STEEEP Care Summary Report

Baylor Scott & White Health Enterprise

FY2017 YTD (July 2016 - September 2016)

BSWH Targets and Performance FY17 YTD (September 2016)

2** 30-day Readmission data lags one month behind all other metrics

30-Day Readmission**

Combined Hospital Acquired

Condition (HAC)

Outpatient Diabetes Bundle

Supportive & Palliative Care

Inpatient Experience Rate

this Hospital 9-10

Outpatient Experience

Recommend this Provider

Emergency Likely to

Recommend

Current Readmission

Rate (%)HAC Points

Percent of Achievement (%)

Palliative Care Attainment

Inpatient PointsOutpatient

PointsEmergency

Points

14.8 21 79.1 60.7 859 718 687

Attainment Levels

BSWH Threshold 14 21 74.0 51.8 400 275 350

BSWH Intermediate 13.8 20 75.0 59.0 600 300 450

BSWH Target 13.6 17 76.7 62.0 700 350 550

BSWH Maximum 13 14 78.0 70.0 900 550 750

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Assessment and Plan - Readmissions

Assessment:

30 Day Readmission All Cause Composite Measure is 14.8% which is worse than

BSWH target of 13.6%

Facilities with small number of patients negatively impacting their readmission rates

Final ICD-10 readmission rules not yet released by CMS

Opportunities exist in scheduling follow-up appointment prior to hospital discharge

ICD-10 seems to have negatively impacted FY 16 performance

Plan:

Develop tactics to reduce readmission based on chart review results

BSWH Heart Failure Integration Initiative ongoing

Workgroups to address AMI, CABG, PNE,THKA readmissions established

Collaborate with BSWQA to address readmissions across the continuum

PIECES risk stratification tool implemented in NTX 10/11/16

Ongoing discussion with leaders to reset FY 17 goals using FY 16 performance as

baseline

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Assessment and Plan - HAC Composite

Lower is better for HAC Composite Metric

Assessment:

For FY17 the HAC composite metric includes all adult patients and current performance for BSWH is 21 with a target goal of 17 (lower is better). BSWH is currently at threshold performance.

13 hospitals are higher than target (worse) 6 hospitals are lower than target (better)

Plan:

Continue with HAC Reduction report out by facility every two months with the focus on areas with the greatest opportunity

The HAC Reduction dashboard provides key monthly data for facility level improvement work so ongoing education is being provided to help stakeholders navigate through this tool

The CLABSI Improvement Committee work as part of the BSWH STEEEP Clinical Value Initiatives and Diffusion Model should help to reduce the incidence of CLABSI’s and provide standardization of evidence practice across BSWH.

Assessment and Plan - Population Health Diabetes Bundle

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Assessment:

• BSWH at MAX Goal.

• NTX, 6 PODs: 5 at MAX Goal/1 at TARGET Goal.

• CTX, 4 Regions: 1 at MAX Goal/3 at INTERMEDIATE Goal

– Both A1C and BP continue to be areas of opportunity

Plan:

Diabetes Council Outpatient Workgroup reviewing/revising Diabetes Medication Protocols to assist with medication choices that

are more patient-centered.

NTX

Conversion to EPIC occurred on 10/1/16. Educating on KEY documentation for the D3 components

Physician Champions continue to work with low performing providers and clinics to improve their scores

HTPN Operations leadership working with all HTPN clinics to improve diabetes care

HTPN care coordination identifying patients not at goal and scheduling appointments with their PCP

Diabetes Improvement Project in Central POD – first round of education completed

CTX

Diabetes AIP Reports revised to make it easier to find patients not meeting targets

Physician education being done to socialize report as well as reminders on how to appropriately document rechecks of blood

pressures by in the appropriate areas to capture the data for the report.

Continuing to implement HTN protocol

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Supportive and Palliative Care Goal

Assessment

The Supportive & Palliative Care Composite Score is based on the achievement

of two metrics:

SPC Staffing plan achieved in order to support 5% of inpatient admissions

(excluding OBGYN and newborns)

SPC Consults Ordered for inpatient admissions (excluding OB-GYN and

newborns)

Staffing accounts for 60% of the composite score and consults ordered

account for 40%

This goal is a follow-up to the successful attainment of the FY16 structural goal.

While no longer a structural goal, it is a goal that we expect to see a consistent

increase in throughout the fiscal year as positions are filled.

Plan

SPC is working closely with hospital leadership to ensure that staffing levels

defined in the goal are achieved early in the fiscal year.

There have been hires made and the new staff are working through credentialing

so there will be an increase in the metric in the next couple of months.

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Assessment and Plan - Service

Assessment: Sites are working to close the gap between their baseline

performance and the 90th percentile rank by 25% this year. At system level, they

are doing well.

Inpatient Experience: Target

Clinic Experience: Max

Emergency Department Experience: Target

Plan:

CNO Press Ganey will be onsite at WAX on Monday

December 12th to meet with BSWH leadership (CMO/CNO, and ED

leadership) and talk with the ED Council about improvement

opportunities;

(Angela.Hochhalter@bswhealth.org for details)

Emergency Department comments are being evaluated with a new tool

to look for improvement opportunities. The same tool will be applied to

clinic and hospital comments in the coming months.

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