The Committee did not meet in February. During that time, the System hired Dr. Shannon as Director of Quality and Patient Safety, a prospect never mentioned at meetings.
The observer arrived
late and missed the report on the System’s quarterly STAR (Set Targets Achieve Results)
plans. Dr. Das (Shannon’s predecessor, who will work with him) was reviewing
the System Quality Dashboard, a computer format for reporting progress on
identified areas requiring improvement. Chairman Michael chided Das for ‘just
presenting’ data, asking her to work with Shannon to provide improvement
recommendations to the Committee.
Committee member
Dr. Munoz argued that while the data could identify centers of excellence in the
System, ‘average is where we want to be,’ and the true function of the data was
to identify and correct obstacles to that, specifically the shortage of nurses. By contrast, Michael argued for quality improvement even
while the Affordable Care Act increases the patient population: "This is
an exercise in quality, not volume." Committee member Dr. Velasquez
suggested the real function of this data is to inform the public that CCHHS is
an institution they can trust and should choose. These three data approaches
reflect different approaches to the System’s mission, and they remain
unreconciled, so the medical staff makes improvements essentially at random.
Das
reported a significant increase in immunizations. The increase, though, put the System at 42% pneumonia and 30% flu immunization,
versus national benchmarks in the mid-80s. Michael asked why the numbers were
so low when immunization is so easy; the medical staff responded:
1. The issue is
providers as well as patients.
2. Every
inpatient gets an order for immunization but with shorter hospital stays by
sicker patients the opportunities to immunize are fewer.
3. There are
cultural barriers, with patients reluctant to receive vaccines.
Munoz argued
that a lack of trust in government is less "cultural" than universal in
that it’s reflected among
the providers, too. But Dr. Barker, head of the CORE clinic for AIDS and TB patients,
urged the group not to set its sights too low, noting that his clinic has a 75%
vaccination rate: "the problem can be fixed if there’s attention paid to
it." He also noted that the New England Journal of Medicine recommends
universal HIV testing, and suggested CCHHS make this a system goal, then a
clinic goal and then a provider goal. Many in the general population are put off by the
risk-assumption form.
Das further
reported improvements in the Emergency Department (ED):
- Through-put: the wait time has gone down from 150 minutes to 117, bettering the internal benchmark of 120 minutes.
- The number of patients who leave without being seen has declined from about 11.5% to 9.5%, still falling short of an 8% internal benchmark (3.6% is the national average). Das said that a significant number of CCHHS patients come to the ED just to be warm and don’t want to be seen; other "sitters" are patients from nearby closed psych facilities.
Michael added
that the Committee did not propose to set quality goals itself but to adopt
goals chosen by the medical and nursing staff. He also stressed the need to
implement CountyCare (the Medicaid waiver program) to keep non-emergent
patients out of the ED.
Dr. Murray of
the Department of Public Health reminded the group that without better data infrastructure
it’s impossible to set goals or assess quality. Michael responded
that Shannon and Das should be given the chance to build that infrastructure,
and that the Committee wants to establish priorities
for improvement. Das agreed that once a process is targeted for improvement,
actual implementation must take place at the dept/division level based on data.
She also noted that the medical staff is using multi-disciplinary teams to
improve processes.
The biggest ED
logjam is in the time from deciding to admit a patient to the time s/he
actually gets moved to a bed: CCHHS is at 226 minutes (that’s nearly 4 hours),
versus a benchmark of 96 minutes. No solution was suggested for this problem,
probably the result of too few beds.
Concerning
patient satisfaction (which correlates with positive
medical outcomes), Das
reported CCHHS mostly does well but is in the bottom 1 percentile in hospital environment
and in the bottom quintile in communication with patients.
Das suggested
that hospital-acquired conditions be tracked in real time on an automated
system; the retrospective data now available are of limited use. CCHHS’s mortality
rate is slightly better than the national average, while its readmission rate
is slightly worse. These two numbers, though, are ambiguous: they reflect
mostly socioeconomic status, plus the community’s ability to care for
outpatients, the quality of that care and patterns of admission which vary by
location.
Das
reminded the group that CCHHS must in the future address pay for performance.
She also reiterated the process for selecting "Big Dots," major goals
for the System: first consider impact on patient outcomes, then system-wide
impact, with other measures subordinate.
Dr. O’Brien,
Director of Graduate Medical Education, reported:
- Every patient encounter is now staffed by an attending physician.
- They’re integrating residents into patient quality and safety efforts.
- They’re using CLER (Clinical Learning Environmental Review) to bring in out-of hospital doctors to help improve care.
- For 2014 they’re revising the affiliation agreement(s) under which residents rotate to County from their home campuses: if they rotate to get training not available at home (toxicology, OB/GYN) the home institution pays, whereas if they rotate to supply patient needs for skills not available at CCHHS (neurosurgery, ENT), the System pays.
Dr. Munoz
proposed an audit of the entire master agreement process. O’Brien conceded
that, while the agreement has been audited for its financial
consequences, no outsider has assessed it for its patient impact. Raju
responded that CCHHS is already checking the agreement against projected
clinical needs. Once that’s complete the Committee and Board can determine
whether additional examination is necessary.
--Submitted by Kelly Kleiman
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