inova health system management team update september 2007
TRANSCRIPT
Quality and SafetyQuality and Safety
2007
Safety GOAL IAH IFH IFOH ILH IMVH ICCC ICGCC IVNAHH
Year to Date Event Rate 0.07 0.163 0.049 0.144 0.19 0.159 0.038 0.044 0
Clinical Effectiveness
Percent of Core Measures at 100% 75% 68% 44% 75% 50% 63% 60% 70% 70%
Percent of 100K Lives Indicators at Target 100% 75% 75% 75% 34% 100% na na na
Regulatory Readiness
Percent of Monthly Mock Surveys Passed 67% 57% 86% 100% 100% 63% 34% 67% 71%
At or better than 2007 goal
At 50% of goal or better
Less than 50% of the goal
Patient SafetyPatient Safety
No harm/interventionMinor intervention
Moderate intervention
Severe permanent harm
Death
2006%
2007 (ytd) %0%
5%
10%
15%
20%
25%
30%
35%
2006% 2007 (ytd) %
Year over year statistics:Year over year statistics:•Safety events 2006: 44Safety events 2006: 44•Safety events 2007: 32Safety events 2007: 32
•Event related mortality 2006: 29%Event related mortality 2006: 29%•Event related mortality 2007: 16%Event related mortality 2007: 16%
Event Classification2006 vs. 2007
Clinical Effectiveness MeasuresClinical Effectiveness Measures
0%
20%
40%
60%
80%
100%
AMI-ASA on discharge
AMI-Beta Blocker on Discharge
AMI-PCI within 90 min
CHF-ACEI for LVSD
CHF-Discharge InstructionsCAP-Pneumovax
CAP-Timely Antibiotics
100K-Central Line Bundle
100K-VAP Bundle
Q1-07 Q2-07 Q1-06
2006 2007 2006 CMS Benchmarks
IHS Avg. IHS Avg. Top VA National
AMI 10th Avg Avg
Aspirin at Arrival 96% 100% 100% 95% 93%
Aspirin Prescribed at Discharge 94% 93% 100% 92% 90%
ACEI for LVSD 88% 100% 100% 86% 83%
Adult Smoking Cessation Advice Counseling 99% 96% 100% 88% 89%
Beta Blocker Prescribed at Discharge 95% 100% 100% 94% 90%
Beta Blocker at Arrival 94% 100% 100% 91% 87%
PCI Received Within 120 Minutes of Hosp Arrival 75% 88% 60% 55%
CHF
Discharge Instructions 50% 70% 93% 68% 62%
LVF Assessment 91% 98% 99% 87% 84%
ACEI for LVSD 88% 100% 100% 84% 82%
Adult Smoking Cessation Advice/Counseling 64% 67% 100% 88% 83%
PNEUMONIA
Oxygenation Assessment 100% 100% 100% 100% 99%
Pneumococcal Vaccination 52% 83% 94% 72% 71%
Adult Smoking Cessation Advise/Counseling 57% 80% 100% 84% 81%
Initial Antibiotic Received Within 4 Hrs of Hosp Arrival 80% 93% 93% 77% 80%
SIP
Prophylactic antibiotics given within one hour of incision 76% 78% 94% 79% 78%
2006:% Green (Top 10%)=7%% Blue (Average) =40%% Red (Below Avg)=53%
2007:% Green (Top 10%)=44%% Blue (Average) =50%% Red (Below Avg)=6%
Inova Health System
Implementation of "Safety Essentials" - Progress Report
August 2007
IAH IFH IFH IFHC IFH IFOH ILH IMVH ICCC ICGCC IVNA Ambul System*
Safety Essentials Core IHVI Women's HH
Safety Oversight Team 4 4 4 4 4 4 4 4 3 3 4 3 9 of 12
Safety Rounds 4 4 4 4 4 4 4 4 2 3 4 3 9 of 12
Safety Coaches 3 3 3 4 4 4 4 4 2 3 2 2 5 of 12
Safety Huddles 4 4 4 4 4 4 4 4 2 4 4 3 10 of 12
RN staffing at 50th percentile 2 4 3 4 3 4 4 3 na na 4 na 5 of 9
Charge RN out of staffing 3 3 3 3 3 4 4 3 na na 4 3 3 of 10
Charge RN standard report WIP Yes Yes Yes Yes Yes WIP WIP WIP WIP Yes WIP
Medical Staff Transparency 2 3 3 3 3 3 3 3 na 2 na 3 0 of 10
Key
Have not started 1
Planning/initial implementation 2
Partially implemented 3
Fully implemented/operational 4
WIP: Work in progress
% of shifts with Charge RN out of staffing: % of shifts with Charge RN out of staffing: (July 07)(July 07)IAH: 79%IAH: 79%IFH: 61%IFH: 61%IFOH: 90%IFOH: 90%ILH: 96%ILH: 96%IMVH: 38%IMVH: 38%
PeoplePeople
Metric 2007 Q2 Goal 2007 Q2 Results
Net New RN’s (FTEs) 98 131.5
Retention of priority clinical staff with less than 2 years experience
80% 71.8%
Reduce Employee Related Injuries by 33%
313 452
Great Places to Work Satisfaction Score
70%
90 Day Action Plans Employee Pulse Check May
67.6%
GrowthGrowth
Metric Q2 2007
YTD Goal
Q2 2007
YTD Results
Equivalent Admissions 83,950 85,168
Outpatient Surgeries 27,135 27,952
Home Care Visits 57,120 40,848
Resident Days 79,183 77,508
Inova Employee Assistance ProgramEAP achieved a 13.5% increase in overall gross revenue as of 8/1/2007. Sales efforts resulted in 46 new contracts
CommunityCommunity
2007 Q2 Goal 2007 Q2 Result
Philanthropy – Gifts $10,000,000 $8,300,000
Disaster PreparednessCaring is Preparing booklet and dvd sent to all employeesPandemic Flu staff prophylaxis plan in place
• Employee +3 to be treated in event of a disaster or flu• Nex Genesis tracking system in place with training planned
for SeptemberTable top drill planned for 4th quarter
CostCost
Metric Q2 2007
YTD Goal
Q2 2007
YTD ResultSystem-wide EBIDA
Margin 14.5% 15.6%
System-wide Operating Expenses (excluding interest and bad debt) per Equivalent Admission
$9,606 $9,267
Patient SatisfactionPatient SatisfactionExcellent Percentile RankingExcellent Percentile Ranking
Quarter 3 (as of September 17, 2007)Quarter 3 (as of September 17, 2007)
Inpatient Goal Actual
Inova Health System 63 72
Inova Alexandria Hospital 44 25
Inova Fairfax Hospital 66 77
Inova Fairfax Hospital for Children 62 85
Inova Fair Oaks Hospital 81 86
Inova Loudoun Hospital 67 82
Inova Mount Vernon Hospital 61 15
(10525402) Overall, would you rate the quality of care provided as:(10525402) Overall, would you rate the quality of care provided as:
Rankings for All Service Lines by Sample Group in Jul-Sep 07*Rankings for All Service Lines by Sample Group in Jul-Sep 07*
Patient SatisfactionPatient SatisfactionExcellent Percentile RankingExcellent Percentile Ranking
Quarter 3 (as of September 17, 2007)Quarter 3 (as of September 17, 2007)Emergency Departments Goal Actual
Inova Health System 73 53
Inova Alexandria Hospital 56 11
IECC Fairfax 96 51
IECC Loudoun 81 86
IECC Reston 87 61
Inova Fairfax Hospital 63 18
Inova Fairfax Hospital for Children 74 90
Inova Fair Oaks Hospital 73 61
Inova HealthPlex 73 61
Inova Loudoun Hospital 61 51
Inova Loudoun Hospital – peds 61 90
Inova Mount Vernon Hospital 42 8
(30525402) Overall, would you rate the quality of care provided as:(30525402) Overall, would you rate the quality of care provided as:
Rankings for All Service Lines by Sample Group in Jul-Sep 07*Rankings for All Service Lines by Sample Group in Jul-Sep 07*
Patient SatisfactionPatient SatisfactionExcellent Percentile RankingExcellent Percentile Ranking
Quarter 3 (as of September 17, 2007)Quarter 3 (as of September 17, 2007)
Outpatient Surgery Goal Actual
Inova Health System 86 74
Inova Alexandria Hospital 82 55
Inova Fairfax Hospital - ASC 79 66
Inova Fairfax Hospital – Women’s OR 94 84
Inova Fairfax Hospital - Woodburn 86 40
Inova Fair Oaks Hospital 93 55
Inova HealthPlex 91 98
Inova Loudoun Hospital 71 14
Inova Loudoun Amb Surgery Center 87 100
Inova Mount Vernon Hospital 98 98
(50525402) Overall, would you rate the quality of care provided as:(50525402) Overall, would you rate the quality of care provided as:
Rankings for All Service Lines by Sample Group in Jul-Sep 07*Rankings for All Service Lines by Sample Group in Jul-Sep 07*
Patient SatisfactionPatient SatisfactionExcellent Percentile RankingExcellent Percentile Ranking
Quarter 3 (as of September 17, 2007)Quarter 3 (as of September 17, 2007)
Outpatient Radiology Goal Actual
Inova Health System 50 79
Inova Alexandria Hospital 64 92
Inova Fairfax Hospital – CT 50 0
Inova Fairfax Hospital - Diagnostic 50 24
Inova Fairfax Hospital – MRI OP 50 95
Inova Fair Oaks Hospital 70 74
Inova HealthPlex 59 92
Inova Loudoun Hospital 59 87
Inova Mount Vernon Hospital 69 95
(20525402) Overall, would you rate the quality of care provided as:(20525402) Overall, would you rate the quality of care provided as:
Rankings for All Service Lines by Sample Group in Jul-Sep 07*Rankings for All Service Lines by Sample Group in Jul-Sep 07*
Overall Progress Overall Progress
Almost one half (38 of 83) of our departments are meeting or exceeding the systemwide goal for their respective area.
Units above 90Units above 90thth percentile – Q3 td 2007 percentile – Q3 td 2007IHVI – Cardiac Step Down LASC – OP surgery ILH – MedicalIFHC – NICU IFH Cardiac cathHealthPlex – OP radiologyHealthPlex – OP surgery IFH – OP MRI ILH Leesburg – OP radiology IMVH – OP radiology IMVH – OP surgery IFOH – Medical IHVI – PCCU ILH – Obstetrics IAH – Medical 2122 IAH – OP radiologyIAH – Neurovascular IMVH – Rehab 5BIFHC – EDILH – peds ED