March 6, 2013 Proceedings of the CCHHS Quality and Patient Safety Committee

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.

Dr. Wakim, head of Provident Hospital and former director of its ED, stressed the need when evaluating ED performance to consider what clinics are available for non-urgent care. Munoz argued the System should be compared to similar safety-net hospitals with similar populations (e.g. Bellevue), and the Stroger chief agreed: comparing patient volume, demographics and doctor/patient ratio will demonstrate the need for resources. Michael concurred that the Committee’s purpose is to identify the resources necessary to achieve the System’s quality goals.

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. 

105 residents are affiliated with the System, including 45 from Rush and 20-some each from McGaw (University of Illinois) and Loyola. Rush has priority, but Dr. Raju stressed that CCHHS is looking for partners to share the System’s vision and respond to its needs first and foremost. "County will leverage our medical education affiliates for the benefit of patients, not for the benefit of other institutions." O’Brien added that a goal was to eliminate duplication of services, e.g. CCHHS ED rotation is excellent so Rush closed its own ED residency.

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.

Wakim reported that the Provident staff has already met with new quality chief Shannon and is ready to implement improvements in clinical care recommended by PriceWaterhouse. The new Stroger chief will report formally in April.

--Submitted by Kelly Kleiman