TEAM STATUS - Report to SHN Steering Team – March 5/07 (based on data submitted up to Dec. 31/06)

Progress towards meeting targets / Overall Status: / Compliance with bundle elements: / Rate:
(AMI Mortality, VAP, SSI)
5
4
3
2
1 / = target sustained; monitoring 1 – 2 x yearly
= target achieved/sustained (4 periods)
= target achieved, not yet sustained
= target not yet achieved
= not yet started / / On Target - Progressing well /  Trend is increasing /  Trend is increasing
/ Requires Monitoring -Concerns impact progress /  Trend is decreasing /  Trend is decreasing
/ Issues or Delays - Not progressing /  Trend not yet stabilized /  Trend not yet stabilized
TEAM and
KEY
CONTACT / TEAM ACTIVE / DATA/
REPORT / PROGRESS TOWARDS MEETING TARGETS
(see attached run charts for team AIM, baseline, targets and current bundle compliance) / OVERALL STATUS / NOTES/ISSUES
Acute Myocardial Infarction (AMI)
AIM: Reduce inpatient STEMI mortality by 40 % by:
  • implementing six evidence based care components by December 2006
  • improving compliance to each component of the bundle to its target level (85 – 95%)
  • improving perfect care to 95% reliability.
/ DEFINITION:
The bundle consists of six evidence-based care components: ASA within 24 hours of admission, ASA at inpatient discharge, timely reperfusion (fibrinolytic within 30 minutes or percutaneous coronary intervention within 90 minutes of hospital arrival), ACE inhibitor or Angiotensin Receptor Blocker (ARB) on inpatient discharge if appropriate, smoking cessation counseling and/or cardiac rehabilitation referral. Perfect care is compliance to all six components: Deaths due to myocardial infarction for patients with a special care unit stay has been selected in addition to AMI mortality. Data represent the number of patients who died per 1,000 discharges with an AMI diagnosis.
Site One
Key Leader and Contact # / Yes
Started June/06 / Reporting Monthly
Last Report
Nov. 06 / Aspirin - Admission / 4 / / Most targets exceeded - working on ECG and thrombolytics. How realistic is it to reach thrombolytic and PCI targets? Perfect Care dependent on these.
Recommended Next Steps:
- Recommend team continue to monitor for sustainability
Aspirin - Discharge / 4
Beta Blocker - Discharge / 4
Thrombolytic or PCI / 2 / Compliance

ACE/ARB - Discharge / 3
Smoking Cessation/ Cardiac Rehab / 4
Perfect Care / 2 / Rate
TBD
AMI Mortality Rate (retrospective) / 16.84%
AMI Mortality with SCU stay (retro.) / 15.38%
Site Two
Key Leader and Contact # / Yes
Started June/06 / Reporting Monthly
Last Report
Oct. 06 based on Sept. data / Aspirin - Admission / 4 / / Most targets exceeded - working on ECG and thrombolytics. How realistic is it to reach thrombolytic targets (not recording PCI)? Perfect Care dependent on these.
Team’s performance has been recognized by the Western Node as a “star”.
Recommended Next Steps:
- Recommend team continue to monitor for sustainability
Aspirin - Discharge / 4
Beta Blocker - Discharge / 4
Thrombolytic or PCI / 2 / Compliance

ACE/ARB - Discharge / 4
Smoking Cessation/ Cardiac Rehab / 3
Perfect Care / 2 / Rate
TBD
AMI Mortality Rate (retrospective) / 9.92%
AMI Mortality with SCU stay (retro.) / 9.09%
Site Three
Key Leader and Contact # / Yes
Started Nov/06 / Reporting Monthly
Last Report
Dec. 06 / Aspirin - Admission / 4 / / - Site visit January 30. Steering team is meeting quarterly; working teams monthly.
- Working on wider range of smoking cessation options/ tools; using FH tools recently developed and in liaison with Smoking Cessation Coordinator. Initiating Discharge Summary outlining discharge medications, investigations and follow-up appointments/interventions. Copy for patient.
- Given low sample size, quarterly reports will be initiated, likely in April.
- Monthly patients seems abnormally low; to investigate.
Recommended Next steps:
Continue with PDSA cycles
Aspirin - Discharge / 3
Beta Blocker - Discharge / 3
Thrombolytic / 2 / Compliance

or PCI / 2
ACE/ARB - Discharge / 4
Smoking Cessation/ Cardiac Rehab / 3
Perfect Care / 2 / Rate
TBD
AMI Mortality Rate (retrospective) / 16.98%
AMI Mortality with SCU stay (retro.) / 21.97%
Site Four
Key Leader and Contact # / No
No local QI support – workload issue / Not Reporting
Last Report
July 06 (baseline) / Aspirin - Admission / 3 / / Site visit Nov. 8. Work progressing;however the team feels the need for ongoing QI support. Data collected, not compiled. Researcher may be able to compile data but payment is an issue. Working on door to balloon time and door to ECG time, as well as care by paramedics. Best communication methods are via ICU CNE monthly meeting and ICU Critical Care Practice Group.
Recommended Next steps:
Explore methods to compile data.
Aspirin - Discharge / 3
Beta Blocker - Discharge / 3
Thrombolytic or PCI / 2 / Compliance
No report
ACE/ARB - Discharge / 3
Smoking Cessation/ Cardiac Rehab / 3
Perfect Care / 2 / Rate
TBD over time
AMI Mortality Rate (retrospective) / 8.33%
AMI Mortality with SCU stay (retro.) / 13.51%
Site FIve
Key Leader and Contact # / Yes
Started June/06 but QI support started Dec. 06 / Reporting Monthly
First report Oct/06 / Aspirin - Admission / 3 / / WR/SS consultant provided some support Dec. to Jan. until new QI consultant started. Date collection is an issue; currently done by Team Leader.
Working on ECG, thrombolytics and smoking cessation.
Team feels it has met the SHN targets and is ready to now address other SHN initiatives; however, most targets have been sustained for 2 – 3 periods only.
Recommended Next Steps:
- Recommend team continue to monitor for sustainability
Aspirin - Discharge / 3
Beta Blocker - Discharge / 3
Thrombolytic / 3 / Compliance

or PCI / 2
ACE/ARB - Discharge / 3
Smoking Cessation/ Cardiac Rehab / 3
Perfect Care / 2 / Rate
TBD
AMI Mortality Rate (retrospective) / 6.17%
AMI Mortality with SCU stay (retro.) / 10.71%
TEAM and
KEY
CONTACT / TEAM ACTIVE / DATA/
REPORT / PROGRESS TOWARDS MEETING TARGETS
(see attached run charts for team AIM, baseline, targets and current bundle compliance) / OVERALL STATUS / NOTES/ISSUES
Ventilator Associated Pneumonia (VAP)
AIM:
Reduce the incidence of Ventilator Associated Pneumonia (VAP) by 50% within 1 year by: implementing the six evidence-based componentsimproving the compliance to each component to 95% or better. / DEFINITION:
Bundle compliance consists of four mandatory components. Elevation of head of bed (HOB), daily sedation vacation, use of oral versus nasal tubes (Oral ETT and Oral NG), and use of EVAC tubes for subglottic drainage. Two additional practices, although not mandatory bundle components, are considered standard in the delivery of quality care to mechanically ventilated patients: peptic ulcer disease prophylaxis (PUD) and deep venous thrombosis prophylaxis (DVT). The VAP rate is the # of cases of VAP per 1000 ventilator days.
Site One
Key Leader and Contact # / Yes
Started June 06 however no
QI support until Dec. 06 / Reporting Monthly
Last report Oct/06 / VAP rate / 3 / / WR/SS consultant provided some support Dec. to Jan. until new consultant started. Date collection is an issue – currently done by Team Leader.
Team feels it has met the SHN targets and sustained most targets and is ready to now address other SHN initiatives, however has had relatively low patient volumes.
Recommended Next Steps:
- Recommend team continue to monitor for sustainability for six months, due to low patient volume. See note under Site Three for all teams.
Compliance to 4 components / 2 / Compliance

Rate

Site Two
Key Leader and Contact # / Yes / Reporting Monthly
Last Report Jan/07 / VAP rate / 3 / / Bundle compliance is recorded for the reporting period; VAP rate is reported for the previous month.
Team is recording in format different from SHN; QI is conducting a monthly audit for 10 patients.
Recommended Next Steps:
Recommend active involvement of QI in PDSA cycles. See note under Site Three for all teams.
Compliance to 4 components / 2 / Compliance

Rate

Site Three / Yes
Started
Nov. 06 / Reporting Monthly
First Report expected Feb. 07 / VAP rate / 1 / / - EVAC tubes are not yet available (in RFP stage) so compliance will be 0% until these are available.
- Site visit January 30. Steering team is meeting quarterly; working teams monthly.
- Working on documentation of VAP rate with daily RT rounds and trying to involve ICP to verify VAP, but workload is an issue
- working on HOB consistently elevated.
Recommended Next Steps:
Continue with PDSA cycles
All VAP Teams:
SHN Steering Team will call a FH meeting involving all site reps., HR, DS and QI to discuss VAP definition and process to obtain ventilator hours/days. ICU Collaborative and SHN vary.
Compliance to 4 components / 1 / Compliance
Rate
Medical Emergency Team (MET)
AIM: Impact patient mortality by:
  • decreasing by 50% the occurrence of cardiac or respiratory arrests and
  • decreasing by 50% the occurrence of cardiac or respiratory arrests that occur outside of an expert/specialized environment.
/ DEFINITION:
A Rapid Response Team (RRT) is a team of clinicians who bring critical care expertise to the patient bedside. This is also known as a Medical Emergency Team (MET) or Critical Care Outreach team (CCO).
Site One
Key Leader and Contact # / Yes
Started spring 06
No QI support – workload / No reports received / No information / / Obtaining data as to utilization of the service as part of evaluation
Recommended Next steps:
Decision Support to review submitted data.
Compliance
Rate
TEAM and
KEY
CONTACT / TEAM ACTIVE / DATA/
REPORT / PROGRESS TOWARDS MEETING TARGETS
(see attached run charts for team AIM, baseline, targets and current bundle compliance) / OVERALL STATUS / NOTES/ISSUES
Surgical Site Infections (SSI)
AIM: Reduce the inpatient Surgical Site Infection (SSI) rate 50 % in designated populations within two years by:
  • implementing the relevant evidence-based care components for designated surgeries
  • improving compliance to each relevant component to 95% or higher.
/ DEFINITION:
The evidence-based care components include: prophylactic antibiotics delivered within 60 minutes prior to surgical incision, appropriate choice of antibiotic and discontinuation within 24 hours of surgery, and appropriate hair removal. Outcomes include a reduced rate of infection for clean surgery (wound classification 1 and 2).
Site One
Key Leader and Contact # / Yes
Started March 06 / Reporting Monthly
Last Report Oct. 06 / Prophylactic Antibiotic - Hip / 3 / / - knee/hip for each measure; very close to target for antibiotic; exceeded target for hair removal
- strongly shifting culture in the OR and internally spreading within SMH OR – starting normothermia for colorectal surgery (teleconference held re: temperature regulation)
- intend to address FH spread in early 2007 and intend to integrate this work into other FH surgical initiatives as patient safety initiatives. Several other sites interested.
- compiling data is problematic – lag time
- Team’s performance has been recognized by the Western Node and invited to present at several learning sessions.
Recommended Next steps:
- continue with local spread within site
- develop FH spread plan – need to identify key leaders
- Decision Support to review their capacity to receive worksheets from all sites, for data compilation.
Prophylactic Antibiotic – Knee / 3
Hair Removal - Hip / 4 / Compliance

Hair Removal - Knee / 4
SSI rate / Rate
No report
TEAM and
KEY
CONTACT / TEAM ACTIVE / DATA/
REPORT / PROGRESS TOWARDS MEETING TARGETS
(see attached run charts for team AIM, baseline, targets and current bundle compliance) / OVERALL STATUS / NOTES/ISSUES
Medication Reconciliation (Med Rec)
AIM: Prevent Adverse Drug Events (ADE) by reconciling medication orders at all key transition points in order to:
  • Eliminate undocumented intentional discrepancies
  • Eliminate unintentional discrepancies.
/ DEFINITION:
Medication reconciliation is the formal process of obtaining a complete and accurate list of each patient’s current home medications, and comparing the physician orders to that list. Intentional discrepancies are to be documented (these are potential medication errors) and unintentional discrepancies are to be eliminated (these are medication errors).
Site One
Key Leader and Contact # / Yes
Started March 06 / Reporting Monthly
Last Report Dec. 06 / undocumented intentional discrepancies / 3 / / - Very close to targets in ED;60 – 70% reliability for completion of key elements on History /Admission form; 84% of medical charts have forms on chart; has achieved success index for national target of 80%
- Medicine team has started PDSA cycles; surgical admissions starting discussions.
- Team’s performance has been recognized by the Western Node and invited to present at several learning sessions.
Next steps:
- Continue with alpha site
- Awaiting approval of spread plan/business case
unintentional discrepancies / 2 / Discrepancies

PAH target for success index / 2
national target for success index / 4 / Reconciliation

All Teams:
  • Active teams are making progress and have demonstrated that improvement is possible.
  • Active teams are submitting data but are no longer submitting monthly reports; run charts are generated based on data submitted.
  • Sites with low volumes of relevant patients might need to report quarterly, rather than monthly, in order to provide an adequate sample size.
  • Once targets are reached, sites with low volumes of relevant patients will need to monitor longer, to ensure sustainability over time.
  • VAP rate is not being consistently recorded across FH.
  • Strategies to promote spread need to be identified and system wide leadership to address current gaps where initiatives are not yet in place; consider option of FH faculty for some initiatives.
  • There is a need to re-visit the ED/Medical Director/Site commitment to these and other SHN initiatives.
  • Sites considering other initiatives: Site Four VAP, Site One CL

Responsibility for report preparation:
This Report is prepared cooperatively by QI/PS and Decision Support. For more information contact:
  • Cathy Weir, Director, Quality Improvement and Patient Safety
  • Barb Saunders, Managing Consultant, Quality and Patient Safety
  • Haleh Vatani, Decision Support
  • Local Quality Improvement and Patient Safety Consultants
/ Reporting Channels and Frequency:
This Report is prepared:
  • Monthly for submission to the Safer Healthcare Now Steering Team, accompanied by run charts for all initiatives, all measures, as needed
  • Monthly for submission to the Quality Council, accompanied by run charts for initiatives to be presented during that meeting
/ Analysis of Run Charts:
Analysis Boxes on the Run Charts are prepared by the local Quality Improvement Consultant supporting the initiative at that site.

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