Hospital Medical Home
Demonstration Project
Winthrop-University Hospital
IPRO Site Visit
11/19/2014
Agenda
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Meet with the residents, QI team
Discuss our successes, challenges/
barriers, solutions, sustainability
Tour the outpatient facility
Meet members of the Hempstead
Pediatric Clinic
Wrap up with Q and A
Winthrop-University Hospital
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591 bed acute care facility
Level 1 Trauma Center, level 1 PICU, level
3 NICU, Regional Perinatal Center
Dental Residency Program
10 Residency Programs
Clinical campus for Stony Brook Medical
School
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Hempstead Pediatric Clinic
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One of the 2 primary continuity site for
Pediatrics Residents
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About 14 to 16 residents per year
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Predominantly serves minority population
• African-American:24%
• Hispanic:67%
• Others: 9%
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Growth over the past year!
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HMH Workplan
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NCQA Certification
Clinical Performance Metrics
Care Transition and Medication
Reconciliation
Resident Continuity Metrics
Inpatient projects
• Sepsis
• CLABSI
6
Successes!
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Office’s goal is to maintain patient safety and
high quality at every patient interaction
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Strong work ethic
Excellent team work
Open lines of communication
Nimble team, adapt to changes as required
Patient Safety is high priority
Defined roles and responsibilities with every
member working at the top of their licensure
capacity
Successes!
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Quarterly Resident Quality Improvement Workshops
• Discuss QI methodology and discuss projects
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Monthly Quality Improvement Meetings
• Data is shared and feedback received on PDSA cycles
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Monthly Staff Meeting
• Team STEPPS, office issues, patient satisfaction etc discussed
as a team
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Daily team huddles
• Discuss high risk patient coming in for visit on the day
HMH Demonstration Project List
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Clinical Performance Metrics
• Appropriate testing for children with
pharyngitis
• HPV vaccine for female adolescents
• Lead screening in children
• Weight assessment and counseling for
nutrition and physical activity
• Well child and preventive care visits in the 3rd,
4th, 5th and 6th year of life
PDSA 1:
Resident
Education
PDSA 2:
Reinforcing
Education with
data
PDSA 1:
Resident
Education
PDSA 2:
Reminder
letter sent to
patient
PDSA 3:
Reinforcing
Education with
data
PDSA 4:
Reminderpho
ne calls
PDSA 1:
Resident
Education
PDSA 2:
Reminder
letter sent to
patient
PDSA 3:
Requested
hospital to start
own
phlebotomy
service
PDSA 4: Started
phlebotomy on
site
PDSA 1:
Resident
Education
PDSA 2:
Implementation
of EMR
PDSA 1:
Reminder
letter sent to
patient
PDSA 2:
Reminder
letter sent to
patient
PDSA 3: Changed
schedule to
accommodate more
visits
PDSA 4:
Follow up
phone calls
Resident Continuity
PDSA 1
Went live with EMR in April 2013
• Residents assigned patients on the EMR based upon the
frequency with which they have seen patients for
regular well visits
• Over a period of a year about 83% of patients have
been assigned to a provider
• A visiting card is given by the residents to remind
patients of their primary provider
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Resident Continuity
PDSA 2
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We have a different IT solution for scheduling and billing
The office manager and registrars manually entered the
primary rendering provider’s name based on the data
from the EMR in order to maintain continuity while
scheduling
The registrars were required to provide a reason on
EMR if appointment was not made with the rendering
provider
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Resident Continuity
PDSA 3
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Teams created based on resident continuity days,
headed by an attending physician
This information was also provided to the registrars
When booking patients if the primary continuity
resident was unavailable the appointment was made
with another team member
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Resident Continuity
PDSA 4
We now plan to manage population proactively
• Start looking at resident’s panel
• Ensure a good mix of age groups, disease conditions and
chronic patient
• Teach residents population management and perform
Personal Improvement Projects using QI methodology
for their OWN patient panel
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Resident Continuity
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Each continuity team took up a clinical
performance metric with the senior
resident as the resident champion
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Collected data, educated fellow residents
on interventions through didactics and
participated in QI presentation
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Data presented at local, regional and
national meetings
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Resident Continuity-Barriers
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ACGME and RRC requirements
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Residents schedule changed often to
accommodate night time coverage, away
rotations etc
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Solution- Ambulatory schedule is available
3 months in advance providing the
registrars with ample appointments to
ensure continuity
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Resident Quality Improvement Projects
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Under the mentorship of an attending physician projects are
led and executed by residents
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This is complemented with systematic training in QI
methodology through series of workshops that provides
hands on training
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All residents in the program are undertaking QI projects
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These projects are presented using a standardized QI
template to the program director and the QI faculty
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Faculty mentorship program to coach faculty that mentors
these residents
Care Transition and Medication
Reconciliation
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Aim: Initiate standardized communication
protocols
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Worked very closely with Clinical
Informatics at the main hospital campus
• Revamped discharge instructions
• CCDA
• Improved identification of PCP
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Care Transition and Medication
Reconciliation
Barriers
• No standardized
communications
protocols
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Continuity of care not
seamless from inpatient
to outpatient site
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Written communication
not available at
transitions of care
Solutions
• Resident led solutions
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Written and or verbal
communication is
provided to the
outpatient site at every
discharge by the
residents
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Follow up appointments
made by residents
before discharge
Readmissions Team
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Winthrop Hospital is a participating site for
National Solutions for Patient Safety
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Readmission team created with a resident
champion
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Targeted ASTHMA as our initial intervention
condition to attempt reducing readmissions due
to asthma exacerbation
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Partnered with the Asthma Coalition of Long
Island at both the inpatient and out patient site
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BREATHE
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Residents provide extensive asthma
education under the supervision of a
pulmonologist during an admission
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Arrange for home care visit, follow up
with PCP and Pulmonologist
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Written Asthma Action Plan at discharge
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BREATHE Winthrop
April-May-June 2013
N = 47
68
70
60
Pre-BREATHE Admits
50
40
30
5
20
Post-BREATHE ReAdmits
10
0
Hospitalizations
Reduction of 93% in
Hospital Re-Admits
BREATHE Winthrop
April-May-June
N = 47
97
100
80
60
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Pre-BREATHE ED Visits
Post-BREATHE Re-Visits
40
20
0
Emergency Department Visits
Reduction of 64% in
Emergency Department
Revisits
Barriers-Population
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Barrier
• Language barrier
• Education and Literacy
of our patient
population
• Transportation issues
with patients often
coming in late for
visits
• Living environment,
other healthcare
needs
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Solutions
• Bilingual staff
• Education materials in
Spanish
• Working with
transportation
companies
• Social worker
(requested)
• Patient navigator
(requested)
Barriers-Structure
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Barriers
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Solutions
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Space- we are growing
at 17% annually and are
outgrowing the existing
space
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Space- Hospital is
actively in discussion to
move the office to a
bigger facility
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Personnel
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Budgeted for more
personnel
• Community Social worker
• Patient Navigator
• More staff to support the
growth
Informatics
Played a huge role during the transformation
process
• Real time data
• Complements daily workflow
• Condition specific templates
• Standardized care transition protocols and
CCDA
• Improved lab and referral tracking
• Enhanced patient safety through Clinical
Decision Supports
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Informatics
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Scope for improvement
• Systems are not interoperable
• Currently registrar are in the midst of
new system that requires them to
check patients in on multiple systems
(looking to create HL7 feeds)
• Lab system not integrated with
outpatient EMR
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Sustainability
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Most changes that were made through the HMH grant were
initiated after a thorough needs assessment, baseline workflow
assessment and with provider buy in
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Since all members of the team were involved in every stage of
the transformation these changes have now been seamlessly
incorporated in our daily workflows
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At monthly QI meetings all interventions are looked at with
real time data and PDSA cycles are rolled out; teams are very
nimble and have adapted to the environment of rapid PDSA
cycles
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Electronic Medical Records have been a very positive change
and now an imperative component of our QI initiatives
Beyond the HMH grant…
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More patient involvement through Patient
Advisory Council
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Incorporate Dental home as part of PCMH
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More stress on Behavioral health
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More community partnerships
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Work with the hospital for further improved
communication using Information Technology
Solutions.
Inpatient Projects
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CLABSI
Sepsis
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HAC Phases for 2014
PIONEER
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ADE
OB-AE
Readmissions
VTE
AVIATOR
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CA-UTI
CLA-BSI
Falls
PU
SSI
VAP
ORBITING
◦ Falls (will be moving into Orbiting soon)
Hospital wide Mortality 2014
50.0%
45.0%
40.0%
35.0%
28.0%
30.0%
25.0%
20.0%
Hospital wide Mortality
2014
22.0%
17.6%
15.0%
10.0%
5.0%
57/261
51/184
38/215
0.0%
1st quarter
2nd quarter
3rd quarter
In Hospital Raw Mortality
40.0%
38.0%
36.0%
34.0%
32.0%
28.32% 28.48%
30.0%
28.0%
26.0%
24.0%
22.0%
20.0%
Expired
Winthrop
State Average
Pediatric Severe Sepsis
Process Measure
Pediatric Severe Sepsis
Adult Severe Sepsis
Adult Severe Sepsis and
Septic Shock Mortality
35
30
25
20
Mortality
Goal
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Statewide
Sepsis
reporting
10
5
0
Baseline
Q2 2013
Q3 2013
Q4 2013
Q1 2014
Q2 2014
Q3 2014
Hospital-wide Com.
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Co-Chairs : Chawla Shalinee
& Lyn Quintos
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ED : Barry Rosenthal
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Quality Specialist: Kristin
Vinson
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Departmental Leads
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Nursing ; PA/NP team
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Housestaff Team
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Sub committee on Education:
Robert D’Antunuo & J. Kutzin
Children’s Medical Center WUH
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Pediatric Team
L. Quintos MD, L. Moldowsky, S.
Zaera
PICU: J. Stambouly, MD
Peds ED: C. Thomas MD ; D.
Sang
ID; L. Krilov, MD
NICU: A. Nash & M. Brassil
Housestaff: A. Connely, J. Chang &
T. Rafii
Education: A. Asuncion & R.
Asselta
Administrative Assistant: A. Bull
WUH Strike Out Sepsis
Multidisciplinary Team
Severe Sepsis – A performance
Improvement Priority for WUH
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Q2 2013 – Multidisciplinary sepsis task force established; Sepsis protocol developed consistent with DOH
regulations, Needs Assessment survey perform to determine baseline knowledge on sepsis recognition and
initial management house-wide.
Q3 2013 – Sepsis Education sub-committee developed hospital-wide sepsis curriculum. Regular Pediatric
Sepsis simulation in the ED and pediatric in-patient floor established. Rapid Response team activation for inpatient severe sepsis/septic shock alerts.
Q4 2013 - Started data sampling for adult in-patient bundle compliance to establish baseline process
measure for improvement. Adult Mortality Outcome measure expanded to include patients presenting
through both ED and in-patient unit.
Q1 2014 – Completed house-wide unit roll-out of Strike Out Sepsis Campaign. Online Sepsis module
launched to complement annual hospital-wide didactic curriculum. Preparation for hospital-wide data
abstraction & reporting in compliance with DOH statewide sepsis mandate. Reporting of in-patient adult
process measure started.
Q2 2014 – Data reporting to NYS DOH started. Modifications in data definition for process measures (time
zero) adopted to be consistent with DOH Sepsis data dictionary. This greatly impacted trends in process
measure. Additional challenge faced with case identification in adult in-pt and extensive resource requirement
for data abstraction
Q3 2014 – Re-design of in-patient screening tool based on feedback from the frontline to improve
identification of patients in the early phase of the severe sepsis continuum. Departmental review of process
and outcome measure started. Recruitment of new housestaff members from IM
Thank you
Questions