south carolina public health institute quality and...
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Good Health Made Possible™
South Carolina Public Health Institute
Quality and Outcomes Workgroup Meeting
Health Sciences South Carolina Healthcare Quality and Patient Safety
October 26, 2011
“In its full mature version, HSSC will serve as a national and international model for the design implementation and integration of basic science, genomic, clinical, public health, and health systems research; use of modern informatics and information technology to analyze diverse types of data; orchestration of research efforts using these data; and dissemination of clinical and health services findings and best practices, data sets, tools, and expertise. This “cycle of quality” will create an attractive environment for other healthcare providers and researchers in the HSSC system, and it will critically improve the health and healthcare systems in South Carolina, and ultimately, across the United States.”
Health Sciences South Carolina Healthcare Quality and Clinical Effectiveness Application to The Duke Endowment January 12, 2006
HSSC ORGANIZATIONAL VISION 2006
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INFRASTRUCTURE BUILDING BLOCKS
• Development of the informatics infrastructure required for rapid learning to identify evidence-based best practices.
• Implementation of the e-IRB and cooperative approval, real-time data warehouse, and research permissions management that will facilitate clinical trials, comparative effectiveness, and translational research.
• Development of the S.C. workforce research capacity and reputation---COEE, epidemiology, analytics, etc.
• Solicitation of federal and foundation dollars to fund innovation---including continuous scanning for new opportunities.
• Facilitation of statewide electronic medical record adoption by primary care physicians, Federally Qualified Health Centers (FQHC), and Rural Health Clinics (RHC) including eligibility for incentives.
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PARTNERSHIPS & CULTURE OF COLLABORATION
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SUPPORTING PARTNERS
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HSSC Quality Care and Patient Safety Council
MISSION Create the environment for successful statewide collaborative
investigations & evidence-based practice by: Bringing stakeholders (investigators and practitioners) together
& aligning efforts Defining and prioritizing common healthcare problems in SC Identifying gaps in knowledge and practice Developing research ideas Coordinating the resources Facilitating funding efforts Monitoring progress. Ensuring dissemination of new knowledge.
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HSSC Quality Care and Patient Safety Council MEMBERSHIP
• Chair, Michael ‘Shawn’ Stinson, MD, Clinical Quality and Patient Safety, Palmetto Health.
• Members include: – MD quality officers/leaders and key quality staff from initial
partners-GHS, MUSC, Palmetto Health, SRHS, and new affiliates-AnMed, Self, & McCleod
– Academic partner representatives- MUSC & USC Schools of Medicine, Schools of Pharmacy, Nursing, Public Health, Engineering.
– SC Quality Trust Partner-Premier, Inc – SCHA and SC DHEC representatives – HSSC Extramural Program Officer Staff
• Data sharing and privacy agreements to foster open discussion and outcome comparisons from Premier, Inc.
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Approve Internally funded quality research projects using a RFP solicitation process in three areas consistent with the 2008-2011 Strategic Plan Clinical Re-engineering Ambulatory Care Rural Health Quality
Monitor findings of the Healthcare Associated Infection Committee –a 4th priority area in the initial plan. Research on Central Line Blood Stream Infections (CLABSI) Identify best practices and variations across partners
Identify opportunities for SC research based on national priorities, plans, and SC partner initiatives, e.g. serve the research function for SCHA.
Capitalize on opportunities to participate in national research projects to extend research capacity and reputation---provide a multi-site network of acute care facilities, e.g. SHEA research network.
Support teams in pursuing external funding---Medication Safety Center Grant, SCTR Grant to assess potential for impacting LTC patient ‘churning’ to ER/hospital and back again through use of telehealth.
HSSC Quality Care and Patient Safety Council INITIAL WORK
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FROM SIMULATION TO OPERATION: Engineering Management Interventions
for Perioperative Services Investigative Team:
Kevin Taaffe, Ph.D (PI) Lawrence Fredendall, Ph.D.
Nathan Huynh, Ph.D.
Sponsored By:
CLINICAL RE-ENGINEERING PROJECT
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Summary of Key Accomplishments
1. Determination of how patient flow is affected by the current delivery of care within perioperative services (POS) via the development of a process flow maps.
2. Identification of opportunities for improvements to patient flow and determination of the impact of such improvements using computer simulation.
3. Utilization of engineering management methodologies to improve POS practices.
Analysis
Simulation models
Process flow maps
Structured interviews
Data collection via innovative “app”
Practice Changes
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AMBULATORY CARE: Experience in Quality Improvement for Practice for Primary Care (EQuIP PC)
Peter Carek, MD, MUSC, Department of Family Medicine, PI & Libby Baxley, MD USC, Department of Family Medicine
AIMS
• Utilizing the Healthy People 2010 Focus Areas of diabetes mellitus, heart disease/stroke, hypertension, and preventive services, faculty and residents will use the principles and tools of quality improvement to address quality of care issues regarding these common chronic medical conditions and services in their practice.
• Examine the impact of the proposed experience on the quality of patient care provided by the participating family physicians after the completion of their formal residency training.
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Family Medicine Residency Program (Location)
Outpatient Visits (#)
Anderson 18,185 Charleston 21,907 Columbia 29,750 Florence 15,864 Greenville 9,705 Greenwood 19,405 Seneca 4,916 Spartanburg 32,251
TOTAL 151,983
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Charleston
Columbia
Florence
Spartanburg Greenville
Anderson
Greenwood
Seneca
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EQuIP - PC
• Initial comments
– “Everyone is meeting, talking, and wanting to improve.”
– “Recognize the value of this project.”
– “Focusing resident projects on QI and PCMH versus a more scattered approach.”
– “Realize that EQuIP fits in umbrella of Practice-Based Learning and Improvement (PBLI) – an ACGME core competency.”
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RURAL HEALTH: Lakelands Rural Health Network Kevin Bennett, Ph.D. & Mark Van Swol, MD
• AIM-To determine if access to a Health Information Exchange (HIE) would impact quality improvement activity & improve performance. – 15-20 provider sites in the Lakelands Rural Health Network – Mix of providers with EMRs/HIE and no EMR – QI coach, QI program implementation – Goal to prevention and chronic illness management
• Lessons Learned – HIEs by themselves not attractive to most providers – Without additional work, data over the exchange not
customized to provider needs/wants, and in some cases too much extraneous info
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• New Research Questions – What basic information does a clinician need to initiate
HIE participation for patient care purposes? – How does this vary by provider type-hospitalist, primary
care, ER, and various specialists? – What are the factor that are predictive of HIE utilization?
• Next Steps – Focused study with select providers to determine what
dataset, format, & workflow factors influence initial and sustained use.
– Evaluation of the impact of HIE use on quality of care measures.
Quality Improvement Facilitation: Lakelands Rural Health Network
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HEALTHCARE ASSOCIATED INFECTIONS
• The HAI Committee members focused on identifying research questions and considering the data available through Premier’s ClinicalAdvisor. ™ Identified research questions related to central line blood stream infections (CLABSI):
– What is the rate of CLABSI in ICU and non-ICU patients?
– What are the risk factors for CLABSI and how do they vary by location?
– Does CLABSI increase the risk of mortality
– How does the rate of infection increase with the length of catheterization
• Small Grant Award made for Study of CLABSI in U.S. Hospitals from 2003-2008:
– PI- Dana Stafkey-Mailey; Co-investigators, Michael Dickson, Brandon Bookstaver, & Stephen Stemkowski (Premier) with Collaborators Dr. Michael Stinson & Mary Prather.
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HEALTHCARE ASSOCIATED INFECTIONS CLABSI RESEARCH PROJECT
• Selected findings using the Premier, Inc database:
– S.C. rate 4.35 per 1000 catheter days compared to 5.74 nationally for all hospital patients (average over the five year period prior to focused efforts).
– Risk factors include age, male, # of days with central line catheter.
– Rates are as high in non-ICU patients as ICU patients (to date national focus has been primarily on ICU patients).
– CLABSI more than doubles the risk of mortality
– Rates and mortality have shown improvement since 2004.
– CLABSI increases cost of care significantly.
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HEALTHCARE ASSOCIATED INFECTION RESEARCH PROJECTS
• Next Steps:
– Update study from 2009 to 2010 to compare baseline to impact of the SCHAIP Committee, the CLABSI Learning Collaborative (SCHA) initiative, transparency of infection rates (SCDHEC), and changes in reimbursement (CMS).
– Collaborate with SCHA staff to evaluate the impact of the CLABSI Learning Collaborative participation by comparing hospitals in SC that participated against those that did not and overall sustainability of improvement rates.
• Participate with SCDHEC in using the data gathered from the Processes of Care Survey of SC Infection Preventionists to identify progress and gaps.
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Examples of Data Analysis SC CLABSI Cost in Dollars
Premier SC Hospitals2008 Compared to 2009
$26,728,668
$16,700,658
$0
$5,000,000
$10,000,000
$15,000,000
$20,000,000
$25,000,000
$30,000,000
2008 2009
Tota
l Dol
lars
for
CLA
BS
I Cas
es
SC CLABSI Case Costs
Total Patient Days for CLABSI CasesPremier Hospitals in SC
7385.97
9653.33
0
2000
4000
6000
8000
10000
12000
1 2
2008 Compared to 2009
Tota
l Day
s fo
r C
LAB
SI I
nfec
tions
SC Days per CLABSI Case
•Cost per Case, Trends, & Variation Across Providers •Total Dollars per Case/Aggregate dollars
•Patient Days, Variation & Trends •Mortality Trends
•Resource Use
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PARTNERSHIP CHALLENGES ….Same Issues as Providers are Facing
• Transitioning from competition to collaboration. • Coordinating initiatives and efforts across organizational
boundaries. • Moving from teamwork in silos to teamwork across
organizations. • Evolving and differentiating based on organizational assets
and unique skill sets. • Identifying resources across the state---project champions,
investigators with research and track record of funding. • Remaining flexible to anticipate and take advantage of big
opportunities in a rapidly changing landscape. • Leveraging collective assets to make a difference in the
health of South Carolinians.
DIRECTIONS & OPPORTUNITIES
•Leverage & extend existing projects to maximize improvement.
•Prepare for full utilization of bioinformatics capability-Statewide Clinical Trials Network
•Take advantage of funding opportunities that fit with South Carolina Needs & Collective Assets
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Overall Funding Success to Date • National Institutes of Health (NIH), Grand
Opportunity Grant – Research Permissions Management System $4.8million
• Federal Communications Commission (FCC), Palmetto State Providers Network $8.4million
• Office of the National Coordinator, Dept. of Health and Human Services (ONC, DHHS), Regional Extension Service $6.4million
• Office of the National Coordinator, Dept. of Health and Human Services (ONC, DHHS), Critical Access Hospitals $234,000
• National Institutes of Health (NIH), Clinical Translational Research Award – SCTR $20million
OFFICE OF THE NATIONAL COORDINATOR, DEPT. OF HEALTH AND HUMAN SERVICES (ONC, DHHS), CRITICAL ACCESS HOSPITALS $234,000
OFFICE OF THE NATIONAL COORDINATOR, DEPT. OF HEALTH AND HUMAN SERVICES (ONC, DHHS), REGIONAL EXTENSION CENTER $6.4million
EXAMPLE: CENTER FOR INFORMATION TECHNOLOGY
ASSISTANCE (CITIA) PROGRAM
Research-Underrepresented Populations in Clinical Trials and Research
What We Are Already Doing
• Purpose: HSSC has embarked on a study with the USC Arnold School of Public Health and College of Mass Communications to ascertain:
– the percent of the state population that is ‘likely’ eligible to participate in clinical trials;
– perceptions of clinical trials by these ‘likely’ eligible people; and
– the degree to which rural, underserved residents are currently represented in clinical trials.
• Approach: Research team will achieve their aims by: – examining secondary data to estimate number of ‘likely’ eligible, rural or underserved
clinical trials participants.
– surveying state clinical investigators to ascertain the degree to which rural or underserved residents are currently participating in clinical trials.
– Conducting regional focus groups with potentially eligible participants to ascertain willingness and barriers to participation in clinical trials.
• Benefits: Through key stakeholder education of findings, we will ensure that a statewide clinical trials program benefits all citizenry, including those living at a distance from academic medical centers.
Research-Underrepresented Populations in Clinical Trials & Research
What We Propose To Do: Create an FQHC Clinical Trials Resource Toolkit
• Purpose: Develop clinical trials administration toolkit that consists of materials and research best practices associated with an outreach educational program.
• Approach: By using expertise of the SC Primary Health Care Association, individual FQHCs, SC Rural Health Research Center, MUSC clinical investigators, and a USC compliance expert, we will enhance the knowledge and skill of FQHCs so that they can more effectively:
– Recruit patients into clinical trials and outcome studies for clinical investigation partners.
– Fulfill the research administration obligations of clinical trials.
– Serve as a liaison to the larger, statewide clinical trials program initiated by this core.
• Toolkit effectiveness will be assessed through tabletop exercises & mock studies.
• Benefits: Improved FQHC-academic clinical research partnerships, thus increased access to study participation by underrepresented populations. Once validated, we will seek federal funding to broadly disseminate the toolkit to other outlets, including rural health clinics and small rural hospitals.
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Bridging the Quality Gap: Can EHR Use Improve Quality of Care Inequities for Vulnerable Populations?
• Proposal seeks to assess the degree to which adoption and expansion of Electronic Health Records (EHR) in outpatient settings ameliorates quality inequities in delivery of select point-of-care services for patients with diabetes.
• AHRQ Small Research Grant (R03) submitted on March 15, 2010.
• Will generate preliminary data to inform a large-scale R01 study.
• Research team: Amy Brock Martin (SC Rural Health Research Center & HSSC), Kevin Bennett (Dept of Family Medicine at USC School of Medicine), and Todd Thornburg (HSSC).
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Improving NCQA Medical Home Certifications for Primary Care Practices in Rural, Underserved SC
• AHRQ Health Services Research Demonstration and Dissemination Grant (R18) to be submitted in early May for approximately $2 million.
• Research team: Drs. Libby Baxley (PI), Kevin Bennett, and Michelle Stanek (Dept of Family Medicine at USC School of Medicine) and Amy Brock Martin (SC Rural Health Research Center & HSSC), and Todd Thornburg (HSSC) with consultation from Peter Carek (MUSC).
• Proposal seeks to translate a proven Patient-Centered Medical Home model in academic practices to those in rural, underserved areas. Modifications to the model will be researched with the outcome being increased number of primary care practices applying to NCQA for medical home certification.
• Practice participation serves as the deliverable for Milestone 3 in the CITIA, SC, the state’s regional extension center.
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Triple Aim 1) The health of
the people. 2) The
experience of care by the people.
3) The cost per capita of providing care.
Discovery – Implementation Future