8-1200 unit, to patients also at risk for bleeds.