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TRANSCRIPT
WORKING TOGETHER TO CREATE AND SUSTAIN CHANGE NYS Partnership for Patients Final Report Prepared by the Healthcare Association of New York State and Greater New York Hospital Association
2012–2014
Greater New York Hospital Association
TABLE OF CONTENTSPresidents’ Message............................................................................................................................ 1
Overview............................................................................................................................................... 3
Culture and Leadership....................................................................................................................... 5
Adverse Drug Events in High-Risk Medications................................................................................ 6
Catheter-Associated Urinary Tract Infections.................................................................................... 8
Central Line–Associated Bloodstream Infections.............................................................................. 10
Early Elective Deliveries...................................................................................................................... 11
Falls....................................................................................................................................................... 12
Pressure Ulcers..................................................................................................................................... 13
Surgical Site Infections........................................................................................................................ 14
Ventilator-Associated Pneumonia and Ventilator-Associated Events.............................................. 16
Venous Thromboembolism................................................................................................................. 17
Readmissions........................................................................................................................................ 18
Rural and Critical Access Hospitals.................................................................................................... 19
NYSPFP-Participating Hospitals......................................................................................................... 21
Message from the Co-Directors......................................................................................................... 23
Endnotes.............................................................................................................................................. 24
Dear Colleagues,
We are proud to celebrate New York State Partnership for Patient’s (NYSPFP) 169 participating hospi-
tals for your many accomplishments over the past three years toward achieving the national goals of
reducing hospital-acquired conditions by 40% and preventable readmissions by 20%.
Thanks to your important work, patients are safer and outcomes are better across New York State.
Hospitals statewide are advancing the Centers for Medicare & Medicaid Services’ (CMS) triple aim of
improved health and better care at a lower cost.
As a joint initiative of the Healthcare Association of New York State (HANYS) and Greater New York
Hospital Association (GNYHA), NYSPFP has been a true partnership based on our hospitals’ shared
mission to advance quality improvement and patient safety. In service to our hospitals, we assumed the
responsibility in 2011 when selected by CMS to lead this national patient safety program in New York
State.
We entered into this collaboration to help New York hospitals improve care delivery and position their
organizations for continued success in this era of extraordinary change and transformation. Recogniz-
ing that quality is at the center of reform, and financial well-being is increasingly tied to improved out-
comes, we aligned our initiatives with Federal and State quality-based reimbursement programs, where
possible. We hope that NYSPFP has helped New York hospitals meet the demands—and prepare for
the uncertainties—of this ever-changing health care landscape.
Your significant progress in reducing preventable readmissions and harm across 10 clinical areas is a tes-
tament to your extraordinary effort and commitment to improve patient safety. The work of New York
State hospitals is so impressive that a May 2014 report by the U.S. Department of Health and Human
Services pointed to NYSPFP’s dramatic improvements in quality and patient safety. CMS affirmed our
collective progress by extending NYSPFP’s program for an additional year through 2014.
On behalf of patients across New York State, thank you for the work you do every day toward achieving
the best outcomes. Through NYSPFP, it has been our privilege to partner with hospitals on this shared
journey of change and progress. We are confident that our hospitals will continue to build on this mo-
mentum and we wish you every success in the years ahead.
The future of health care in New York State is in the best of hands—yours.
Dennis P. Whalen
President
Healthcare Association of New York State
Kenneth E. Raske
President
Greater New York Hospital Association
3
OVERVIEW From 2012 through 2014, NYSPFP hospitals made tremendous progress in enhancing patient safety and quality of care across the state by achieving significant improvements in almost every PFP focus area.
The data in this report represent NYSPFP hospitals’ collective efforts and illustrate that fewer patients in New York State are at risk of becoming injured or developing an unexpected medical condition or complication while in the hospital. And once discharged, fewer patients are readmitted. Participating hospitals’ accomplishments in the following areas are especially noteworthy:
• Reduced Early Elective Deliveries: 1,832 fewer babies were delivered before full term when not medically necessary, giving them a healthier start on life and reducing risk for mothers.
• Reduced Readmissions: 25,351 readmissions were avoided within 30 days of discharge. • Reduced Central Line–Associated Bloodstream Infections: 1,279 fewer infections resulted from
the use of central intravenous lines that provide patients with fluids and medications and withdraw blood.
NYSPFP Progress-at-a-Glance: The graph on the following page illustrates the change in performance for each outcome measure from the baseline to data available as of November 2014.
NYSPFP worked with participating hospitals to increase their capacity for crosscutting improvement by further developing an infrastructure that would be sustainable beyond the program. NYSPFP’s ap-proach has been embedded in a set of four Guiding Principles designed to foster and operationalize a culture of safety and continuous quality improvement: innovate, engage, integrate, and hardwire improvements in care.
IN
NOVATEENGAGE
INTEGRATEH
ARD
W
IRE
CULTURE OF
SAFETY
4
NYSPFP 40/20 GOAL IMPROVEMENT FROM BASELINE
-40% -20% 0% 20% 40% 60% 80% 100%
28.36%
40.51%
-31.17%
5.15%
15.58%
19.76%
20.33%
9.51%
49.64%
19.29%*
29.74%
16.01%*
-8.06%
16.39%
11.04%
89.58%*
CAUTI Population Rate
CLABSI SIR
SSI COLO SIR (2010 Baseline)
SSI COLO SIR (2013 Baseline)
SSI HPRO SIR
SSI CABG SIR
VAP Rate (2012)
IVAC+ Rate
ADE Rate
Pressure Ulcers, Stage 2 >
Falls with Moderate > Injury
Falls with Any Injury
VTE Rate
PPR Rate
All Cause Readmission Rate
OB-EED
Rate worsened Rate improved but < 40/20 goal
Rate met preventable goal** Observed rate met 40/20 goal
(*) Also at CMS benchmark(**) Preventable goal is CMS’ calculation for the reduction in preventable events
The results in this report are considered interim and subject to final verification by CMS.
5
Recognizing that hospitals had made improvements and were committed to continued progress through the Partnership, NYSPFP focused on the need to develop a safety culture and build capacity to sustain that progress.
APPROACH AND INNOVATIONSTo achieve those goals, NYSPFP provided support in a number of key areas, including Culture of Safety, Data Management, Patient and Family Engagement, and Building Capacity.
For Culture of Safety: NYSPFP facilitated the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture annually and provided hospital-specific workbooks, compara-tive reports, and education for analysis and strategic planning. NYSPFP also educated more than 1,200 hospital staff on improving communications and teamwork skills using the TeamSTEPPSTM program.
For Data Management: To help hospitals track their progress in the 10 clinical focus areas, NYSPFP developed a robust data management and analysis system that included a web-based comparative dashboard and initiative-level data. In addition, NYSPFP periodically provided hospitals with a variety of hospital-specific reports that focused on clinical areas, readmissions, and on hospitals’ high- and low- performance areas.
For Patient and Family Engagement (PFE): NYSPFP developed the Patient and Family Engagement Resource Guide and provided educational sessions and conferences to help hospitals engage patients and families, further incorporate their voices into hospital operations, and enhance patient-centered care.
For Building Capacity: NYSPFP addressed CMS’ goal of achieving no harm across the board by assist-ing hospitals with building capacity for rapid change. The tactics included integrating hospital-acquired conditions (HACs) prevention activities; incorporating safety practices across the care delivery system; encouraging the involvement of physicians and front-line staff; and offering materials and conferences that focused on organizational best practices.
CULTURE AND LEADERSHIP
6
ADVERSE DRUG EVENTS IN HIGH-RISK MEDICATIONSAdverse drug events (ADEs) are injuries caused by medication use. Hospitalized patients are harmed by an estimated 380,000 to 450,000 preventable ADEs each year, nationwide. ADEs can nearly double a patient’s risk of dying.1 The more serious adverse events are caused by a relatively small number of medications, known as high-risk medications, including anticoagulants, insulin, and opioids. These medications, because they are used so often with so many patients, coupled with their inherent risks, are responsible for the ma-jority of ADE harm.2
APPROACH AND INNOVATIONSAs an emerging area of patient safety, NYSPFP’s ADE initiative brought new thinking and experiences to hospitals. It also brought new challenges for measuring and comparing performance, because there are no widely accepted evidence-based ADE metrics, and ADE data collection varied by hospital. Recognizing the need to provide hospitals with comparable data while aligning with CMS’ 2014 strategies, NYSPFP utilized four new measures for improved comparisons and launched them in an ADE pilot.
Hospitals collected data on blood glucose, international normalized ratio (INR), and the use of reversal drugs for opioids. One important finding was the value of involving the pharmacist in the quality improvement process, especially for medication reconciliation at admission and discharge.
RESULTS AND OUTCOMESOverall, hospitals’ efforts reduced the statewide ADE rate by 49.64%.
0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8
Jul-1
2
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-1
3
Jul-1
3
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
2.0
AD
E Ra
te P
er 1
,000
Pat
ient
Day
s
Year and Month
ADVERSE DRUG EVENT RATE FOR HIGH-ALERT DRUGS
The ADE rate decreased by 49.64%, meaning 1,811 ADEs were prevented.
7
RATE OF UNIQUE INPATIENTS WHO HAVE AT LEAST ONE BLOOD LUCOSE RESULT THAT IS GREATER THAN OR EQUAL TO 200 MG/
DL PER 100 UNIQUE INPATIENTS PRESCRIBED INSULIN
RATE OF UNIQUE INPATIENTS WITH AN INR GREATER THAN 5 PER 100 UNIQUE INPATIENTS PRESCRIBED WARFARIN THERAPY
RATE OF EPISODES A REVERSAL AGENT IS ADMINISTERED PER 100 INPATIENTS PRESCRIBED OPIOIDS
RATE OF UNIQUE INPATIENTS WHO HAVE AT LEAST ONE BLOOD GLUCOSE RESULT THAT IS LESS THAN OR EQUAL TO 50 MG/DL PER
100 UNIQUE INPATIENTS PRESCRIBED INSULING
Hospitals now have data in four new metrics to use for comparative analysis.
8
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTIs) Urinary catheters are often essential to patient care; however, the longer a catheter is left in place, the great-er the potential for infection. CAUTIs account for 35% of hospital-acquired infections3 and not only expose a patient to the risks associated with infection, but also cause discomfort, pain, and a longer hospital stay.
APPROACH AND INNOVATIONSNYSPFP identified a rising trend in CAUTI and prioritized it as one of the first initiatives. NYSPFP provided hospitals with education and resources to implement evidence-based practices for catheter insertion and maintenance, and shared advanced interventions.
NYSPFP engaged a national expert, Sanjay Saint, M.D., as an advisor. Dr. Saint provided additional program-ming and resources, including a CAUTI “GPS” tool to improve understanding of the barriers to reducing catheter use, and a two-tier approach for units with increasing rates. He also led a series of regional confer-ences and “Office Hours” webinars that delved into many clinical and socio-adaptive issues of catheter use. Hospitals piloted a series of advanced practices, such as ensuring the medical necessity of catheter inser-tions in the emergency department and using nurse-driven protocols, including daily review of the catheter and hard or soft discontinuation of catheters.
RESULTS AND OUTCOMESNYSPFP hospitals have made measurable progress in reducing CAUTIs, and have significantly reduced uri-nary catheter use:
• 28.36% decrease in the CAUTI population rate, a measure that takes into account a decreasing cathe-ter utilization ratio
• 21.28% reduction in catheter use
9
CAU
TI P
opul
atio
n Ra
te P
er 1
0,00
0 Pa
tient
Day
s
Year and Month
1098
76
54
Jan
-12
32
10
Feb-12
Mar-12
Apr-12
May-12Ju
n-12 Ju
l-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12 Jan
-13
Feb-13
Mar-13
Apr-13
May-13Ju
n-13 Ju
l-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13 Jan
-14
Feb-14
Mar-14
Apr-14
May-14Ju
n-14 Ju
l-14
CAUTI POPULATION RATE PER 10,000 PATIENT DAYSUr
inar
y Ca
thet
er U
tiliza
tion
Ratio
Year and Month
0.35
0.30
0.25
0.20
0.15
0.05
0
Jan-
12Fe
b-12
Mar
-12
Apr-1
2M
ay-1
2Ju
n-12
Jul-1
2Au
g-12
Sep-
12O
ct-1
2N
ov-1
2De
c-12
Jan-
13Fe
b-13
Mar
-13
Apr-1
3M
ay-1
3Ju
n-13
Jul-1
3Au
g-13
Sep-
13O
ct-1
3N
ov-1
3De
c-13
Jan-
14Fe
b-14
Mar
-14
Apr-1
4M
ay-1
4Ju
n-14
Jul-1
4
0.10
URINARY CATHETER UTILIZATION RATIO
10
CENTRAL LINE–ASSOCIATED BLOODSTREAM INFECTIONS (CLABSIs) A central intravenous line is used to provide fluids and medications, withdraw blood, and monitor the pa-tient’s condition. While central lines are an integral part of patient care, their use can result in bacterial in-fections that enter the bloodstream. An estimated 30,100 CLABSIs occur in U.S. hospitals every year,4 which puts patients at risk and can add up to three weeks to a hospital stay.
Through NYSPFP, hospitals accelerated their ongoing efforts to reduce CLABSI and achieved CMS’ 40% reduction goal.
APPROACH AND INNOVATIONSNYSPFP focused CLABSI reduction efforts on using insertion and maintenance bundles, increasing review of the line’s necessity, and extending those efforts beyond the intensive care unit to patient floors and units hospital-wide.
As part of these efforts, NYSPFP worked with hospitals to develop protocols related to the principle of “No Line—No Infection,” discouraging unnecessary line insertion and promoting prompt removal of lines as soon as medically indicated. The “Scrub the Hub” principle encouraged staff to maintain the lines’ integrity and keep them germ-free, especially during long-term use. NYSPFP also developed a customized tracking tool for nurses to evaluate the necessity of a central line. RESULTS AND OUTCOMESNYSPFP-participating hospitals exceeded the CMS goal of 40% with a reduction of 40.51%, and prevented 1,279 bloodstream infections.
CLA
BSI S
tand
ardi
zed
Infe
ctio
n Ra
tio
Year and Month
1.2
0.8
0.6
0.4
0.2
0
1.0
Jan-1
0
Mar-1
0
May-1
0
Jul-1
0
Sep-1
0
Nov-1
0
Jan-1
1
Mar-1
1
May-1
1
Jul-1
1
Sep-1
1
Nov-1
1
Jan-1
2
Mar-1
2
May-1
2
Jul-1
2
Sep-1
2
Nov-1
2
Jan-1
3
Mar-1
3
May-1
3
Jul-1
3
Sep-1
3
Nov-1
3
Jan-1
4
Mar-1
4
May-1
4
Jul-1
4
CLABSI STANDARIZED INFECTION RATIO
11
Delivering a baby by cesarean section or inducing labor before 39 weeks (unless medically necessary) increases the risk of injury for newborn and mother, prolongs hospital stays, and increases health care costs. NYSPFP partnered with the New York State Department of Health (DOH) in 2012 to reduce the statewide EED rate to 5% or lower.
APPROACH AND INNOVATIONSDOH’s New York State Perinatal Quality Collaborative and NYSPFP supported the success of more than 100 hospitals that implemented “hard” stop protocols to prevent the scheduling of deliveries prior to 39 weeks gestation that were not medically necessary. This strategy, in conjunction with promoting a standardized practice for calculating gestational age, had a tremendous impact on the results. In addition, providers, staff, and most importantly, expectant parents, received educational materials on gestational age and early delivery.
RESULTS AND OUTCOMES NYSPFP hospitals reduced EEDs by 89.58% to achieve the CMS benchmark of < 2%.
EARLY ELECTIVE DELIVERIES (EEDs)
PERCENT OF ALL SCHEDULED DELIVERIES AT 36 0/7 TO 38 6/7 WEEKS GESTATION WITHOUT DOCUMENTATION OF LISTED
MATERNAL OR FETAL REASON
0%
5%
10%
15%
20%
25%
30%
Jun-12
Rate
of S
ched
uled
Del
iver
ies <
39 W
eeks
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13Apr-1
3
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Year and Month
Participating hospitals reduced EEDs by 89.58%, which means 1,832 fewer early deliveries.
12
FALLSHospital patients are susceptible to falls for a number of reasons, including being weak, light-headed, or unsteady from their illness, surgery, medications, or other treatments. Patient falls are among the most fre-quently reported adverse events in hospitals5 and sometimes result in serious hip and spine fractures, and head injury. Falls can often lead to increased length of stay and readmission.
APPROACH AND INNOVATIONSHospitals in New York have been working on fall prevention with success for many years. Given NYSPFP’s “no harm across the board” theme, fall efforts focused on preventing falls that result in moderate or great-er patient harm by integrating risk assessment, safety practices, and safety equipment into nursing care delivery. A national expert, Patricia Quigley R.N., Ph.D., led fall injury prevention workshops and provided advanced insight into how to prevent different types of falls.
RESULTS AND OUTCOMESNYSPFP hospitals achieved a 29.74% reduction in falls with moderate or greater harm, and reduced falls with any harm by 16.01%, resulting in a rate below the CMS benchmark of 0.5.
Year and Month
J M
M J
S N
J M
M J
S
RATE OF FALLS WITH ANY HA
Rate
Year and Month
0.6
0.5
0.4
0.3
0.2
0.1
0
Jan-1
2Fe
b-12
Mar-1
2Ap
r-12
May-1
2Ju
n-12
Jul-1
2Au
g-12
Sep-
12Oc
t-12
Nov-1
2De
c-12
Jan-1
3Fe
b-13
Mar-1
3Ap
r-13
May-1
3Ju
n-13
Jul-1
3Au
g-13
Sep-
13Oc
t-13
Nov-1
3De
c-13
Jan-1
4Fe
b-14
Mar-1
4Ap
r-14
May-1
4Ju
n-14
Jul-1
4Au
g-14
Sep-
14
RM PER 1,000 PATIENT DAYS
Rate
0.14
0.12
0.10
0.08
0.06
0.04
0.02
0
Jan-12
Mar-12
May-12
Jul-12
Sep-12
Nov-12
an-13ar-
13ay-
13ul-1
3ep-13
ov-13
an-14ar-
14ay-
14ul-1
4ep-14
RATE OF FALLS WITH MODERATE OR GREATER HARM PER 1,000 PATIENT DAYS
13
Pressure ulcers impact more than 2.5 million6 hospital patients each year and can cause infections and other serious complications, requiring additional treatment and a longer hospital stay.
When NYSPFP began, hospitals’ pressure ulcer rates were already better than CMS’ benchmark. Par-ticipating hospitals improved even more by adopting new strategies and implementing and hardwiring practices learned from NYSPFP’s pressure ulcer initiative into their day-to-day patient care.
APPROACH AND INNOVATIONSNYSPFP advanced the use of evidence-based practices from the Institute for Healthcare Improvement and the NYS Gold STAMP (Success Through Assessment, Management, and Prevention) Program. Hos-pitals focused on daily screening and assessment of all patients for pressure ulcer risk, with extra vig-ilance for those at high risk for developing pressure ulcers. In addition, NYSPFP provided education in areas such as: moisture-related pressure ulcer development, managing incontinence, the impact of nutrition on preventing pressure ulcers, and strategies for bed-bound patients in the emergency and operating rooms. RESULTS AND OUTCOMESAfter starting the program with a rate lower than CMS’ benchmark, NYSPFP hospitals further reduced the pressure ulcer rate for Stage II and greater by 19.29%.
PRESSURE ULCERS
FACILITY-ACQUIRED PRESSURE ULCER RATE
Pres
sure
Ulc
er R
ate
Per 1
00 P
atie
nts
Year and Quarter
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0Q1
2012Q2
2012Q3
2012Q4
2012Q1
2013Q2
2013Q3
2013Q4
2013Q1
2014Q2
2014Q3
2014
Starting below the CMS benchmark, NYSPFP-participating hospitals further reduced the pressure ulcer rate by 19.29% for Stage II and greater; 822 pressure ulcers were prevented.
14
SURGICAL SITE INFECTIONS (SSIs)Surgical site infections occur in 2% to 5% of surgical inpatients, and as many as 60% of SSIs are considered preventable.7 Patients who develop an SSI usually need to stay an additional week or more in the hospital, sometimes in intensive care,8 and are more likely to be readmitted with complications.
APPROACH AND INNOVATIONSNYSPFP focused on SSI prevention for four procedures—hip (HPRO), colon (COLO), coronary artery bypass graft (CABG), and abdominal hysterectomy (HYST). Kick-off in-person conferences drew more than 600 par-ticipants, followed by a year-long curriculum of best practices for each phase of surgical care: pre-admission, pre-procedure, operating room, post-hospital anesthesia unit, and discharge.
Changes in the Centers for Disease Control and Prevention’s SSI colon surveillance system in 2013, along with national comparisons, prompted NYSPFP to aggressively address New York State’s higher SSI colon rate. Nationally renowned surgeons Patcheon Dellinger, M.D., and Robert Cima, M.D., advised NYSPFP and were faculty for in-person conferences and advanced topic tutorials. NYSPFP also disseminated an Ad-vanced SSI Colon Bundle that addressed leading research and evidence, and provided tools and resources applicable for other surgical procedures. RESULTS AND OUTCOMESNYSPFP hospitals’ SSI performance was mixed. SSI SIRs (Standardized Infection Ratios) decreased 15.58% for hip surgery and 19.76% for CABG. Although abdominal hysterectomy had also trended downward since 2010, it increased 3.14% in the final three months of the program. While hospitals saw a 31% increase in SSI colon from 2010—reflecting a national trend—early data show progress with a 5.15% reduction since NYSPFP introduced the Advanced SSI Colon Bundle in the spring of 2014.
15
CABG SSI STANDARDIZED INFECTION RATIO
CAB
G S
SI S
tand
ardi
zed
Infe
ctio
n Ra
tio
Year and Month
0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep-
10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep-
11
Nov
-11
Jan-
12
Mar
-12
May
-12
Jul-1
2
Sep-
12
Nov
-12
Jan-
13
Mar
-13
May
-13
Jul-1
3
Sep-
13
Nov
-13
Jan-
14
Mar
-14
May
-14
Jul-1
4
COLO SSI STANDARDIZED INFECTION RATIO
CO
LO S
SI S
tand
ardi
zed
Infe
ctio
n Ra
tioYear and Month
0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
New Criteria
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep-
10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep-
11
Nov
-11
Jan-
12
Mar
-12
May
-12
Jul-1
2
Sep-
12
Nov
-12
Jan-
13
Mar
-13
May
-13
Jul-1
3
Sep-
13
Nov
-13
Jan-
14
Mar
-14
May
-14
Jul-1
4
HPRO SSI STANDARDIZED INFECTION RATIO
HPR
O S
SI S
tand
ardi
zed
Infe
ctio
n Ra
tio
Year and Month
0
0.2
0.4
0.6
0.8
1.0
1.2
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep-
10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep-
11
Nov
-11
Jan-
12
Mar
-12
May
-12
Jul-1
2
Sep-
12
Nov
-12
Jan-
13
Mar
-13
May
-13
Jul-1
3
Sep-
13
Nov
-13
Jan-
14
Mar
-14
May
-14
Jul-1
4
HYST SSI STANDARDIZED INFECTION RATIO
HYS
T SS
I Sta
ndar
dize
d In
fect
ion
Ratio
Year and Month
0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Jan-
12
Feb-
12
Mar
-12
Apr-1
2M
ay-1
2
Jun-
12
Jul-1
2Au
g-12
Sep-
12
Oct
-12
Nov
-12
Dec-
12Ja
n-13
Feb-
13
Mar
-13
Apr-1
3M
ay-1
3
Jun-
13
Jul-1
3Au
g-13
Sep-
13
Oct
-13
Nov
-13
Dec-
13Ja
n-14
Feb-
14
Mar
-14
Apr-1
4M
ay-1
4
Jun-
14
Jul-1
4
16
VENTILATOR-ASSOCIATED PNEUMONIA (VAP) AND VENTILATOR-ASSOCIATED EVENTS (VAEs)
Ventilators are life-saving devices for critically ill patients, but they can also lead to life-threatening infections like pneumonia and sepsis, and other complications. Studies estimate that ventilators are used for more than 300,000 patients each year in the United States.9 VAP is one of the leading causes of death among hospi-tal-acquired infections, with a mortality rate as high as 40%.10 In 2012, hospitals across the country reported more than 3,900 VAP cases to the National Healthcare Safety Network (NHSN).11
APPROACH AND INNOVATIONS NYSPFP started its program work with the Institute for Healthcare Improvement VAP prevention bundle of evidence-based practices and added advanced VAP and VAE prevention strategies. Those strategies focused on developing and implementing oral care, early activity and mobility protocols, and reducing or eliminating sedation. Additional education was provided on other HACs, such as strategies for preventing delirium and the appropriate use of narcotics and sedatives. NYSPFP also provided education on the new NSHN VAE surveillance criteria.
RESULTS AND OUTCOMESNYSPFP-participating hospitals saw dramatic success in the first year of the initiative, with a 20% VAP de-crease in 2012. The new VAE measure and initiative showed positive trends and improvements in all areas. The new Infection-Related Ventilator-Associated Complication (IVAC) rate decreased by 8.89% since its inception in 2013.
IVAC
Rat
e Pe
r 1,0
00 V
entil
ator
Day
s
Year and Month
0
0.2
0.4
0.6
0.8
1.0
1.2
Jan-1
3
Feb-13
Mar-13
Apr-13
May-13
Jun-1
3Ju
l-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-1
4
Feb-14
Mar-14
Apr-14
May-14
Jun-1
4Ju
l-14
INFECTION-RELATED VENTILATOR-ASSOCIATED COMPLICATION RATE
17
VTE encompasses two conditions, deep vein thrombosis and pulmonary embolism. VTE is not uncom-mon among hospitalized patients, but it is estimated that at least 50% of VTEs may be preventable.12
APPROACH AND INNOVATIONSNYSPFP provided a VTE learning network for hospitals across the state in 2012 via regional conferences, followed up by webinars to address VTE prevention, medication management, and CMS’ new VTE core measures for 2013. VTE rates in the State remained steady and low. In 2014, NYSPFP refocused resourc-es on VTE after determining that the rate was increasing slightly and New York State showed one of the higher rates nationally. The interventions included: assessing risk; implementing pharmaceutical and mechanical prevention techniques; transition and titration of medications; and integrating that work with the hospital’s ADE (anticoagulants) teams. In addition, pharmacy-driven teams were encouraged to provide medication reconciliation and patient education on high-alert drugs at discharge. As part of this initiative, hospitals also had access to one-on-one consultations with a national VTE expert at IPRO. RESULTS AND OUTCOMESNYSPFP hospitals’ VTE rates have been relatively flat and within normal variation range since 2010. The impact of the summer and fall 2014 interventions will be assessed when the final data is available.
VENOUS THROMBOEMBOLISM (VTE)
VENOUS THROMBOEMBOLISM RATE
VTE
Rate
per
100
Pat
ient
s
Year and Month
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep-
10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep-
11
Nov
-11
Jan-
12
Mar
-12
May
-12
Jul-1
2
Sep-
12
Nov
-12
Jan-
13
Mar
-13
May
-13
Jul-1
3
Sep-
13
Nov
-13
Jan-
14
Mar
-14
May
-14
Jul-1
4
18
READMISSIONSHospital readmissions are both common and costly. Approximately 18.4% of hospitalized Medicare patients are readmitted unexpectedly within 30 days of being discharged.13 Readmissions take a personal toll on the patient and family and impact hospital resources. The issue is complex and challenging, as there are many reasons why a patient may wind up back in the hospital.
APPROACH AND INNOVATIONSSince 2012, NYSPFP’s readmission prevention work has closely examined activities related to admission, hospital stay, medication reconciliation, and discharge. NYSPFP provided hospitals with tools and resources, including hospital-specific quarterly reports, to help identify the greatest opportunities for improvement. NYSPFP and participating hospitals worked with palliative care and community-based care transitions pro-grams, nursing homes, home care, and behavioral health to extend their approach across the continuum of care.
In 2014, NYSPFP launched a rapid-cycle pilot project for hospitals to test new care processes and communi-cation strategies on targeted units. As part of the program, hospitals had access to top experts from leading readmissions reduction initiatives, such as BOOST and Project Red. NYSPFP also developed and released the NYSPFP Preventable Readmissions Action Planning Guide and disseminated tools to help hospitals conduct readmission chart abstraction, patient and family interviews, and community provider outreach to better understand the causes of readmissions. RESULTS AND OUTCOMESParticipating hospitals have achieved significant decreases in readmission rates, including a 16.39% reduc-tion in potentially preventable readmission rates, and an 11.04% reduction in all-cause patient readmissions within 30 days of discharge.
ALL-CAUSE READMISSION RATE
Rate
Year and Month
UCL 13.83%
CL 13.33%
LCL 12.82%
0.110
0.115
0.120
0.125
0.130
0.135
0.140
0.145
Jan-20
10
Mar-
2010
May-20
10
Jul-2
010
Sep-20
10
Nov-201
0
Jan-20
11
Mar-
2011
May-20
11
Jul-2
011
Sep-20
11
Nov-201
1
Jan-20
12
Mar-
2012
May-20
12
Jul-2
012
Sep-20
12
Nov-201
2
Jan-20
13
Mar-
2013
May-20
13
Jul-2
013
Sep-20
13
Nov-201
3
Jan-20
14
Mar-
2014
May-20
14
19
Small rural and Critical Access Hospitals (CAHs) are often at the heart of their communities as the major source for the delivery of health care services. To advance their quality improvement efforts and pro-vide rural hospitals with a forum to address safety from their unique delivery systems, NYSPFP teamed up with the statewide CAH Quality Committee to form a rural/CAH Pod. In all, 23 hospitals joined the group.
APPROACH AND INNOVATIONSDue to their lower volume of cases, the rural hospitals focused on a strategy that combined their data to achieve the 20/40 goal through a “no harm across the board” approach. Hospitals developed a unique “change package” by starting with NYSPFP program elements and adding components and resources relevant to their needs. Some of their tailored programming included working with the MATCH tool, community linkages to reduce readmissions, and additional work on culture and patient engagement. In addition to their rural/CAH Pod work, many hospitals also participated in NYSPFP’s readmission, CAUTI, and ADE pilots.
NYSPFP developed a separate data reporting infrastructure and provided monthly individualized and Pod reports to each hospital which included low-volume metrics such as average days since the last event for all initiatives.
By scheduling quarterly in-person meetings and monthly calls, the hospitals benefited from the synergy of shared learning and teaching. The rural/CAH Pod also led NYSPFP’s patient and family engagement efforts by working with a national expert to build the initial syllabus for NYSPFP’s statewide education and PFE resource guide.
RESULTSThe Pod’s successful shared learning and improvement approach resulted in reducing harm across the board (all PFP initiatives excluding readmissions) by 50% when comparing January to June 2012 with January to June 2014.
RURAL AND CRITICAL ACCESS HOSPITALS
20
0
5
10
15
20
25
J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A
2012 2013 2014
NO HARM ACROSS THE BOARDRURAL/CAH POD
21 21
NYSPFP thanks the following hospitals for their extensive work to meet CMS’ PfP goals:
NYSPFP-PARTICIPATING HOSPITALS
Adirondack Medical Center
Albany Memorial Hospital
Alice Hyde Medical Center
Auburn Memorial Hospital
Aurelia Osborn Fox Memorial Hospital
Bassett Medical Center
Bellevue Hospital Center
Bronx-Lebanon Hospital Center—Concourse Division
Bronx-Lebanon Hospital Center—Fulton Division
Brookdale University Hospital and Medical Center
Brookhaven Memorial Hospital Medical Center
The Brooklyn Hospital Center
Brooks Memorial Hospital
Buffalo General Hospital
Burdett Care Center
Burke Rehabilitation Hospital
Canton-Potsdam Hospital
Carthage Area Hospital
Catskill Regional Medical Center
Catskill Regional Medical Center—Grover M. Hermann Division
Cayuga Medical Center at Ithaca
Champlain Valley Physicians Hospital Medical Center
Chenango Memorial Hospital
Claxton-Hepburn Medical Center
Clifton Springs Hospital and Clinic
Clifton-Fine Hospital
Cobleskill Regional Hospital
Columbia Memorial Hospital
Community Memorial Hospital
Coney Island Hospital
Cortland Regional Medical Center
Crouse Hospital
Cuba Memorial Hospital
DeGraff Memorial Hospital
Delaware Valley Hospital
Eastern Long Island Hospital
Eastern Niagara Hospital Lockport
Eastern Niagara Hospital Newfane
Elizabethtown Community Hospital
Ellenville Regional Hospital
Elmhurst Hospital Center
Erie County Medical Center
F.F. Thompson Hospital
Faxton-St. Luke’s Healthcare—St. Luke’s Memorial
Flushing Hospital Medical Center
Forest Hills Hospital
Franklin Hospital
Geneva General Hospital
Glen Cove Hospital
Glens Falls Hospital
Good Samaritan Hospital Medical Center
Gouverneur Hospital
Harlem Hospital Center
HealthAlliance—Broadway Campus
HealthAlliance—Mary’s Avenue Campus
Highland Hospital of Rochester
Hospital for Special Surgery
Huntington Hospital
Interfaith Medical Center
Ira Davenport Memorial Hospital, Inc.
Jacobi Medical Center
Jamaica Hospital Medical Center
John T. Mather Memorial Hospital
Jones Memorial Hospital
Kenmore Mercy Hospital
Kings County Hospital Center
Kingsbrook Jewish Medical Center
Lake Shore Health Care Center at TLC Health Network
Lenox Hill Hospital
Lewis County General Hospital
Lincoln Medical and Mental Health Center
Little Falls Hospital
Long Island Jewish Medical Center
Lutheran Medical Center
Maimonides Medical Center
Margaretville Memorial Hospital
Massena Memorial Hospital
Memorial Sloan-Kettering Cancer Center
Mercy Hospital of Buffalo
Mercy Medical Center
Metropolitan Hospital Center
MidHudson Regional Hospital of Westchester Medical Center
Millard Fillmore Suburban Hospital
Montefiore Medical Center—Einstein Division
Montefiore Medical Center—Henry and Lucy Moses Division
Montefiore Medical Center—The North Division
22
NYSPFP-PARTICIPATING HOSPITALS cont.Montefiore Mount Vernon Hospital
Montefiore New Rochelle Hospital
Moses-Ludington Hospital—Ticonderoga
Mount Sinai Beth Israel
Mount Sinai Beth Israel Brooklyn
The Mount Sinai Hospital
Mount Sinai Queens
Mount Sinai Roosevelt
Mount Sinai St. Luke’s
Nathan Littauer Hospital
New York Community Hospital of Brooklyn
New York Hospital Queens
New York Methodist Hospital
NewYork-Presbyterian Hospital—Allen Pavilion
NewYork-Presbyterian Hospital—Columbia University Medical
Center
NewYork-Presbyterian Hospital—Lawrence
NewYork-Presbyterian Hospital—Hudson Valley Hospital
NewYork-Presbyterian Hospital—Lower Manhattan
NewYork-Presbyterian Hospital—New York Weill Cornell Medical
Center
Niagara Falls Memorial Medical Center
Nicholas H. Noyes Memorial Hospital
North Central Bronx Hospital
North Shore University Hospital
Northern Dutchess Hospital
Northern Westchester Hospital
Nyack Hospital
O’Connor Hospital
Olean General Hospital
Oneida Healthcare
Orange Regional Medical Center
Orleans Community Health
Oswego Health
Peconic Bay Medical Center
Phelps Memorial Hospital Center
Plainview Hospital
Putnam Hospital Center
Queens Hospital Center
Richmond University Medical Center
River Hospital
Rome Memorial Hospital
Roswell Park Cancer Institute
Samaritan Hospital—Troy
Samaritan Medical Center—Watertown
Saratoga Hospital
Schuyler Hospital, Inc.
Seton Health
Sisters of Charity Hospital of Buffalo
Sisters of Charity Hospital—St. Joseph Campus
Soldiers and Sailors Memorial Hospital
South Nassau Communities Hospital
Southampton Hospital
Southside Hospital
St. Barnabas Hospital
St. Catherine of Siena Medical Center
St. Charles Hospital
St. Elizabeth Medical Center—Utica
St. Francis Hospital, The Heart Center
St. James Mercy Hospital
St. John’s Episcopal Hospital South Shore
St. John’s Riverside Hospital—Andrus Pavilion
St. Joseph Hospital (Bethpage)
St. Joseph’s Hospital Health Center (Syracuse)
St. Joseph’s Hospital Medical Center (Yonkers)
St. Luke’s Cornwall Hospital—Newburgh
St. Peter’s Hospital
Staten Island University Hospital
Staten Island University Hospital—South Site
Stony Brook University Medical Center
SUNY Downstate Medical Center
Syosset Hospital
UHS Binghamton General Hospital
UHS Wilson Regional Medical Center
United Memorial Medical Center
Unity Hospital
Vassar Brothers Medical Center
WCA Hospital
Westchester Medical Center
White Plains Hospital
Winthrop-University Hospital
Women and Children’s Hospital of Buffalo
Woodhull Medical and Mental Health Center
Wyckoff Heights Medical Center
Wyoming County Community Health System
23
MESSAGE FROM THE CO-DIRECTORS
Three years ago, hospitals around the State joined with HANYS and GNYHA to improve hospital care
and patient outcomes through the collective effort of the New York State Partnership for Patients.
Leaders emerged at each hospital to help drive innovative improvements and teams of champions
were developed to implement, measure, and sustain those efforts.
Staff at all levels attended dozens of webinars and in-person sessions, and participated in coaching
calls to share best practices and learn from local and national experts, as well as each other. Hospitals
united to achieve common goals: reduce hospital-acquired conditions and avoidable readmissions.
NYSPFP admires the major changes and progress so many hospitals have made in such a short pe-
riod of time. Care for thousands of patients has been improved because of your efforts, and even
more lives will be impacted as these innovations in care delivery are spread and sustained.
That so much was accomplished—amid the responsibilities and challenges you each face every day—
demonstrates how much you care about the patients you serve and your dedication to improving the
quality of their lives.
We are proud to have worked so closely with you. Your deep-seated commitment has helped ad-
vance our shared mission, and your success is measured by the most important metrics of all—safer
patients, better care, and enriched lives.
Congratulations, and keep up the great work.
Kathleen Ciccone
Co-director, NYSPFP
Lorraine Ryan
Co-director, NYSPFP
24
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www.hret-hen.org/index.php?option=com_content&view=article&id=2&Itemid=127 (accessed January 26, 2015).
3. HRET, AHA. “On the CUSP: Stop CAUTI Implementation Guide,” access through CAUTI: Implementation Guide (February
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(accessed January 25, 2015).
4. Centers for Disease Control and Prevention (CDC). “Bloodstream Infection Event (Central Line–Associated Bloodstream Infec-
tion and Non-Central Line–Associated Bloodstream Infection)” (January 2015). Available at http://www.cdc.gov/nhsn/PDFs/
pscManual/4PSC_CLABScurrent.pdf (accessed January 26, 2015).
5. Currie, L. “Chapter 10: Fall and Injury Prevention,” Patient Safety and Quality: An Evidence-Based Handbook for Nurses (April
2008). Agency for Healthcare Research and Quality (AHRQ), Rockville, MD. Available at http://www.ncbi.nlm.nih.gov/books/
NBK2653/ (accessed January 29, 2015).
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www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/index.html (accessed Jan-
uary 29, 2015).
7. Anderson, D.J., Podgorny, K., and Berrios-Torres, S., et. al. “Strategies to Prevent Surgical Site Infections in Acute Care Hospi-
tals: 2014 Update.” Infection Control and Hospital Epidemiology (June 2014); vol. 35, no. 6. Available at http://www.jstor.org/
stable/10.1086/676022 (accessed January 26, 2015).
8. CDC. “Surgical Site Infection (SSI) Toolkit Activity C: ELC Prevention Collaboratives (December 21, 2009). Available at http://
www.cdc.gov/HAI/ssi/ssi.html (available under “Toolkits”; accessed January 26, 2015).
9. CDC. “Device-Associated Module: Ventilator-Associated Event Protocol” (January 2015). Available at http://www.cdc.gov/
nhsn/PDFs/pscManual/10-VAE_FINAL.pdf (accessed January 26, 2015).
10. HRET, AHA. “Ventilator-Associated Pneumonia Change Package” (2014). Available at: http://www.hret-hen.org/ ( item under
Ventilator Associated Events “Resources”; accessed January 26, 2015).
11. Dudeck, M.A., Weiner, L.M., et al. “National Healthcare Safety Network (NHSN) Report, Data Summary for 2012, Device-As-
sociated Module.” American Journal of Infection Control (2013); 41(12): 1148–66. Available at http://www.cdc.gov/nhsn/
PDFs/2012-data-summary-nhsn.pdf (accessed January 29, 2015).
12. Maynard, G., and Stein, J. “Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improve-
ment.” AHRQ (August 2008); available at http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/
resources/vtguide/vtguide.pdf (accessed January 29, 2015).
13. Gerhardt, G., Yemane, A., Hickman, P., et al. “Data Shows Reduction in Medicare Hospital Readmission Rates During 2012.” Medi-
care & Medicaid Research Review (2013) vol. 3, no. 2. Available at http://www.cms.gov/mmrr/Downloads/MMRR2013_003_02_
b01.pdf (accessed January 29, 2015).
25
© 2015 NYS Partnership for Patients