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AJMXXX10.1177/1062860613519567American Journal of Medical QualityWhite

American Journal of Medical Quality 2014, Vol 29(2S) 3­S–28S © 2014 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613519567 ajmq.sagepub.com

Pulse: A Report on the UHC Annual Conference 2013 Academic Medical Centers Tap Into Innovative Pulse of Change

Member Comments on the Value of the Conference

Cindy White, RN, MBA1

“Ability to network and learn from people who are in similar roles to mine. Also the keynote speakers gave me a lot to think about, especially in terms of changing health care and individuals/patients.” “Every AMC deals with the same issues—learning about various approaches and priorities and lessons learned is priceless.” “I really like the forward-thinking general sessions; they help us focus on the future and the possibilities. But the breakout sessions are helpful for the here and now to help us move forward with our metrics— sharing strategies. I find both extremely helpful.”

Vice President, Member Relations and Business Development, UHC

The unstoppable pulse of change was found everywhere during the UHC Annual Conference 2013, where more than 1300 UHC members were joined by 170 UHC and Novation staff and nearly 300 business partners to explore new ways to improve patient care and organizational efficiency. Held in Atlanta, Georgia in October 2013, the meeting was a much-anticipated annual event for academic medical center (AMC) leaders and their teams and network partners.

Gaining Fresh Perspectives Plenary speaker and creativity expert Tom Kelley described “vuja de” as the ability to look at a challenge with fresh eyes to create new solutions. This phenomenon was very much in evidence as UHC members learned from each other during 70 rapid-fire presentations and nearly 60 poster demonstrations that unveiled improvements in readmissions, patient experiences, workforce productivity, cost control, and other urgent challenges. Attendees were energized by preconference activities and plenary and rapid-fire sessions that offered information on powerful new solutions with promising results. During conference breaks, receptions, and dinners, participants eagerly engaged in networking with their peers to discuss presentation highlights and share ideas.

Optimizing Innovation Technology pioneer Eric Topol, MD, predicted that biosensors and other digital devices will completely transform the health care landscape, providing more data-driven care to patients beyond the hospital. The next day, attendees viewed some of these innovations during the interactive UHC Start-up Challenge: Innovation Delivered, which was held on October 18, 2013. Five digital entrepreneurs presented their innovative concepts in health care to a live 1

UHC, Chicago, IL

Corresponding Author: Cindy White, RN, MBA, UHC, 155 North Wacker Drive, Chicago, IL 60606. Email: [email protected]

4S audience and a panel of 3 expert judges; they competed for a cash prize and advisory support. Keeping pace with technology and identifying which breakthroughs actually enhance patient care are important challenges faced by AMCs and their network partners. Throughout the conference, UHC staff and business partners were available to demonstrate new comparative databases and other tools to assist members in driving progress while adroitly responding to financial and legislative challenges.

Applauding Peak Performance UHC members enjoy the fruits of shared goals, including performance improvement and supply chain efficiencies. Annual awards are presented to honor exceptional performance in these areas, and members came together to applaud the winners on the evening of October 17, 2013. Amid glittering stars and a violinist who literally soared over the stage, members shared camaraderie and dinner while toasting their colleagues’ success. In spite of facing the rebuilding necessitated by Superstorm Sandy damage, NYU Langone Medical Center prevailed to capture first place in the UHC Quality Leadership Award. Other winners were Emory University Hospital; Emory University Hospital Midtown; Mayo Clinic–Rochester, MN; Rush University Medical Center; Beaumont Hospital, Royal Oak; Fletcher Allen Health Care; The Ohio State University Wexner Medical Center; University of Utah Health Care; and University of Colorado Hospital. UK HealthCare, Thomas Jefferson University Hospital, and Stanford Hospital & Clinics were recognized as UHC Rising Stars. The UHC Supply Chain Performance Excellence Award was won by University of Wisconsin Hospital and Clinics, Fletcher Allen Health Care, Denver Health, University of Mississippi Medical Center, University of Utah Health Care, and Wishard-Eskenazi Health (#1 Public Safety Net hospital). Parkland Health & Hospital System received the UHC Supplier Diversity Leadership Award, and UCSF Medical Center captured the UHC Sustainability Award.

Turning Ideas Into Reality After the conference, attendees continue to share insights through blogs, conversations, and Web-based learning events. UHC members (120 AMCs and almost 300 affiliated hospitals) are keenly aware that they are at a critical juncture in modern health care, where the strongest and most durable solutions will emerge through shared knowledge and collaboration. Their experience at “Pulse” in Atlanta is an important stepping-stone in their performance improvement journey.

American Journal of Medical Quality 29(2S) UHC’s Mission To create knowledge, foster collaboration, and promote innovation to help members succeed.

Transforming Innovation Into Results Julie L. Cerese, RN, MSN Senior Vice President, Performance Improvement, UHC

Jacob J. Groenewold, MBA Senior Vice President, Supply Chain, UHC

Richard P. Lofgren, MD, MPH, FACP President and Chief Executive Officer, UC Health (Former Senior Vice President and Chief Clinical Officer, UHC)

Steven J. Meurer, PhD, MBA, MHS Senior Vice President, Business Development and Product Innovation, UHC

Helping UHC members capitalize on meaningful innovations was a dominant theme at the UHC Annual Conference 2013. Discerning the important distinction between true innovation and mere imitation produces results in quality outcomes and efficiency for academic medical centers (AMCs) and their network partners across the country.

Dimensions of Innovation Physician and plenary speaker Eric Topol’s radical view of technology’s role in health care was overwhelmingly enjoyed but elicited mixed reactions. Some attendees were excited about the breakthroughs on the horizon, whereas others were concerned about stilldeveloping technology’s potentially disruptive impact on care delivery. For example, mobile biosensors have the potential to improve care but may actually hinder timely and accurate diagnosis and treatment if used incorrectly. Many questions still remain. If less care occurs inside the hospital, how can the current brickand-mortar infrastructure be adapted to provide the right care at the right time? When evaluating all technological innovations, health care leaders need to apply disciplined analysis to differentiate the wow factor from real value. Innovation is more than the allure of new technology. Health care leaders are expanding the definition to embrace both human and technical aspects of innovation. During his plenary presentation on creative confidence, Tom Kelley put a human face on innovation when he described how infant warming in resource-poor countries was better accomplished with low-tech warmers than with more-expensive, high-tech incubators.

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White During a UHC Member Board of Directors meeting held in conjunction with the conference, a presentation by Roy Rosin, chief innovation officer of the Penn Medicine Center for Health Care Innovation, highlighted how the patient experience can be enriched through small, high-touch changes. His organization conducted a pilot study in which patients were provided with the mobile phone number of the practice administrator of orthopedics, resulting in an uptick in first-time appointments and a decrease in no-shows. This small-bore tactic did not involve technology, but the creative approach satisfied patients and improved results.

innovation. Many AMC leaders are considering immense budget cuts in the next several years. They must carefully execute these multimillion-dollar reductions, paying attention to the overall impact on care. Here is where innovative ideas that have proven successful can evolve into standardized practices to improve outcomes and efficiency. From redefining workforce roles to questioning the value of new devices, leaders are redesigning their organizations to deliver better care while improving economic viability.

Fresh Ideas on Display

As patient care increasingly migrates to ambulatory settings, leaders must reevaluate the optimal use of their facilities and create teams to manage seamless transitions from one setting to the next. Maximizing capacity and maintaining the right staff mix are cost-efficient, yet demand significant changes in AMC practices from the past. Accessible ambulatory care—a critical link to quality and cost-effectiveness across the entire clinical enterprise—is receiving more attention than ever as AMCs aim to match services with patient demand. An emphasis on “systemness” was more evident at the 2013 UHC conference than in years past. Making strategic decisions that aid not only flagship AMCs but also affiliated hospitals and other system entities was on the minds of many attendees. “Innovation distinguishes between a leader and a follower,” said legendary entrepreneur and Apple cofounder Steve Jobs. The UHC conference provides AMC leaders with a unique forum in which to air divergent views, share advice, and create refreshing and innovative solutions that work for their particular institutions. Bringing members together in a collegial, noncompetitive atmosphere encourages frank discussion and ideation, reminiscent of the “culture of creative confidence” espoused by plenary speaker Tom Kelley.

At a March 2013 UHC Governing Board meeting, featured speaker Peter H. Diamandis, MD, chairman and chief executive officer of the XPRIZE Foundation, noted that innovation is a state of mind wherein linear thinking is transformed into exponential results through the power of crowd collaboration. Health care has an unprecedented opportunity to absorb and benefit from technologies making the news, such as cloud computing and artificial intelligence. Diamandis urged the use of incentive competition and crowd ideation to expand discovery and drive gamechanging product development. As a champion of meaningful innovation, UHC applied Diamandis’ concepts and sponsored a live competition among finalists selected after a national vetting process conducted by innovation accelerator AVIA. During the event, 5 early-stage companies presented their unique product concepts and competed for a grand prize. In a stimulating 60-minute session, members previewed emerging technologies and began conversations about how these prototypes may apply to their patient care challenges. Some AMCs have appointed chief innovation officers to scout and take advantage of breakthroughs. Others are realigning roles to ensure that they are making the best use of early-stage concepts within their organizations. To help members gauge the impact of new technologies on costs, patient care, physician relationships, and reimbursement, UHC provides data and other tools for conducting meaningful technology assessments.

Translation of Innovation Into Efficiency Facing inescapable cost pressures, AMCs are challenged to look at short-term costs and long-term investments with fresh eyes. No longer can new technology be embraced to merely boost revenue or market share; now, technology must meet specific criteria to reach improvement and efficiency targets. Physician preferences and “first in the market” positioning for technologies such as robotic surgery have to be reevaluated. Although they grab headlines and deliver some benefits, are they truly delivering better patient outcomes at a reduced cost? Efficiency—producing high-quality outcomes consistently and cost-effectively—is and should be the goal of

Intense Focus on Continuity and Systems

Radically Transforming Health Care Through Technology Eric Topol, MD Chief Academic Officer of Scripps Health, with a background in cardiology, genomics, and technology

Health care is at a historic crossroads, with wireless technologies and genomics pulling physicians and patients into a new type of partnership, according to Eric Topol, MD, a leading researcher in individualized medicine. Drawing on his experience as a technologist and cardiologist, Topol urged AMC leaders to take advantage of the digital revolution to improve care inside and beyond the hospital.

Unleashing the Power of Technology Topol called citizens of the world “digital immigrants” who have experienced seismic change in less than a

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decade. Gone are the behemoths of mainframe computing, replaced by mobile phones and social networking that connect people on an unprecedented scale. Topol recalled the crucial role of social networking during the Arab Spring protests, when demonstrators shared breaking news and raw emotions to communicate that “people of power were losing out to the power of the people.” Yet he maintained that health care is stuck in an outmoded “control/alt/delete” model, adopting a mass view of medicine rather than pursuing data-enriched customized care. Claiming that there is no such thing as an average patient, Topol rejected mass screenings that deliver false positives when human beings can be digitized to yield very precise, individualized data for improved diagnosis and treatment. Although acknowledging the importance of security, the author of The Creative Destruction of Medicine argued that true democratization of medicine is within reach and called for health care leaders to adopt digital tools.

lives. Molecular-based diagnoses are becoming increasingly successful, with insurance covering much of the cost. DNA-sequencing technologies provide useful insights into cancer mutations and spot chromosomal abnormalities in fetuses without using invasive amniocentesis. Sharing genomic data is leading to a more informed public. When Angelina Jolie discussed her decision to have a preventive double mastectomy to reduce the risk of developing breast cancer, she ignited the “Angelina effect” and a public discussion of genetic testing. Topol also described how 900 patients are participating in a DNA-sharing project at Oregon Health & Science University to provide information on the sequencing of tumor cells as part of a publicly available database. He predicted that this unprecedented data exchange may lead to a new era of massively open online medicine.

Shaking Up Medical Care With Mobile Monitoring

Topol warned health care leaders about the dangers of resisting change and remaining ossified in a 1960s model of mass medicine. Easy-to-use technology fuels consumers’ desire for more information as they clamor for “nothing about me without me” involvement in their health decisions. He predicted that the patient room in 2020 will simply be a blank room as care is pushed farther from the hospital setting. Capturing data with mobile devices empowers patients and reduces the need for costly office visits and laboratory testing. Topol shared the example of an online clinic that showed an average savings of $88 per episode over traditional in-office care, with its patients embracing the new model and being willing to recommend it to others. Topol’s forecasted digital revolution promises to make treatment better and more accurate without hospitalization while aiding compliance and ensuring that the right medications are used, based on individualized patient data. Technology can actually free physicians and patients from the constraints of traditional care and turn their relationship into a true health partnership.

The advent of wearable sensors is an exciting phenomenon in which blood pressure, glucose levels, and other vital signs can be tracked and reported beyond the hospital’s walls. This technology places patients and their health data on center stage, allowing them to stay in touch with their physicians while avoiding complications and hospital stays. Topol asked, “Who wants to pay $3000 for an uncomfortable night in a sleep lab when the same physiologic data can be monitored from home?” Smartphones now have biosensor capabilities that turn them into “soul-mate devices that know your body.” In addition to monitoring, patients use smartphones to take photos of their pills or wounds to share with their physicians during assessments. Topol demonstrated how a smartphone can be used in physicals when he converted his phone to an otoscope on The Colbert Report to check the comedian’s eardrum, which was perforated after a diving trip. Wristbands that detect seizures, necklaces that predict strokes, and “ICU on your wrist” watches that monitor electrocardiograms, blood pressure, and oxygen saturation are now available or in development to advance medical care beyond the hospital. Topol no longer uses a traditional stethoscope because new-generation stethophones provide more robust data. Some medical students now receive these mini ultrasound devices on their first day of training, representing a new generation adeptly using digital tools.

Understanding the Promise of Genomics The sequencing of the human genome has opened new horizons in testing and treatment. Costs have plummeted for mapping DNA and developing family-based genomic diagnoses, leading to individualized therapies that save

Rebooting How Physicians Practice

Unlocking Creativity Through Empathy and Risk Taking Tom Kelley General manager of IDEO and seasoned innovation practitioner

Creativity expert Tom Kelley provided illuminating examples of how to unlock creativity using empathy, experimentation, and vivid storytelling.

Understanding Creativity as a Business Imperative Creativity has come of age as a business asset, moving from “the kids’ table to the real work done at the board

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White table,” according to Kelley, general manager at innovation consultancy IDEO. Citing an international survey, he reported that 80% of the respondents claimed that creativity is critical to economic growth, yet only a quarter believed that they were living up to their creative potential. This gap needs to be filled by building creative confidence, defined by Kelley as “the ability to come up with breakthrough ideas and the courage to act on those ideas.” Creative confidence will only be realized if individuals feel free to take risks and explore unconventional paths. Kelley and his brother David, founder of the innovative d.school (Institute of Design at Stanford University), conducted 100 interviews and discovered a “flipping process” that goes on when individuals achieve a heightened level of creative confidence. They glow with energy and become more resilient in the face of obstacles, which are behaviors sought by leading companies.

Using Fresh Eyes to Drive New Solutions Kelley advocated the use of empathy to envision new ways to solve a challenge. He cited an example in which students were challenged to create an infant incubator for use in developing countries. Rather than create solutions in isolation, the students flew to Nepal to understand the people’s needs on the ground. The greatest issue was maintaining body temperature, especially for fragile premature and low-birth-weight infants. The fieldwork led to a radically changed assignment: A low-cost infant warmer, rather than a high-tech incubator, fulfilled the need. The fieldwork was extended to India, where mothers had their own belief system about warming babies. The mothers resisted the idea of using an LCD temperature indicator to heat the device to 37°C, but they felt better about warming if an “OK” signal was given. The warmer was delivered at a hundredth of the cost of a traditional incubator and is now used in 10 countries to warm infants and potentially save lives. Borrowing techniques from other industries was urged by Kelley. A Formula One pit crew that can change a tire in 8 s was invited to London’s Great Ormond Street Hospital to share ideas on coordinated actions with the intensive care unit team. The hospital staff reduced technical errors by 42% and information errors by 49% by adapting ideas from the elegant, ballet-like movements learned from the Formula One crew.

Embracing the Anthropologist’s Tool Kit Kelley encouraged using anthropology principles to supplement one’s own experience: look, ask, try, and learn. He spoke of an elderly patient in Germany who claimed to have no trouble opening pill bottles. However, when asked to show how she took her medication, she invited the interviewer into her kitchen, where she proceeded to use part of a meat slicer to open the bottle. This

inconvenient and potentially dangerous situation would never have come to light in a distance interview, but the “show us” approach highlighted her daily difficulties. Kelley warned against relying on data that are not substantiated with direct observation. He referred to this process as “vuja de” (rather than déjà vu) because eyes are opened and participants can ask the all-important “why” questions.

Transforming a Scary Experience Into Fun Doug Dietz of GE Healthcare was confident about the performance of his company’s pediatric magnetic resonance imaging scanners until he realized that he was missing the voice of the customers: kids. Although technicians praised the innovative technology, pediatric patients were terrified of the large unit and often had to be anesthetized to undergo scans. Horrified at this situation, Dietz redesigned the scan experience from a child’s perspective, tapping into the perspectives of kids, parents, and a children’s museum. The GE Adventure Series emerged as a result, transforming the scan into a pirate ship, safari, or other kid-friendly experience complete with scripts and stickers. One young patient was so thrilled with the scan that he wanted to return the next day to repeat it.

Finding Safe Ways to Experiment Acknowledging that health care providers cannot take risks that jeopardize patient care, Kelley still insisted that individuals must be free to develop prototypes and even fail to ultimately arrive at winning solutions. Thomas Edison called his numerous experiments “a thousand ways that did not work.” Kelley encouraged the audience to “squint at but don’t kill” half-baked ideas. He recounted how staffers built “the ugliest prototype in the history of IDEO” in 5 minutes to demonstrate a concept that evolved into a sinus surgical tool. If people are ridiculed, they will shut down and stop offering ideas. If the bar is lowered and people can safely express suggestions, learning will increase and more ideas will be produced. A big believer in checklists, Kelley encouraged health care leaders to involve patients in ideation for better care.

Using the Power of Storytelling Stories can enliven ideas that may be blurred by data. Kelley advocated the use of stories that are simple, unexpected, credible, and emotional and that use concrete details. He described workers in rural India trying to convey the basics of the germ theory of disease to local women to make drinking water safer. Instead of challenging traditional beliefs, the team used singing and dancing to convey ideas and then slowly introduced microscopes to show villagers when water is safe for their children. Through empathy and safe experimentation, health care leaders can build a durable culture of creative

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Unique Competition Showcases Innovative Health Care Solutions Cindy White, RN, MBA Vice President, Member Relations and Business Development, UHC

As an innovation champion, UHC put leading-edge technology on display at the premiere of the UHC Start-up Challenge: Innovation Delivered, a live competition in which 5 entrepreneurs battled for the judges’ vote and a $10 000 grand prize. HealthLoop’s automated patient followup platform captured top honors at the fast-paced, interactive session moderated by Tom Main, partner at Oliver Wyman.

Vetted Contestants From Across the Digital Landscape The 5 contestants were selected by innovation accelerator AVIA after a rigorous screening of hundreds of emerging pioneers across the country. The finalists represented the latest thinking in powerful analytics, efficiency, and patient engagement. HealthLoop (healthloop.com) features an automated platform that performs postdischarge e-mail check-ins with patients, asks questions, delivers reminders, and detects problems. Claiming that 1 in 7 surgical cases has complications, founder Jordan Schlain, MD, and chief executive officer Todd Johnson demonstrated how risks can be reduced by connecting to patients at home. Evidence-based guidelines are incorporated into the follow-up protocol, and frequent communication generates rich patient data to help guide care. Early users report that 82% of patients are opting in to the system, resulting in an 87% reduction in unnecessary calls to the health care provider while maintaining high patient involvement and satisfaction. The Center for Applied Value Analysis (CAVA; cavalue.com) offers value-based analytics to help providers strengthen margins while improving care. Comparative clinical and financial metrics can be analyzed for pharmaceuticals, medical devices, and other technology. Chief executive officer Josh Feldstein and senior medical director Allan Korn, MD, provided actual data examples for evaluating the returns on robotic surgery and comparing the costs of 4 antithrombotic drugs to demonstrate CAVA’s focus on “How you use what you buy, not what you buy.” Kit Check (kitcheck.com) combines radiofrequency identification technology and cloud computing to make pharmacy kit inventory more efficient. Chief executive officer Kevin MacDonald demonstrated how an organization can reduce labor-intensive manual checks, eliminate expired products, and potentially save millions of dollars by scanning kits for fast, accurate restocking. VGBio (vgbio.com) focuses on monitoring patients’ vital signs at home to avoid acute events and hospitalizations. Echoing comments from technologist Eric Topol, MD, in

American Journal of Medical Quality 29(2S) his plenary presentation, chief executive officer Gary Conkright advocated for “proactive medicine” and showed how smartphones can be used to monitor chronic disease symptoms and detect early warning signs. Sensors can track heart rate, respiration, pulse, and activity levels to monitor health status and prompt check-in calls from the care team. In a video interview, Martin Burke, DO, University of Chicago Medicine, praised the proactive system and said it delivered $100 000 in savings to the hospital. Tonic Health (tonicforhealth.com) reenvisions the medical data collection process by using friendly graphics and game-like features to engage patients in the waiting room. Chief executive officer Sterling Lanier demonstrated how Tonic’s tablet platform replaces dreary paperwork with an intuitive, entertaining way to capture data and hold patients’ attention. Health care providers also have used Tonic to conduct surveys on patient satisfaction, risk factors, and other topics.

A Picture of the Future in Minutes In his plenary presentation, innovation expert Tom Kelley extolled the power of vivid, crisp storytelling as a way to unlock creativity. The 5 contestants used compelling storytelling techniques, with video vignettes, entertaining anecdotes, and hard data, to explain the benefits of their digital breakthroughs. Each company had 10 minutes to present its core idea and value proposition and then answer pointed questions from the 3-judge panel. The judges and audience heard evidence of how each product was designed to improve the patient experience, deliver better care, increase efficiency, and reduce costs.

On-the-Spot Judging After each presentation, the company representative was questioned by the 3 judges, who evaluated each idea through a different lens: Kavita Patel, MD, fellow and managing director of delivery system reform and clinical transformation at the Engelberg Center for Health Care Reform at the Brookings Institution; Glen Tullman, former chief executive officer at Allscripts; and Steve Lieber, president and chief executive officer of Healthcare Information and Management Systems Society (HIMSS) Worldwide. The judges’ questions often focused on how the innovations could migrate from hospitals to other settings and interface with larger electronic medical record platforms. At the competition’s conclusion, the more than 1500 conference attendees in the audience were invited to submit their votes via smartphones. They also were encouraged to e-mail ideas to the presenters about their products as well as their sales messages. As the winner, HealthLoop received $10 000, advisory support from UHC and AVIA for 1 year and a speaking opportunity at the Venture+ Forum at the 2014 HIMSS Annual Conference. The other competitors received plaques honoring their participation as well as valuable exposure to the AMC leaders in attendance.

Congratulations. UHC is pleased to recognize these leading academic medical centers for their accomplishments in leadership and performance excellence.

NYU Langone Medical Center Emory University Hospital Emory University Hospital Midtown Mayo Clinic – Rochester, MN Rush University Medical Center

University of Wisconsin Hospital and Clinics

Beaumont Hospital, Royal Oak

Fletcher Allen Health Care

Fletcher Allen Health Care

Denver Health

The Ohio State University Wexner Medical Center

University of Mississippi Medical Center

University of Utah Health Care University of Colorado Hospital

University of Utah Health Care Wishard-Eskenazi Health (#1 Public Safety Net hospital)

Parkland Health & Hospital System

UK HealthCare Thomas Jefferson University Hospital Stanford Hospital & Clinics

UCSF Medical Center 155 North Wacker Drive Chicago, Illinois 60606

312 775 4100 uhc.edu

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Rapid-Fire Session Abstracts 2013 Smart Anesthesia Monitor: A Real-Time RulesBased Decision Support Tool for Anesthesia and Surgical Care Bala Nair, PhD, and Gene Peterson, MD, PhD, MHA University of Washington Medical Center

Background. Anesthesia Information Management Systems, like most other electronic medical records, are designed largely as record-keeping systems, limiting their potential to improve patient care. Intervention detail. We designed and implemented a rules-based decision support module called the Smart Anesthesia Manager (SAM) to address our patient care concerns and business problems. Over the course of 5 years, we have progressively introduced a number of decision rules to improve patient safety, quality of care, waste reduction, and regulatory compliance in the anesthesia care continuum. We have been successful in changing and sustaining anesthesia provider behavior with this point-of-care solution. Specifically, real-time detection and notification of selected issues have improved patient monitoring, core measure compliance (antibiotic administration and β-blocker protocol), and billing and regulatory compliance as well as reduced wastage of anesthetic agents. Our current focus is on improving perioperative glucose management. Results. Real-time notification with SAM was able to reduce extended gaps in blood pressure monitoring from 15.7 ± 4.5 to 6.7 ± 2.0 instances per 1000 cases (P < .05). Provider response to comply with accepted methods to manage intraoperative hypotension and hypertension increased by 22% (P < .05) and 15% (P = .02), respectively. With regard to core measure performance, SAM notifications improved first-dose antibiotic compliance from 88.5% to 99.3% (P < .05), whereas the antibiotic redose compliance increased from 62.5% to 95.2% (P < .05). β-Blocker Surgical Care Improvement Project measure compliance improved to 100% from 60.5% (P < .05). With SAM, capture of missed documentation of invasive line procedures resulted in an additional revenue capture of $140 000 per year. Real-time messages led to real-time correction of incomplete or wrong documentation in the anesthesia record, leading to an additional 1200 compliant anesthesia records per year. This led to a reduced need for back-end amendments to the records, which in turn resulted in decreased accounts receivable. SAM messages to reduce excessive fresh gas flows resulted in a 28% reduction in sevoflurane, a 33% reduction in desflurane, and a 12% reduction in isoflurane consumption. This translated to an annual savings of $104 000. Current work on real-time reminders for glucose management has

American Journal of Medical Quality 29(2S) improved compliance with hospital-based perioperative glucose management protocols by 2-fold.

Reengineering Patient Flow at a Busy Academic Emergency Department Joshua Kosowsky, MD, FACEP Brigham and Women’s Hospital

Background. Like emergency departments (EDs) in many academic medical centers, our ED was plagued by long wait times and low patient satisfaction. We had considered adding space to reduce overcrowding, but there was no appetite for continuing dysfunctional processes on a larger scale. Instead, we set out to reengineer patient flow entirely. Intervention detail. We adopted a LEAN approach, breaking down each element of our care process from the perspective of the patient and emerging with a new model and a new vocabulary. Beginning at arrival, rapid “check-in” replaced full registration, deferring the latter to the bedside. Routine triage gave way to a “rapid assessment,” and patient care areas were retooled to accommodate “any patient in any bed.” Care teams were charged with staying “a bed ahead,” allowing patients to travel “direct to bed” during most hours of the day. We created a “flow manager” position to oversee throughput and troubleshoot potential bottlenecks. In the end, we were able repurpose waiting-room space into patient care space, thereby achieving a modest increase in our clinical footprint. Results. Before the process redesign, wait times to see a provider in our ED averaged 70 minutes, our walkout rate was more than 3%, and patient satisfaction in the ED ranked as low as the 6th percentile among like-sized academic medical centers. Over a 2-year period (October 2010 to September 2012), median door-to-provider time declined by 80%, the walkout rate fell by more than 50%, and patient satisfaction climbed to the 99th percentile.

Emergency Department Community Placement Project (EDCPP): ED Recidivism Reduction Project Karen Elizabeth Mitchell, RN, MSN, CMCN, Christian Tomaszewski, MD, MBA, and Catherina Madani, RN, MSN, PhD(c) UC San Diego Health System

Background. San Diego has the third largest homeless population in the United States, second only to New York and Los Angeles. Homeless patients account for nearly one third of emergency department (ED) visits, resulting in longer ED wait times and avoidable inpatient

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White admissions. Many of these patients are nonfunded or underinsured, contributing to rising unreimbursed health care costs. EDs are ill equipped to meet the psychosocial needs of homeless community members and do not have the capacity to assist them with housing, substance abuse treatment, and mental health care. Intervention detail. The EDCPP is designed to bridge the highest ED users into community-based homelessness prevention services, substance abuse treatment, and intensive case management. The goal for this project is to identify the neediest and costliest patients and provide resources to address their substance abuse, homelessness, and mental health issues and to reduce recidivism among this population by 20%. A cohort of 215 patients is electronically preidentified in EPIC electronic medical records. Inclusion criteria are homelessness with frequent ED visits (2 or more visits per month over the past 12 months) and associated complaints of co-occurring disorders, substance abuse, and alcohol-related illness. On patient presentation, the Best Practice Advisory flag is initiated and acknowledged. Afterward the ED physician/psychiatrist places a Community Placement Order. Patient consenting, screening, and placement (to community partners) are done by ED staff. Results. There was a cost-benefit savings of $168 231, based on program expenses (contractual bed cost) of $38 234 (6 months) = 4.4 (return on investment); 78% reduction in ED visits among EDCPP-placed patient cohort; and 3.8% increase in Press-Ganey patient satisfaction scores.

Actively Managing Care Transitions: A Post–Acute Care Model to Optimize Quality and Cost Bernard Boulanger, MD, MBA University of Kentucky Hospital

Colleen Swartz, DNP, MSN, MBA, RN, NEA-BC University of Kentucky HealthCare

Background. At UK HealthCare, we currently have approximately 11 000 opportunity days for patients discharged with external agency transition, including home health, skilled nursing facility (SNF), long-term acute care hospital (LTACH), and inpatient rehabilitation facility (IRF). There is a 55% opportunity within the inpatient rehabilitation discharges. A model to quantify and describe a post–acute care framework was presented for prioritizing working relationships and building clinical consensus to allow smooth transitions of care from acute care settings to post–acute care destinations. Intervention detail. Data were presented to quantify opportunity days in each post-acute category (eg, home with home health,

LTACH, IRF, SNF) and the translation to average daily census for current state and then 5- and 10-year forecast, given population growth and forecasted growth in certain Medicare severity diagnosis-related groups. Informal discussions also have occurred to reduce opportunity days with facilities and, thus, lead to more formalized partnerships. Results. UK HealthCare continues to develop a model to understand opportunities for post–acute care framework and the impacts on cost, quality, and service. This model could allow others to conduct similar analyses and provide a foundation for discussion of potential partnerships and/or systems alignments to improve care transitions for patients.

Implementation of a Patient Blood Management Program in an Academic Medical Center Aldijana Avdic´, BSN, RN, PB, MS, Rhonda Evans, BSN, RN, OCN, and Richard LeBlond, MD, MACP University of Iowa Hospitals and Clinics

Background. Blood transfusion rates are on the rise, yet the efficacy in hemodynamically stable patients has not been demonstrated, and many life-threatening complications are underrecognized. In response to the latest scientific evidence, our institution implemented a patient blood management program with the aim of improving safety and effectiveness of the blood transfusion and utilization process. Intervention detail. Through multidisciplinary collaboration, our 4 key working groups address best practices, appropriate utilization, and patient safety and guide fundamental process improvement activities. The chief quality officer and the blood management coordinator play active roles to ensure that the progress is consistent and deliberate. Work groups made substantial progress on short-term changes and long-term plans. The Order Set team successfully created an order set in Epic with evidencebased indications, which are audited by the Transfusion Committee. The Awareness and Education team developed a communication plan to drive awareness among staff and the community in addition to providing competency, ongoing training opportunities, and protocols for management of transfusion-related adverse events. The Anemia Management team screens and manages anemia in the presurgical patient population. A bestpractice alert fires when a predefined low result is identified, which initiates a workup. Diagnosing and treating anemia creates an opportunity to optimize our patients prior to surgeries with significant blood loss. Finally, the Iatrogenic Blood Loss team has implemented

12S strategies to reduce phlebotomy-induced anemia, including use of minimal volume tubes, reducing the number of draws and the amount of blood that is wasted with each draw. Results. Several measures have been used to evaluate the blood management project. The overall blood utilization rate has decreased by nearly 30% between January 2011 and June 2013. The total number of cases with blood product use per discharge decreased from 14.4% to 11.5%. One of our goals has been to reduce the 2-unit to 1-unit transfusion orders. Currently, 76% of the transfusion orders are single-unit orders, compared with 12% before we implemented the program, reducing our 2-unit orders to an average of 20% to 30% per month. We also are measuring the average number of red blood cell (RBC) units per hospitalized patient discharge, which has decreased from 0.53 to 0.34. Our average number of lab draws per day decreased from 3.92 to 2.90 in intensive care units, and the percentage of patients with more than 2 draws for consecutive days decreased from 58% to 27%. The transfusion guidelines criteria are now consistent with the best practices. As part of Epic, 100% of indications are currently documented, whereas before the blood management program, only 37% of RBC orders had documented indications. Based on the recently published data on complication rates, our blood management program has potentially decreased annual adverse events: avoided 281 complications (4%), reduced length of stay by 10 540 patient days (1.5 days per unit), reduced nursing time related to transfusions by 15 458 hours, and saved 47 lives (0.9%). Our total estimated savings through June 2013 are more than $12 million for purchase costs, transfusion costs, and adverse event cost savings.

Cost and Value Positioning at Yale-New Haven Health System Thomas Balcezak, MD, MPH, FACHE, and Richard D’Aquila, MPH, FACHE Yale-New Haven Hospital

Background. Academic health systems are increasingly focused on controlling costs while improving patient safety and clinical quality. Yale-New Haven Health System (YNHHS) implemented a Cost and Value Positioning Initiative in 2011 that uses comprehensive data analytics and benchmarking to link cost and quality and improve efficiency in clinical redesign, labor, nonlabor, and human resource focus areas. Intervention detail. Cost and Value Positioning aims to reduce YNHHS’s base budget by more than $125 million per year and sustain these savings over the next 5 years. The project grew out of YNHHS’s analysis of its current cost structure as

American Journal of Medical Quality 29(2S) well as an evaluation of coming changes in reimbursement levels and methodologies. YNHHS aims to achieve approximately half of its targeted savings through maximizing labor efficiencies, optimizing nonlabor products and pricing, and human resource and benefit redesign. The other half of the system’s cost savings stem from an innovative approach to clinical redesign that systematically identifies variation in practice across the health system and compares quality outcomes and financial performance with internal and external benchmarks. A centralized governance structure with direct participation from executive leadership guides the efforts of all 4 Cost and Value Positioning focus areas. Each area has its own steering committee and network of subcommittees. Clinical redesign is led by senior physician leaders from all the system’s organizations and features a close partnership with analytics and decision support to identify areas of variation and track how its projects improve the quality and efficiency of care delivery. The Cost and Value Positioning Initiative relies predominantly on internal resources and is positioned to become a perpetual element of YNHHS’s operations. Results. Cost and Value Positioning has achieved more than $75 million in savings to date (November 2013). Clinical redesign has launched 3 system-wide projects that focus on blood utilization management, proper use of intensive care unit versus non–intensive care unit care, and palliative care. More than 30 delivery network–specific projects are in progress and address clinical care across departments and services. Notable redesign successes include improved care management protocols for patients with hip fracture and sickle cell disease.

Safety in Numbers: PSN Analysis Across 8 Inpatient Surgical Units Drives Change in Medication System Amy Alexander, DNP, RN, ACNS-BC, Nicole Bennett, MS, RN, CNRN, Elizabeth Laessig-Stary, MS, RN, and Jessica Weber, MS, RN, ACNS-BS, CCTN University of Wisconsin Hospital and Clinics

Background. Medication-related events were the leading Patient Safety Net (PSN) reports submitted in 2011 and 2012 for the inpatient surgical division in a Midwestern academic medical center. Medication administration is critical to safe patient care, and nursing plays an important role in this process. Intervention detail. The objective of this quality improvement project was to increase safety associated with the process of medication administration utilizing the PSN system to identify areas to focus improvement efforts. Four clinical nurse specialists

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White (CNSs) in the inpatient surgical division collaboratively reviewed each medication-related PSN event over a 2-year period. Events were first split into 2 groups: nursing practice surrounding medication administration or nonnursing/system-related. Examples of nonnursing/system-related issues included delays in medication delivery, errors in medication reconciliation, and events associated with provider ordering at admission or discharge. Each PSN report was further analyzed and events were placed into categories to track decreases in specific medication errors and develop solutions. Recurrent issues were bundled, and the CNS group shared these with appropriate committees and multidisciplinary team members to substantiate the need for systems changes. Examples of changes that occurred included creation of best-practice alerts in the electronic medical record during ordering and verification of certain medication and changes to the timing of “note orders” for nurses in the medication record. The CNS group also provided formal and informal education to nursing staff regarding medication errors based on the analysis of the PSN. Results. Although we did see a decrease in medication-related events, we acknowledge the limitation of this outcome being dependent on individuals filing reports. As the project evolved, the focus of the group transitioned from analyzing categories with the highest number of errors to completing mini root cause analyses for each PSN report. Collaboration within the surgical CNS group identified trends that were not appreciated on an individual unit-basis level. As clinical experts in our surgical areas, we are able to formulate innovative solutions that previously were not considered through the traditional review of the PSN.

Bundled Payment as a Driver for Change: Redesigning Care and Aligning Incentives Across the Continuum Richard Donoghue, MS, CPA, CHFP, Sarah Munson, MPH, and Mary Enquist, MPH NYU Langone Medical Center

Background. NYU Langone Medical Center (NYULMC) is participating in Medicare’s Bundled Payment for Care Improvement initiative for cardiac valves (Medicare severity diagnosis-related group [MS-DRG] 216-221), joint replacements (MS-DRG 469-470), and spinal fusions (MS-DRG 459-460). Early results suggest that care delivery redesign focused on physician-led care protocols and care coordination interventions can reduce Medicare costs and improve quality. Intervention detail. NYULMC’s Clinically Integrated Network, the NYUPN,

was established in 2011 and provides the framework for testing care redesign strategies by aligning the hospitals and physicians to better manage care for patients across the continuum. Physicians lead care standardization and redesign initiatives, using Medicare claims data to identify the cost drivers in the episode of care, which includes the hospital stay and 90 days post discharge. The physicians work closely with a team of registered nurse (RN) clinical care coordinators (CCCs) established to guide patients through the episode of care. The RN CCCs work with patients prior to admission to prepare for surgery and establish the appropriate level of post–acute care. Clinical pathways were developed collaboratively with strategic post–acute care providers in the New York City metropolitan area with the goals of standardizing and streamlining care across the episode. The clinical pathways are integrated into the medical center’s enterprisewide electronic medical record, and the NYULMC Health Information Exchange allows the RN CCCs to electronically connect with post–acute care providers. Results. Preliminary estimates of the first quarter of (Q1) 2013 cost savings compared with baseline are approximately 10%. Discharges to facility-based post–acute care, 90-day readmissions, and hospital length of stay decreased during Q1 2013 compared with a 3-year baseline period. Discharges to facility-based post–acute care for cardiac valve, joint replacement, and spine fusion patients were 23%, 46%, and 32% in Q1 2013 compared with 73%, 71%, and 43%, respectively, at baseline. The 90-day readmission rates were 29%, 14%, and 12% in Q1 2013 compared with 39%, 14%, and 18%, respectively, at baseline, and hospital lengths of stay in Q1 2013 were 9.10, 3.48, and 4.51 days compared with 10.02, 4.81, and 5.22 days, respectively, at baseline.

A New Creative Organization of Advanced Practice Providers (APPs): A Solution for Academic Institutions to Meet Future Health Care Demands Bart Sachs, MD, MBA, CPE, FACPE, FACHE, Christopher Rees, MHA, MBA, and Patrick Cawley, MD, MHM, FACHE Medical University of South Carolina (MUSC)

Background. University medical centers face a need to organize consistent management of APPs, which include advanced practice registered nurses and physician assistants. The situation is exacerbated because of complex billing regulations and standards required by regulatory agencies, inconsistent reimbursement defined for various licensed providers, different state professional licensing definitions for scope of work, difficulty quantifying

14S service outcomes, and increased Accreditation Council for Graduate Medical Education house staff work hours restrictions. Intervention detail. MUSC created an organizational plan to improve contracts, salary payments, standard work activities, oversight reporting responsibilities, and educational and training standards for APPs and establish a standard metric evaluation of individual and group work performance. The key to the new organized approach was agreement on a master service contract created among the 3 separate parts of the Medical University. Overall contracts do not specify individual providers; instead, they specify the type of clinical services to be provided. Therefore, the contracts negotiate for clinical positions rather than for specific people. Responsibility for individual provider performance and revenue production is shifted to the purchasing group (academic department or physician). The internal agent (clinical department) purchases services at a fair market value through a scope of work agreement with the employerprovider agent. Each purchaser department must create a “scope of work” contract that specifies the clinical work activity performed by an APP full-time employee. Results. We developed a financial formula to calculate projected average revenue per APP: TPR = [(AR) × (ADSE)] + [(AIP) × (AR)], where ADSE = (NP + FU) patients, TPR is total APP revenue for all clinical services, AR is the average revenue per patient encounter, ADSE is the arrived number of outpatient encounters, AIP is the arrived number of inpatient encounters, NP is new patients, and FU is follow-up patients. Based on calculations, with an APP encountering at least 4 new patients and 4 follow-up patients per day, the total expense burden for APP is covered. Additional clinical patient invoiced service work provided beyond these 8 patients accrues directly to the contribution margin. Historically, no service invoices have been generated for these individual providers. Our enterprise has benefited from improved patient access, better programs for maintaining disease managed care, and significant enhanced revenue. With 20 patients seen per day by each current APP, revenues increase to ~$12 million per year. A review of performance metrics shows that our new arrangement has met each initial strategic project goal.

Naming Conventions for Trauma Activation: Unidentified and Mass-Casualty Incident Patients Teresa Lienhop, MSN, MBA, RN, FACHE

American Journal of Medical Quality 29(2S) care. Although the original intent was for use in the trauma patient, it was extended to mass-casualty and unidentified patients who were recognized initially with a single identifier. Intervention detail. Following an adverse event involving dual identifiers, a temporary naming convention using the military alphabet was devised as an electronic preregistered process for trauma, unidentified, or mass-casualty patients. The military alphabet provided a logical basis and provided expansion capability using traditional alphabet lettering. All patient documentation utilizes the temporary name and medical record number (MRN) as the dual identifier for 24 hours to complete emergent diagnostic and surgical interventions while reinforcing the safe delivery of patient care. The corporate policy was drafted and the merge/notification process was developed with a specified time constraint for conversion to the valid patient name. The “go live” date was established to allow for corporate training and trial of the process in a scheduled emergency management event. This project provides substantiation for a standardized electronic process for preassignment of an MRN to a temporary name to improve the acute patient care process. Results. Preimplementation, an MRN was not immediately available to process with laboratory specimens, and activation time varied dependent on patient presentation. With 28% of the trauma center’s patients self-presenting, delays were related to patient identification verification. Postimplementation, 100% of patients had a preassigned MRN on arrival, with an average electronic activation time of 1 minute accounting for patients arriving without prenotification. The laboratory had almost instant usability of the MRN accompanying the specimen rather than waiting for patient identity verification for specimen analysis or blood bank testing. The time from specimen arrival to first order placed decreased from 5 minutes pre implementation to 2.2 minutes, and the first lab result for a type A activation decreased from 16 to 7.1 minutes post implementation. The process evaluation regarding the merge to a verified identity merited changes that allowed exceptions for physician request, patient transfer, discharge, or death to allow for continuity of care.

Mobile Pharmacy: Prescription Bedside Delivery Valerie Garber, PharmD, James Gray, PharmD, MBA, Robert Portwood, MHA, and Amy Rackers, RPh Barnes-Jewish Hospital

Truman Medical Centers Lakewood

Background. This organizational change was a coordinated approach to ensure appropriate identity verification using dual identifiers for the safe delivery of emergent

Background. Filling prescriptions after a hospital stay can be a challenge. In fact, < 50% of patients from BarnesJewish Hospital in St Louis, Missouri, were getting their medications filled after discharge. This fact inspired the

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White deployment of Mobile Pharmacy, a program that delivers discharge prescriptions to inpatients at the bedside as the final step of the discharge process. Intervention detail. The goal of Mobile Pharmacy is to have as many patients as possible go home with their medications. Every patient is asked if they would like to use Mobile Pharmacy by case management staff at admission. Participating patients then have their discharge prescriptions faxed to the Mobile Pharmacy by nursing staff just prior to discharge. Within 60 minutes, technicians deliver the completed order to the patient’s room, collect co-payments, pick up the original prescriptions, and offer pharmacist consultation. Pharmacists are available by phone or in person to answer any questions the patients have about their new prescriptions. Results. Mobile Pharmacy eliminates the numerous barriers patients face when attempting to obtain prescription services following discharge. Patients no longer have to find a pharmacy and wait for their medications to be filled. Prescription edits and insurance issues are taken care of while the patient receives treatment, so there is no delay once the patients leave the hospital. For those patients who cannot afford their medications, case managers are readily available to assist the uninsured with medication vouchers. By removing these barriers, prescription access has improved, along with patient satisfaction and compliance. The hospital believes that Mobile Pharmacy, along with other initiatives, also is helping decrease readmissions. Since the launch of the program on August 13, 2012, Mobile Pharmacy has served more than 16 000 patients and filled more than 74 000 prescriptions. This represents 35% of the patients who have been discharged to home from this facility. In the past 8 weeks, the capture rate has averaged 44%. As the program continues to become part of this hospital’s culture and standard work, it continues to surpass original operational predictions. The Mobile Pharmacy program fully embodies Barnes-Jewish Hospital’s vision to be national leaders in medicine and the patient experience.

Automating and Streamlining the Labor Management Plan to Strengthen the Clinical Enterprise Rita Barry, RN, BSN, and James Fenush Jr, RN, MS Penn State Hershey Medical Center

Background. Cost pressures, quality mandates, increased competition, and an ever-changing landscape have left many nurse executives feeling cornered, with few foreseeable options but to cut expenses for short-term stability. It is important to take a proactive approach to this challenging environment, leveraging labor resources with

a cost-effective, repeatable process that increases quality, staff satisfaction, and patient satisfaction. Intervention detail. A series of strategic and operational tactics were designed to guide the development of a strategic labor plan and the creation of standardized workflows associated with staffing adequacy for a department of nursing. The chief nursing officer, human resources, nurse leaders, and direct care nurses partnered with the nursing financial liaison to lead the development of a strategic labor plan that included the standardization of workflows, policies, and practices across an organization. A comprehensive nursing workforce analysis and workflow assessment served to guide the revision of a plan, with the aim of ensuring adequate core staffing coverage augmented by the right size of contingency resources to adjust to fluctuating levels of patient volume and acuity. The analysis guided a refinement of internal processes, implementation of a state-of-the-art technology solution, best-practice work strategies, and a cultural transformation that reaffirms the mission of the organization and its commitment to deliver exceptional patient- and familycentered care. Results. Process and quantitative measures of success include the following: reduction in overtime as a percentage of productivity, reduction of average pay period incidental worked time costs, demonstrable leader adoption rate of staffing and scheduling technology, registered nurse/patient care assistant (RN/PCA) fill rate, RN/PCA full-time employee leakage, and a reduction in the time spent on scheduling and staffing by leadership/ scheduling teams. Ensuring a comprehensive, crossdepartmental labor management initiative combining best practices and technology with a cultural renaissance is an effective and necessary endeavor in today’s tumultuous health care environment.

Achieving a Quality “BHAG”: Mobilizing an Academic Medical Center to Achieve Greatness on the Quality and Accountability Scorecard William Bornstein, MD, PhD Emory Healthcare

Background. In 2005, UHC rolled out the first iteration of a new annual composite quality scorecard for academic hospitals: the UHC Quality & Accountability Scorecard (Q&A Scorecard). In 2006, Emory Healthcare (EHC) set the goal for its 2 eligible hospitals, Emory University Hospital (EUH) and Emory University Hospital Midtown (EUHM), to be in the top 10% of participating hospitals by 2012, even though at the time, EUH ranked 71st and EUHM 59th out of 81 hospitals. Intervention detail. In 2005, UHC undertook a study of the cultural characteristics of top- compared with average-performing hospitals

16S in the Q&A Scorecard and identified that top performers shared 5 factors: a shared sense of purpose, leadership style, an accountability system, a focus on results, and a culture of collaboration. EHC used these characteristics as a foundation for an internal assessment and redesign of its quality initiatives. Beginning in 2006 and aligned with the goal of achieving top-decile performance in the Q&A Scorecard by 2012, EHC formed its Office of Quality, appointed operating unit–based chief quality and chief medical officers under the oversight of the system-level chief quality and medical officer, and began a series of initiatives, which included the formation of the EHC Quality Academy (with mandatory attendance for leaders) and increased focus on credibility and visibility of metrics with incorporation in all incentive plans, development and ingraining of a cultural framework (the EHC Care Transformation Model), and formation of the innovative Quality Acceleration Team (chaired by the EHC chief executive officer). Results. Average performance of academic hospitals in the Q&A Scorecard measures has improved significantly since the inception of the scorecard in 2005. Performance of the Emory hospitals has improved more rapidly, with EUH and EUHM ranking, respectively, 10th and 11th in 2011, 6th and 10th in 2012, and 2nd and 3rd in 2013, out of 101 hospitals. EHC is the first and only system to have had 2 hospitals simultaneously in the top 10 in this scorecard.

From the Boardroom to the Bedside: Preventing Hospital-Acquired Pressure Ulcers Christine Walden, MSN, RN, NE-BC, and W. Brian Floyd, RN, MBA Vidant Health (Vidant Medical Center)

Background. Reducing hospital-acquired pressures ulcers (HAPUs) in an academic medical center requires a comprehensive, focused, and intentional approach. Challenged with an increased prevalence of HAPUs, lack of standardized processes, potential for decreased reimbursement, and board mandate of zero events of harm, Vidant Medical Center implemented a Pressure Ulcer Prevention Program utilizing change management techniques, clinical protocols, and statistical analysis to demonstrate statistically significant HAPU reduction. Intervention detail. Vidant Medical Center, a 909-bed academic medical center, embarked on a targeted journey toward HAPU reduction. Initially, the program used traditional improvement methods, addressing the causative factors of turning, moisture management, appropriate bed surface, and nutritional screening and included implementation of a revised bed management process, nutritional resources and protocols, and Lift Team implementation on 6 patient care units. These methods yielded

American Journal of Medical Quality 29(2S) marginal improvements. From October 2011 to August 2013, the organization underwent incremental change and transformed from traditional approaches to utilizing statistical analysis, Lean methodology, and change management principles to drive HAPU reduction. Improvements were made in the measurement process with centralized HAPU verification and separation of device- versus non–device-related HAPUs. Frontline staff, patients, and families were engaged in reduction efforts. Policies and procedures were revised to incorporate best practices, with systematic tracking of associated cost savings secondary to standardization. A robust education platform was developed, including the optimization of the electronic health record. Outcomes were analyzed using Pareto and control charts, and process controls, such as bedside process mapping with patients, families, and members of an interdisciplinary team, were used to ensure compliance and sustained change. Results. Use of a patient safety portal provided continuous surveillance and centrally collected and verified results. Between October 2011 and August 2013, the HAPU prevalence rate decreased from 3.9% to 2.2%, a 43.6% reduction. Device-related HAPUs decreased by 26.8%, from 2.0 to 1.5 per 1000 patient-days. Endotracheal tube–related HAPUs decreased from 1 HAPU every 12.5 days to 1 every 31.9 days. Skin bundle compliance rates increased from 83.5% to 94.9%. Lean methods resulted in modification of 8 device-related policies and procedures, yielding a cost savings of $803 000 related to products and supplies.

Improving Transparency of Our Medication Errors by Telling Stories Jennifer Ketchum, RN, and Patrick Sayer Monroe, PharmD, RPh The University of Texas MD Anderson Cancer Center

Background. Results from a 2011 survey on safety showed that we needed to be more transparent with our errors among all practitioners who could make a similar error. Intervention detail. Our primary objective was to create a process to develop a video series that highlights the system failures and the interventions of medication events that can be shown to all clinical operations throughout the institution. A secondary objective was to increase our reporting culture by showing these videos. Our methods consist of a multidisciplinary team that identifies medication events for video consideration from our medication event database. The identified events must originate at prescribing or ordering and continue through our medication management processes until they reach the patient or result in a “near miss” before administration. A process has been developed to produce the videos and distribute

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White them through the facility for viewing. This process began in October 2012, and a new video is produced each month. We recently have expanded this project to include other event types. Results. Since this project began, we have created 13 videos that have been shown throughout our institution. Our reporting trend rate for medication errors has shown a steady increase since 2012.

Training Transformation: Preparing a Workforce for a Move to a New Health Care Facility Sally Black, RN, MSN, MBA, OCN, NEABC, Emily Lowder, PhD, RN, NE-BC, and Katherine Pakieser-Reed, PhD, RN University of Chicago Medicine

Background. As many university medical centers build new hospital facilities and prepare to move their workforce into these facilities, a systematic approach to training and patient care simulation is critical to ensure success and efficiency. We designed and implemented such a program to prepare our clinical and procedural staff for the expansion of our medical center into a new adult hospital facility in February 2013. Intervention detail. Beginning 6 months prior to the move-in date, lists of new safety measures and pieces of equipment and technology were compiled to address all necessary aspects of training. Learning paths were created for 173 individual roles within the organization. Each piece of training was built by vendors, educators, and internal clinical experts, and 5 ways to deliver the education were implemented (station, class, online, mock room, or tour). Employees were trained in a 2-phase approach, with basic new equipment and safety measures trained during phase 1 and department-specific training occurring in phase 2. Following the completion of both phases, “Day in the Life” simulation scenarios allowed staff to test the systems and workflows in real time. Issues that arose from these simulations were systematically logged, prioritized, and addressed prior to the move. Staff members began daily rehearsals of patient transfers 2 weeks before the move to ensure safe and effective transitions in care. Results. More than 200 educators, vendors, and internal clinical experts assisted in designing the training program, which resulted in the education of 2300 clinical and procedural staff. The training program was completed under budget for training hours; reduction of hours without loss of content occurred as the program continued and was refined (eg, originally budgeted at 20 hours per RN but actually delivered in < 16 total hours). The more than 1500 issues that arose during training were answered by clinical leadership and communicated to employees. On

move-in day, 157 patients were safely transferred to the new hospital facility, and feedback regarding the move was uniformly positive. Sharing and disseminating information about the development and implementation of our successful training program may be valuable to other organizations facing similar challenges.

Bridging the Gap at a Vulnerable Time: Primary Care Connector Nursing Susan Day, MD, MPH, Anne Norris, MD, Jean Romano, MSN, RN, NE-BC, and Maryam Behta, PharmD University of Pennsylvania Health System

Background. The new Centers for Medicare & Medicaid Services readmission reduction program under the Affordable Care Act has imposed large financial penalties on hospitals for 30-day readmission rates above the national average. Because of the vulnerability of patients after discharge from acute care, experts recommend primary care follow-up within 7 to 10 days after discharge. Intervention detail. To assist patients with complex care decisions after discharge, Penn Medicine has partnered with 12 patient care medical homes (PCMHs) to implement a primary care connector nurse (PCCN) program. The program supports safe patient transitions by systematically bridging care between the hospital and the PCMHs. Patients admitted to a Penn Medicine hospital belonging to a PCMH are risk stratified into 3 categories: High risk for readmission (has disease of interest—acute myocardial infarction/heart failure/pneumonia/chronic obstructive pulmonary disease—and would benefit), potential risk for readmission (qualify but waiting for patient to be stable or confirmed with the diagnosis of interest [eg, rule out pneumonia]), or intermediate risk for readmission (does not have disease of interest but is at high risk and would benefit). Patients are triaged on their risk level utilizing a calculation based on UHC patientlevel risk evaluation values (eg, severity of illness, risk of mortality, and case mix index) and an assessment of patient barriers to self-management. PCCNs intervene directly with patients in the hospital to provide diseasespecific education. They also assess discharge readiness and collaborate with the patient and the inpatient team to establish postdischarge care plans prior to discharge. PCCNs communicate the care plan and immediate transition needs to the outpatient care team with the goal of preventing readmission. PCCNs also conduct a postdischarge phone call to the patient and formally hand the patient off to the PCMH team. Results. From November 2012 to August 2013, a total of 8284 patients were screened, and 3017 (36.4%) were identified as candidates for care navigation. Of these, the PCCNs were able to enroll 788 (26.1%) patients into the program. The 7-day

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American Journal of Medical Quality 29(2S)

readmission rate declined (7% to an average of 4.5%), and the 30-day unplanned readmission rate is trending downward (14.9% to an average of 14.5%). The 75% scheduled follow-up appointments for enrolled patients is 8% greater than for nonenrolled patients.

A Clinical and Financial Analysis of Reduced Incidence of Acute Hospital-Associated (HA) Deep-Vein Thrombosis and Pulmonary Embolism (DVT/PE) at Thomas Jefferson University Hospital

Evaluating the Impact of Pharmacy Interactions and Direct Patient Care Services on Satisfaction Scores

Kamini Patel, RN, MSN, MBA, Dustin Ottemiller, MBA, Matthew Vibbert, MD, and Geno Merli, MD

Kara Roelse, PharmD, and Michael Verbosky, PharmD Tampa General Hospital

Background. Hospitals are developing and implementing initiatives to increase patient satisfaction with their health care. Pharmacists have the potential to improve patient satisfaction as it relates to understanding new medications, identifying potential side effects, and assisting in the hospital discharge process by expanding direct patient care services. Intervention detail. Expanded pharmacy direct services included an admission patient interview, medication reconciliation, a 24-hour pharmacy phone line, discharge counseling, and promotion of the on-site outpatient pharmacy. This initiative was over a 3-month time frame (December 2012-February 2013). The primary objective of this prospective quality improvement project was to evaluate the impact of pharmacist direct patient care services on patient satisfaction scores, outpatient pharmacy use, and revenue. Patient satisfaction scores were evaluated by the Hospital Consumer Assessment of Healthcare Providers and Systems Survey questions in the medication, pain management, and care transitions domains. Secondary objectives included identification of resources required for service expansion and assessment of the pharmacy interventions identified during medication reconciliation. Outcome measures included the differences in survey scores between patients with pharmacy interaction and without, outpatient pharmacy revenue and utilization, medication reconciliation errors, and service workflow resources. Results. Of the 430 patients admitted to the pilot unit, the pharmacist saw 43% (n = 186) of patients at admission and 16% (n = 67) at discharge. The survey return rate was 19% (64/342). Patients with pharmacist interaction had higher scores in the medication (80.1% vs 50%) and care transitions domain (70.6% vs 48.5%) compared with those without. Outpatient pharmacy use increased (46% vs 33%) as well as projected revenue ($45 504 vs $6070). Of the 165 patients assessed for medication errors, 41% (67/165) had at least 1 error. The most common errors identified were missing medications (n = 31, 46%), incorrect doses (n = 15, 22%), and patient medication misunderstanding (n = 12, 18%). Admission and discharge counseling time averaged 19 and 7 minutes, respectively.

Thomas Jefferson University Hospital (TJUH)

Background. HA DVT/PE is a major preventable, underdiagnosed, costly, and serious health complication. About 350 000 to 600 000 incidences occur yearly in the United States, accounting for about 100 000 deaths. In stroke patients, the prevalence rate of DVT is 20% to 50%, and PE is the third most common cause of death. In 2011, TJUH had a high rate of DVT/PE among neuroscience patients. Intervention detail. To address the problem of HA DVT/PEs at TJUH, we examined our evidence-based practices and piloted a multimodal prophylaxis approach in the neuroscience units. This multimodal approach aimed to improve effective delivery of mechanical (staff and patient education, intermittent pneumatic compression [IPC] auditing/compliance, IPC devices in all rooms), pharmacological (modified orders, ultrasound screening, risk stratification, and medications), ambulation prophylaxis (distance markers, modified orders, and nursing flow sheets), and other miscellaneous changes (improved documentation/forms, smarter ultrasound screening). Using administrative data for all patients discharged alive during 2011-2012, 2 multiple linear regressions were used to predict the length of stay (LOS) and direct cost resulting from a DVT or PE diagnosis. Acute DVT/PE multiple linear regressions were conducted independently. The variables used include direct cost of patient stay, LOS, count of ICD-9 diagnosis codes and procedure codes, and count of ICD-9 DVT or PE codes and its respective complications. Results. Over the course of our intervention, TJUH Neuroscience HA DVT/PE rates improved from 4.17% (January 2011) to 1.58% (December 2012). Additionally, the overall hospital rate for Patient Safety Indicator 12 reduced to 9 per 1000 by December 2012 from 22 per 1000 two years prior. The regression model demonstrated an additional 5.97 days (P < .001) and $6173 in direct cost (P < .001) for each DVT and related complication diagnosis and an extra 2.73 days (P < .001) and $7145 in direct cost (P < .001) for each PE and related complication diagnosis. Extrapolating the results, the estimated reductions of HA DVT/PE was 87 cases annually, equating to $1.3 million in direct costs. HA conditions, such as DVT/PE, represent opportunities for improvement to slow declining margins while enhancing quality of care. By providing preventive measures and improved treatment of high-risk

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White patients, hospitals can have a positive impact on the economic burden as well as improved outcomes for these diseases.

Acquisition of a New Hospital Into a Magnet Organization: A Strategic Nursing Plan for Cultural and Clinical Integration Sue Fitzsimons, PhD, RN, CENP Yale-New Haven Hospital

Background. Acquisition of hospitals represents a complex phenomenon affecting clinical and cultural aspects of employees and the organization. In 2012, a 1008-bed Magnet medical center acquired a 511-bed Catholic hospital. A new vision, strategic plan, influential leaders, and engaged nursing staff were required to successfully lead cultural and clinical integration within a complex integrated system. Intervention detail. Prior to the acquisition, the chief nursing officer and senior nursing leaders used their influence to make the Magnet model transparent across the organization. This model set the stage for the creation of a framework that aligned the hospital’s 4 strategic business plan dimensions with nursing’s strategic plan priorities (hardwire common purpose, optimize structured operational processes, expand effectiveness as a highly reliable organization, and maximize cost/value positioning). To operationalize these priorities, 9 objectives and 50 outcome measures were identified. Within each of these objectives, 35 key nursing initiatives were identified and linked to a set of actions aimed at achieving/surpassing outcome targets. For example, a nursing priority, to hardwire a common purpose, involves 3 objectives with several key initiatives (committee alignment; standardization of education, research, and practice model; Magnet redesignation; collaborative governance redesign; data management integration). The Office of Data Management was created to integrate numerous database systems used within the parent hospital to collect and monitor the majority of the 50 structure, process, and patient (nursing-sensitive) measures included in the nursing strategic plan. The electronic reports with their respective measures included nursing staff demographics, caregiver hours per patient day, nurse sensitive and Magnet Recognition Program metrics, ambulatory metrics, patient satisfaction/Hospital Consumer Assessment of Healthcare Providers and Services, and employee satisfaction/engagement survey results. Results. We have found that our strategic nursing plan is critical to building commitment to our new organization’s purpose, vision, and values. Early results include the following: •• Successful implementation of Epic electronic medical record

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Practice standardization Patient identification barcoding Standardization of meeting agendas Shared governance redesign Service line integration Nurse manager non–value-added work decrease Integrated nursing database

Transfusion-Free Joint Replacement: A Successful Transfusion Reduction Program Leigh Hubbard, BSN, RN, Darcy Abbott, RN, MS, CEN, Gary Ferguson, MD, and John Froehlich, MD, MBA The Miriam Hospital

Background. Transfusion after elective surgery comes with risks of infection and reaction; cost of collection, storage, and administration of blood; and a fear by patients of receiving blood. Recent literature supports the safe reduction of transfusion, especially in elective surgical patients. Because of the risks, costs, and fears associated with blood transfusions, our 247-bed teaching hospital initiated a Transfusion Reduction Project within the elective primary total joint replacement population. This reduction occurred in phases, and action items were considered after literature review and discussion of the impact any change in practice would have across the patient care spectrum. Intervention detail. Phase 1 involved abandoning preoperative autologous blood collection. The increased cost and peer-reviewed evidence discouraging predonation was discussed with the surgeons and eventually led to 100% buy-in. Phase 2 involved a shift from transfusing based solely on hemoglobin level to transfusion after thoughtful evaluation of hemoglobin, symptoms of anemia, and past medical history. This approach to transfusion was combined with decreasing the postoperative transfusion trigger from a hemoglobin level of 9 to < 8. Phase 3 involved the introduction of intraoperative tranexamic acid (TXA) administration. Surgeons discussed studies of TXA and agreed on a standard route of administration; operating room nurses were educated; and pharmacy supported its use. Over the course of 2 months, all surgeons began to consistently use intraoperative TXA. Results. Within 1 year, the rate of transfusion for elective primary joint replacement dropped from 20% to 5%, and this rate has been maintained. This has led to an estimated savings of more than $152 000, greater efficiency for inpatient nursing care, and decreased risks for patients. Endorsement by leadership and acceptance by surgeons was critical to maintain best practices and sustain the gains achieved. Real-time data sharing was critical to maintaining staff and surgeon interest as each phase of the project was implemented. The project development, implementation, and factors of sustainability will be

20S communicated, along with lessons learned and thoughts for future transfusion reduction. This project illustrates the importance of collaboration, decreased variability, and use of real-time data to successfully implement changes that are impactful and sustainable.

It’s OK to Be Different: Using Harris CareFx and the UHC Clinical Data Base/ Resource ManagerTM to Improve Physician Documentation Mary Kay Brooks, RN, MSN, CPHQ University of Iowa Hospitals and Clinics

Background. Physician documentation is critical to quality patient care, hospital reimbursement, and accurate risk adjustment. Actionable information from Harris Carefx and UHC Clinical Data Base (CDB) was used to help our physicians adopt best practices to improve their documentation in a way that accurately reflects the condition of our patients. Intervention detail. Harris Carefx and UHC CDB data were utilized to identify and improve physician documentation housewide in an academic medical center over a 12-month period. Overall and population-specific metrics were provided to physicians and senior leadership on a monthly basis. These tools provided the necessary data to clearly identify documentation opportunities and provide evidence to our physicians to embrace our current diagnosis-related group (DRG) assurance efforts. Our physicians found the specialized Harris Carefx data by service or Medicare severity DRG (MS-DRG) to be extremely helpful in strengthening the communication between themselves and staff from hospital coding, DRG assurance, and quality office. High-volume or high-opportunity populations were targeted first, and clinical champions were utilized to drive improvement in each area. Customized approaches for data sharing, education, and ongoing performance monitoring were imperative to roll out this project housewide. Results. Specific clinical departments, MS-DRGs, and individual physicians have sustained greater than 5% to 20% improvement on the following metrics: case mix index, expected length of stay, expected mortality, admit severity of illness, admit risk of mortality, and hospital reimbursement.

Continuous Observation Process Reduced Fall Rates and Sitter Utilization Joan Miller, MSN, RN Indiana University Health

Background. Specialized caregivers (sitters) are thought to alleviate the demands on nurses’ time by providing

American Journal of Medical Quality 29(2S) constant companionship to patients. There is no evidence to support that sitters improve nursing efficiency or patient outcomes. Sitter expenses averaged $760 325 per year at one hospital, which was a 74.5% increase from previous years, with a 2.8% fall rate. Intervention detail. The hospital partnered with a school of nursing to match course requirements with organizational need. A group of Doctor of Nursing Practice students and direct care nurses used Lean Six Sigma principles to develop a systematic approach to maximize practice while reducing sitter expenses. The team synthesized data, observed current process, conducted focused interviews, and critiqued evidence. The process was redesigned to transition from a physician-driven order around sitters to an evidencebased model of continuous observation. Care conferences were integrated throughout the process to identify etiologies based on the patient’s behavior and alternative interventions. The team created daily job responsibilities that clearly defined work requirements when sitters were used. Results. Post implementation, there was a statistically significant reduction in sitter expenses from $32 586 per pay period to $18 813 (P = .000), with a subsequent significant reduction in fall rates from 2.8% to 1.9% (P = .001). Nursing practice has moved from obtaining nonlicensed resources to alleviate the perceived demands on nurses’ time to maximizing nursing practice around vigilance and attainment of patient needs. Organizational efficiency and patient outcomes are improved when academic course projects are aligned with hospital problems to drive learning strategies and innovative care delivery.

Supercharging the Sourcing Process With eSourcing Tools Osvaldo Torres, BS, and Eric Tritch, MBA, BS University of Chicago Medicine (UCM)

Background. Most health care provider organizations typically solicit and receive bid proposals via a combination of e-mail and hard copy documents traded between the provider and the potential suppliers. Using best practices from other industries, UCM’s strategic sourcing team developed a plan to implement eSourcing into the health care environment to improve both the process and the results. Intervention detail. UCM has implemented an eSourcing tool as a key part of its strategic sourcing process to sustain an efficient and standard online sourcing process that drives the correct work early in the process, significantly reduces the cycle time to complete a request for proposal (RFP)/request for quote, and manages the information to allow for future contract rebids without starting from scratch. The team had experience in various

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White industries (manufacturing, retail, aerospace, energy, and consulting) that proved that eSourcing tools drive a better process and planned to put that into action in the health care setting. The team reviewed the various tool options and selected EC Sourcing’s FlexRFP tool to implement. They were operational in a few months and had run 12 projects through the tool within the first calendar year. Results. UCM has seen significant savings ($9.5 million in calendar year 2012) and reduced cycle time on the sourcing process (average 6 months down to 30 days). This is a repeatable process that allows for efficient knowledge transfer and learning from one project to the next and a process that pleases both internal and external stakeholders with transparency, efficiency, and favorable results.

Development of a Multidisciplinary Case Review Committee to Reduce Readmissions, Mortality, and Sepsis by Standardizing Care and Limiting Clinical Variations Deborah Winograd, RN, Ben Bengs, MD, Devon Jeffcoat, MD, and Jeffrey Eckardt, MD UCLA Health System

Background. Readmission, mortality, and sepsis are significant adverse outcomes that harm patients and greatly increase health care costs. Evaluation of these events to determine cause and to establish methods for prevention is needed. Intervention detail. The UCLA Department of Orthopaedic Surgery spans 2 hospitals. UHC data show that Ronald Reagan UCLA and Santa Monica UCLA had readmission rates of 9.1% and 6.6%, respectively, within the UHC orthopedic surgery service line over a 2-year period (Q1 2010-Q4 2011), for an average of 7.8%. Historical mortality and sepsis data showed a combined rate of 0.95% within the UHC orthopedic surgery service line over the same 2-year period. A multidisciplinary committee was formed to evaluate the causes of these readmissions, mortality, and sepsis cases in July 2012 with the goal of reducing these events. The readmission rate in the first quarter of the study (JulySeptember 2012) was 8.6%. By facilitating multidisciplinary, nonpunitive case review, the team was able to accurately determine the major causes of readmission, mortality, and sepsis and standardize care to target these causes. By limiting clinical variations, readmission rates decreased to 4.4% in the following quarter (OctoberDecember 2012), with a last-month readmission rate of 3.9%. Mortality and sepsis were cut in half (1.4% in the first quarter, reduced to 0.7% in the following quarter). Results. This study assessed the effectiveness of a multidisciplinary team’s review of readmission, mortality, and sepsis to determine the causes of these adverse

outcomes and to standardize care to decrease these events. Early results were not expected; however, the team was able to quickly and effectively motivate physicians, nurses, and ancillary support staff to work together as a team to eliminate clinical variations, which led to significant reductions in these events. The team also determined that nonpunitive case review and multidisciplinary discussions and care planning improved morale and willingness to disclose complications. As the team continues to meet, there has been overwhelming interest by physicians, staff, and hospital leadership to observe the process and join the committee. The UCLA Department of Orthopaedic Surgery feels strongly that initial successes have laid a foundation for sustained improvement and further implementation of standardized care models.

Amplifying Excellence Through Care Delivery Redesign Jill Payne, MSN, RN, CNML IU Health Methodist Hospital

Background. With increased demands to improve patient outcomes and reduce care expenditures, hospitals will be challenged to evaluate care delivery models. The future of health care lies in an organization’s ability to differentiate to stay ahead of the expanding commoditization curve. With choice comes the organizational obligation to continuously redefine expectations and set a new standard for excellence. Intervention detail. An intraprofessional team used principles of innovation to disrupt the traditional care delivery model to design a new model based on the Institute of Medicine’s Six Aims. The new model consists of boundary expander nurses managing patient care needs at the patient’s access point, an intraprofessional team directing care for a group of patients, and a quality/safety strategist to ensure that evidencebased care requirements are effectively and efficiently deployed. Redefining work allowed a trajectory for professional practice to be aligned with professional development and career growth opportunities. Job-to-be-done theory was used to enhance the environment around workflow efficiency and optimize patient self-care management. Results. Through initial design, a pilot has demonstrated strong outcomes, including a 70% reduction in patient falls, 85% reduction in hospital-acquired infections, and productivity targets below the benchmarked 40th percentile. Further prototype testing will be integrated into care design through full deployment. By designing a system based on what patients truly want from health care, professional excellence is amplified and providers are better positioned to meet the foreseeable demands of health care.

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A $5.44 Million Cost Avoidance in Reduction of Hospital-Acquired Pressure Ulcers (HAC PUs) Through Comprehensive IMPROVE Phillip Botham, BSN, RN, ET, CWON, Patrick Cawley, MD, MHM, FACHE, Christopher Rees, MHSA, MBA, Bart Sachs, MD, MBA, CPE, FACPE, FACHE (designee), and Danielle Scheurer, MD Medical University of South Carolina

Background. PUs are a major cause of morbidity for hospitalized patients and are a financial burden for health care systems. Intervention detail. The objective of this project was to reduce the incidence and prevalence of HAC PUs at a large academic tertiary care medical center. The methods utilized included (1) improving documentation and coding of all ulcers, including presenton-admission designation; (2) improving prevention efforts (early identification of risk; use of visual cues for at-risk patients on the wristband, chart, and door; and initiation of aggressive prevention strategies for risk patients); (3) widespread adoption of the SKIN bundle (surface, keep moving, incontinence management, nutrition); (4) widespread education by unit-based subject matter experts (eg, “SKIN team” members) via a trainthe-trainer model; (5) improving treatment for early-stage ulcers with standardized order sets; and (6) improving accountability of unit teams by having them present all stage II to IV ulcers to senior leadership. Results. The prevalence of hospital-acquired stage II to IV PUs was reduced from 16% (quarter 1 2012) to 3.3% (quarter 4 2012), for an estimated cost savings of $5.4 million for calendar year 2012.

Utilizing Visual Tools to Engage Patients to Facilitate Customized Pain Medication Management Kapil Anand, MD, DDS Cedars-Sinai Health System

Peachy Hain, RN, MSN, and Neema Haria, MHSA Cedars-Sinai Medical Center

American Journal of Medical Quality 29(2S) pain management with the Patient Engagement Board, incorporating patients in their care plan. By graphing the patient’s pain and listing medications corresponding to different thresholds for pain directly onto the Patient Engagement Board, the entire patient care team is able to set reasonable expectations for pain management with the patient. In addition, Cedars-Sinai modified the WongBaker Facial Grimace Scale by including behavioral anchors that can allow for more precise identification of the patient’s pain and functionality. These visual tools are introduced to the patient in the surgeon’s offices prior to the patient’s surgery. The 2 primary metrics for success are focused on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions targeting pain management: “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” (Q1) and “During this hospital stay, how often was your pain well controlled?” (Q2). Although important, HCAHPS scores may not paint the full picture of pain management. Currently, Cedars-Sinai is exploring more effective metrics, such as Pain Scores, which can be extracted from the electronic medical record. Results. By using this approach, Cedars-Sinai was able to increase HCAHPS scores on the pilot nursing units from 77% to 82% for Q1 2013 and from 62% to 67% for Q2 2013, both of which are above the 70th percentile of UHC hospitals. This approach was the result of a successful collaboration between anesthesiologists, surgeons, nurses, and pharmacists. This collaboration created a centralized communication tool for the entire care team to address pain management issues with patients and family members. With the integration of the Pain Graph into the Patient Care Board, Cedars-Sinai Health System has seen significant improvements in its management of patient pain, as evidenced by patient satisfaction scores among its surgical patient population.

Leveraging the Relationship Between Days Wait for an Appointment and Outpatient Satisfaction Scores to Improve Retention Rates, Reimbursement, and Reporting Metrics Eric D. Hixson, PhD, MBA, Andrew Proctor, MS, and Steven Spalding, MD The Cleveland Clinic Foundation

Background. Postoperative pain management is one of the most complex challenges of a patient’s hospital stay. Inappropriate management of a patient’s pain medication profile often leads to increased length of stay, uncontrolled postdischarge pain, and poor patient satisfaction. Intervention detail. Cedars-Sinai Health System utilizes an innovative approach to engage patients in their own

Background. With increasing responsibility for containment of health care costs and intense competition between systems for health care dollars, patients are more selective in their search for care. Access to care may have a significant impact on a patient’s satisfaction with the health care experience and the likelihood that they will

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White return to the system for care. Intervention detail. A stratified random sample of new and established ambulatory visits between June 2010 and December 2012 received a standardized satisfaction survey. Of those surveyed, 177 114 responses were returned, representing experience with 19 service lines; the relationship between calendar days wait and top box satisfaction with ability to get an appointment when wanted was assessed. Results. New patients waited significantly fewer days than established patients (17.1 vs 26.1; P < .05) but had nonsignificant differences in satisfaction (4.4 vs 4.39). Using nonlinear regression, new visits were observed to have a significant, negative linear relationship with longer days wait, whereas established patients had a bowl-shaped relationship, with the satisfaction nadir occurring at approximately 60 days wait. Significant differences were noted among the functional forms of medical and surgical specialties. Patients are more willing to wait for subspecialists than primary care, and same-day appointments are more likely weekday and result in higher satisfaction. Patients older than 60 years were less dissatisfied with longer days wait. No significant differences were noted between men and women. Parents seeking care from pediatric subspecialists were less satisfied with longer days wait. Organizations that endeavor to understand patient needs regarding appointment scheduling and that implement processes to address these areas will develop a significant competitive advantage and be better prepared for changes in quality reporting and reimbursement. Strategies must account for the notable differences across service lines and not rely on across-the-board tactics to be successful.

Enhancing Quality and Safety in Insulin Therapy: A Multidisciplinary Approach to Create and Validate Continuous Infusion Insulin Protocols Komal A. Pandya, PharmD, BCPS, Rachelle Firestone, PharmD, BCPS, Patricia Parker, PharmD, BCPS, and Jeremiah Duby, PharmD, BCPS UC Davis Medical Center

evaluated the following CIIT protocols in a baseline assessment phase: intensive care unit (ICU) hyperglycemia management, ward hyperglycemia management, and diabetic ketoacidosis/hyperosmolar hyperglycemic state (DKA/HHS). Findings of this phase were used to justify the creation of new CIIT protocols. Each protocol was then evaluated in a pre-post new protocol implementation study design. Development of new protocols involved comprehensively changing the management of hyperglycemia, empowering the bedside nurse, simplifying calculations for insulin infusion rate titration to individual dose-response, and creating wide safety thresholds and mechanisms. End points examined included the following: incidence of hypoglycemia (BG < 70 mg/dL), severe hypoglycemia (BG < 40 mg/dL), ICU length of stay (LOS), hospital LOS, duration of mechanical ventilation, and glycemic variability. Results. ICU hyperglycemia: The newly implemented insulin protocol was found to dramatically reduce rates of hypoglycemia and severe hypoglycemia—11% versus 53% (P < .0001) and 0% versus 9% (P = .0004). Patients receiving the new insulin protocol experienced a statistically significant decrease in ICU LOS, hospital LOS, and duration of mechanical ventilation. Ward hyperglycemia: A matched cohort of 42 patients who were managed with the new protocol experienced dramatically reduced rates of hypoglycemia—14% versus 35% (P < .0001)—compared with those managed with the old protocol. DKA/HHS: The newly implemented DKA/HHS CIIT protocol was found to dramatically reduce rates of hypoglycemia and severe hypoglycemia: 1% versus 35% (P < .0001) and 4% versus 0% (P < .0001). Patients receiving the new protocol also had a 34% reduction in average number of episodes of extreme glycemic variability per patient. Conclusion. A pharmacist-led multidisciplinary effort was successful in designing and implementing an innovative process for optimizing the safety and efficacy of CIIT.

Geospatial Analytics to Predict Readmissions Lee Reis, BS, Eric D. Hixson, PhD, MBA, Steven Spalding, MD, and Timothy Sullivan, MBA The Cleveland Clinic Foundation

Background. Continuous infusion insulin therapy (CIIT) is used in the hospital setting to manage hyperglycemia. Although clinical evidence suggests that both hyperglycemia and glycemic variability negatively affect patient outcomes, guidelines only highlight goal blood glucose (BG) ranges without recommending safe and effective methods to attain these goals. Intervention detail. At the University of California, Davis Medical Center, multidisciplinary task forces led by pharmacists systematically

Background. Reducing hospital readmissions is a national cost savings and quality-of-care initiative. Geospatial analysis combines location intelligence and mapping techniques to promote greater understanding of the interplay between population characteristics and geography, and this novel approach can provide valuable information to hospital systems in the era of population health management. Intervention detail. This pilot project examined

24S the role of distance to a hospital as a risk factor for readmissions. Furthermore, the pilot explored differences in comorbidities based on geographic locations. All surgical patients discharged to home or home with home health care from the Cleveland Clinic Health System in 2011 and 2012 within the UHC database were included (n = 66 597) and stratified into cardiac and noncardiac populations. Home addresses were used to geocode the data and group patients by drive time to the health system. All readmissions within 30 days of the index discharge to the academic medical center or one of its 8 affiliated community hospitals were identified. Two outcome measures were assessed: all-cause readmission and readmission for infection. Infection readmissions were identified using the primary diagnosis. Results. The average length of stay and UHC expected mortality both have a positive relationship with increased driving distance from the hospital system. However, the readmission rates for all patients related to infections or other causes did not demonstrate a strong correlation with increased driving distance. Readmission rates for cardiothoracic surgery patients have a negative relationship with increased driving distance in our sample. This result may indicate that local patients are more likely to return to the hospital as an alternative to seeking appropriate outpatient care or are being readmitted to hospitals outside the scope of the analysis. Further investigation is needed into additional location-related variables and the effect of travel distance on patient preferences for follow-up care to improve the predictive power of this model and identify valuable insights into causes of readmissions.

Bundling: What Went Right, Wrong, and Still the Unknown Brittany Cunningham, MSN, RN, CSSBB, and Robin Steaban, RN, MSN Vanderbilt University Medical Center

Background. Starting January 1, 2014, Vanderbilt will go into a partnership with Medicare to test a bundle payment system using cardiac surgery patients (Medicare severity diagnosis-related groups [DRGs] 216-221) covering 3 days before the valve procedure and extending 90 days post discharge. The last 2 years have been used to study our Medicare, internal, and other data to identify opportunities in the system where we might be able to increase quality and decrease cost. Intervention detail. As soon as we decided to apply our findings to the bundle initiative, Medicare allowed analysis on their full claims data. Immediately, we uncovered that transfer patients had higher numbers of procedures, direct costs, and lengths of stay. When breaking down inpatient costs, the operating

American Journal of Medical Quality 29(2S) room (OR) supplies had little variance between the DRGs. We decided that the only intervention in the OR would be the renegotiation of the valve contracts. The most valuable piece of the Medicare data was the view of the post–acute care section of the continuum, shedding light on the expenditure and associated costs. In our population, the most costly group was the readmission group, accounting for 31% of the spending. After readmissions, inpatient rehabilitation, long-term health, and skilled nursing facilities came in accordingly. We did extensive analysis on our readmissions to find that there was no significant difference in the discharge location of patients, that the majority of the patients were returning within 14 days, and that the most common reasons for readmission were heart failure and arrhythmias. This showed us where to focus and what interventions to make. Results. After looking at our data, we formed 11 working groups to tackle the redesign of the continuum covering presurgery to 90 days postoperative using operational leaders to lead the workgroups, putting accountability in the operational front line. The data from Medicare were most informative to tell us where to put our efforts across the continuum. We still have much to learn, such as how the patients will interact with us along the 90 days. We are hopeful that with the new process and coordination we have put in place, the quality will be increased and costs will be lower.

Analyzing Readmissions From the Provider Perspective Ashley Busuttil, MD, and Nasim Afsar-manesh, MD, SFHM UCLA Health System

Background. A retrospective review of 30-day Medicine readmissions at our tertiary teaching institution and its community affiliate suggests that discharge best practices may be insufficient to eliminate all preventable readmissions. Furthermore, practitioners are not systematically notified of patient readmissions, which may lead to decreased provider accountability and incomplete understanding of readmission causality. Intervention detail. A process was developed to notify the index discharging attending via e-mail within 24 hours of patient readmission. The physician is queried about index and readmission preventability and causality. Hospitalizations deemed potentially preventable are reviewed for targeted system interventions, either existing or requiring development. Objectives include raising provider awareness and accountability, demonstrating sustainability of a near real-time readmission review process that incorporates treating provider insight, and real-time implementation of

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White targeted readmission interventions. Results. A total of 431 readmissions were identified, with corresponding e-mail queries sent to the index discharging physician. Physician response rate was 57% to 73% based on hospital site. At our tertiary academic center, responders categorized index and readmission hospitalizations as 7% and 9% preventable, 73% and 49% not preventable, and 20% and 42% potentially preventable. At our community affiliate, providers categorized index and readmission hospitalizations as 3% and 13% preventable, 78% and 46% not preventable, and 19% and 41% potentially preventable. The following clinical themes were identified: health system needs, including high-level outpatient services such as blood transfusions or IV antibiotic infusion (19.8%); patient factors, including comorbid dual diagnoses or noncompliance (12.9%); discharge process failures, including medication reconciliation and hospital handoff (11.2%); interhospital care, including inadequate outpatient follow-up or readmissions from skilled facilities with health care–acquired infections (5.2%); goals of care needs in advanced chronic illness (5%); access to care for the underinsured (3.4%); and social factors, including unsafe home situations (2.5%). The following interventions are in development targeting these identified themes: enhanced utilization of our Evaluation and Treatment Center, which provides high-level outpatient care; enhanced inpatient care standardization to select high-utilizing patients; hospital-wide multidisciplinary collaboration with case management to ensure discharge best practices; collaboration with regional skilled facilities to implement infection control policies; and a health system–wide effort to systematically address goals of care for chronic disease patients.

Workplace Violence and Safe Environment Culture at Denver Health Kathy Boyle, PhD, RN, and Sherry Stevens, SPHR Denver Health

Background. Denver Health and Hospital Authority is Colorado’s “safety net” health care provider. Denver Health is a comprehensive, integrated health organization with multiple components, including a 525-bed hospital, the Rocky Mountain Regional Level I Academic Trauma Center, the 911 medical response system for the City and County of Denver, Denver Public Health Department, an 8-clinic network of Family Health Centers, 19 schoolbased health centers in the Denver Public Schools, the Rocky Mountain Poison and Drug Center, a 100-bed detoxification facility, and 3 correctional care sites. Denver Health has approximately 5600 employees.

Understanding that there is a direct link between employee safety and employee engagement and how that engagement affects safe patient care and patient and family satisfaction, Denver Health is using a multidisciplinary team to address workplace violence and construct a safe culture. Intervention detail. We audited our organization’s risk of violence and surveyed employees in the work units at highest risk on their perceptions of safety. This illustrated the need for 2 work groups: one for patient aggressors and one for nonpatient aggressors. The platform for our work built on 3 components: support, awareness, and prevention. Our efforts are ongoing, but we have already started the following initiatives: held individual meetings with every employee victim, held staff group meetings post assault for support, created a desktop icon with resources and instructions for those involved in assaults, received training from external experts in prevention, delivered training for staff members, provided annual training refresher, increased security, initiated use of security-specific code alerts, created armband codes for potentially violent patients, created a quick response threat assessment group, and supported an intervention and mentoring program for at-risk young adults. Results. Our goal was to increase reporting of events and eventually decrease assaults. We have increased reporting of events through our Patient Safety Net system for patient aggressor assaults. We have captured nonpatient aggressor events and continually track them for continued focus on potential activity. We ensure that employees will not be penalized for seeking help or if they are concerned about another employee. Ongoing awareness, support, and prevention will help Denver Health to engage our employees to create and sustain a safe culture.

Additional Rapid-Fire Sessions 2013 Electronic Core Measures Abstraction: Improving Efficiency While Sustaining Accuracy Ellen Robinson, PT, ATC; Harborview Medical Center HPPDE: Creating a Common Language to Promote Quality Kerry Bradford, BSBA, and Gwen Moreland, MSN, RN, NE-BC; University of Kentucky Hospital Rush CPR: Clinical Program Redesign, Not Resuscitation David Ansell, MD, MPH, and Raj Behal, MD, MPH; Rush University Medical Center A Comprehensive Health System Approach to Medicare’s Value-Based Purchasing Program Brenda Clemens, RN, BHA, CPHQ, and Sherry Watson, BSN, CPTC, MBA; UCLA Health System Building a Culture of Patient Experience Excellence: How to Create an Interconnected Strategy of Best

26S Practices in Data Use, Reporting, Tactics, and Senior Leader Engagement Amy Helder, MS, CPHQ, ACHE, and Christy Patton, MBA; The Ohio State University Wexner Medical Center Leveraging RFID Technology to Improve Patient Safety in the Operating Room Barbara Doster, RN, BS, MBA; UAB Hospital Using Process Improvement and CPOE to Increase Discharges Before 11:00 am Sherri Del Bene, RN, MN, NEA-BC, Raghu Durvasula, MD, and Arkan Kayihan, MBA, MS, Six Sigma Black Belt; University of Washington Medical Center Providing Timely, Low-Cost Access to Specialty Care in a Fee-for-Service Setting: Implementation of an eConsult System Nathaniel Gleason, MD; UCSF Medical Center Faces Behind the Data: How Eliminating the Denominator Transformed One Hospital Velinda Block, DNP, RN, NEA-BC, and Ben Taylor, MD, MPH; UAB Health System Pedal to the Metal: Driving Synergy and Speed to Support Our Cost Savings Goals Pamela Negri, BA, JD, and Dorcas Safly, BA; Oregon Health & Science University Analysis of Voluntary Reports of Near-Miss and LowHarm Patient Safety Incidents in an Integrated Health System: Findings and Implications Jeffrey Leland, MS, and Timothy Morgenthaler, MD; Mayo Clinic in Rochester Improving Resource Utilization in 7 ICUs Through a Multifaceted Quality Improvement Program Sara Gregg, MHA, and David Murphy, MD, PhD; Emory University Hospital Midtown Embracing “N = 1” Jordan DeMoss, MSHA; UAB Health System Stay Healthy Outpatient Program (SHOP): An Innovative Approach to Reducing Readmissions Kelly Dodds, ANP-BC, CNS-BC, and Carmen Smith, MHS, RRT, AE-C; Barnes-Jewish Hospital Developing a Patient Safety Program in the Outpatient Setting Stephanie Davis, MA, RN-BC, and Dawn England, MPH, CPHQ; University of Minnesota Physicians Super UHC User Group Strives to Reduce Supply Costs Michelle Pieterse, MBA, RN, Michael Samborski, MBA, and Taylor Smith, MBA; The University of Arizona Health Network Medical Centers Pharmacy’s Role in Transitional Care Bruce Thompson, RPh, MS; Hennepin County Medical Center Driving Quality Results Through the Balanced Scorecard Lynda Barrett, MBA, and Noel Luell, MBA, MHA; The Emory Clinic, Inc, PC

American Journal of Medical Quality 29(2S) The NewYork-Presbyterian Targeted Care Intervention for Complex Care Management Victor Carrillo, MPA, BS, and Peggy Chan, MPH, BA; NewYork-Presbyterian Hospital Promoting Patient Safety Through a Multidisciplinary Approach to Alarm Management Patricia Covelle, RN, BSN, MM, James Piepenbrink, and Deborah Whalen, MSN, MBA, APRN-BC, RNP; Boston Medical Center Managing Your Medication for Education and Daily Support (MYMEDS): The Value of a Clinical Pharmacist in Primary Care Practices Robin Clarke, MD, MSHS; UCLA Medical Center Admit One: A Collaboration Across Primary Care Clinics at 8 Academic Medical Centers to Benchmark and Reduce Hospital Readmission Rates Lawrence Friedman, MD; UC San Diego Health System Jeffrey Fujimoto, BS; David Geffen School of Medicine at UCLA Ning Tang, MD; UCSF Medical Center Applying Athletic Principles to Medical Multidisciplinary Rounds Can Improve Both the Efficiency and Quality of Patient Care Frederick Southwick, MD; UF Health Shands Hospital The Perfect Storm: A System Approach to Reducing Variation in Transplant Surgery Edwin Hall, BS; University of Toledo Medical Center Improving Medication-Related Transitions in Care Using Innovative Pharmacy Technician Services in Collaboration With Social Workers, Case Managers, and Clinic Staff Joseph Cesarz, MS, PharmD, and Barbara Liegel, RN, MS; University of Wisconsin Hospital and Clinics Development and Implementation of a System-Wide Acute Transfer Database Charles Pu, MD, CMD; Massachusetts General Hospital Financial Impact of Adding Nurse Practitioners to Inpatient Models of Care Utilizing Structural Empowerment Theory Pam Jones, DNP, RN, ACNP-BC, FAANP, and April Kapu, MSN, RN, ACNP-BC; Vanderbilt University Hospital A Tool for Measuring and Seeking Supply Chain Optimization Philip Pettigrew, BS, MBA; Denver Health Partners in Benchmarking: How Partners HealthCare System (PHS) Evolved Operational Benchmarking From Entity to System Kate Heffernan, BA, and Erin Schulz; Brigham and Women’s Hospital/Newton-Wellesley Hospital Transitioning to Value-Based Care While Successfully Riding the Fee-for-Service Train Richard Gitomer, MD, MBA; Emory University Hospital Midtown

White Developing Effective Physician Leadership in Academic Medical Centers Joseph Hopkins, MD; Stanford Hospital & Clinics Safe Care Through Storytelling Kathy Dutton, RN, MSN, NEA-BC, Dave Galloway, AA, and Becky Ross, MBA, BS; Vidant Health (Vidant Medical Center) Healthcare Purchasing News Department of the Year 2013: The Greenville Healthcare System Journey John Mateka, MBA, MHA; Greenville Health System (Greenville Memorial Hospital) A Model for Making Strategic Recruitment Decisions Holly Nandan, MHA/MBA, CHE, and Lori Straube, MBA; Loyola University Medical Center Ann Peterson, BA; Loyola University Health System System Development and Integrating Supply Chain Across a New System Diane Haney and Kamy Leeret, BSBM; University of Colorado Hospital Utilization of the UHC Clinical Resource Manager to Improve Medication Use Within a Transplant Service Line Jordan Dow, PharmD, MS, and Siddhartha Singh, MD; Froedtert & The Medical College of Wisconsin

Posters 2013 Employee Influenza Vaccination Program: Culture Change Management Oregon Health & Science University Mobile Pharmacy: Prescription Bedside Delivery Barnes-Jewish Hospital Art to Heart: The Effects of Staff-Created Art on the Postoperative Rehabilitation of People Recovering From Cardiovascular Surgery Vanderbilt University Medical Center Radiofrequency Technology in Surgery: Use It or Lose It The University of Arizona Health Network (The University of Arizona Medical Center, University Campus) Using a Written Turning Clock as a Pressure Ulcer Prevention Tool in Geriatric Patients UAB Health System (UAB Hospital) An Interdisciplinary Approach to Transitional Care Coordination Leads to Reduction in Readmissions University of Maryland Medical System (University of Maryland Medical Center) The UHC/AACN Nurse Residency Program: Assessment of Retention and Engagement in Leadership Activities 2007-2012 at an Academic Medical Center Thomas Jefferson University Hospital Using Nurse-Identified Barriers to Impact Patient Pain Satisfaction Scores Santa Monica UCLA Medical Center and Orthopaedic Hospital

27S Cutting Costs Without Cutting People Pennsylvania Hospital of UPHS Improving Care Quality via Patient and Family Engagement: Bedside Shift Report Patewood Memorial Hospital No Interruptions: You Are in the Red Zone UAB Health System (UAB Hospital) Community Collaboration and Intensive Case Management for Patients With High ED Utilization Harborview Medical Center Rethinking Preventable Readmissions: The Patient Perspective on Care Transitions Emory Healthcare Enhancing Staff Communication and Improving the Safety of Chemotherapy Preparation and Administration Through Use of an Electronic Chemotherapy Status Board (ECSB) Rhode Island Hospital Respiratory Care Practitioner (RCP) as COPD Case Manager: A Viable Model UC Davis Medical Center Up Early and Often: Postoperative Day Zero Mobilization Status Post Total Joint Arthroplasty The Miriam Hospital Engaging Nurse Residents in Improving NurseSensitive Quality Outcomes The Nebraska Medical Center Broadening the Function of the Electronic Medical Record to Improve Service Excellence in the Emergency Department Oregon Health & Science University Assessing Antibiotic Stewardship Programs Using a Standardized Framework: The University of California Experience UCLA Health System (Ronald Reagan UCLA Medical Center) Closing the Loop on Unexpected Results Northwestern Memorial Hospital Meeting the Target: 12% Reduction in Laboratory Supply Costs University of Kentucky Hospital Where Does the Day Go: An Analysis of an Intern’s Work Time Post Duty-Hour Reform University of Pennsylvania Health System (Hospital of University of Pennsylvania) Improving Rates of IPC Therapy Utilization Thomas Jefferson University Hospital SICU Roadmap to Zero CLABSI UAB Health System (UAB Hospital) Care at Arrival: Emergency Department Model for Improving Time to Care and Patient Throughput With a Physician in Triage Northwestern Memorial Hospital

28S Utilization of Shared Governance to Sustain Continuous Improvement The Methodist Hospital System (Houston Methodist Hospital) Immediate Rooming Saves Time in an Academic Neuroscience Clinic University of Kentucky Hospital Rejuvenating Bedside Report Poudre Valley Hospital Daily Rehab Rounds in a Surgical Trauma ICU Decreases Hospital Length of Stay The University of Tennessee Medical Center at Knoxville Optimizing Patient Care and Professional Practice Through the Use of Clinical Protocols: Oregon’s Experience Oregon Health & Science University Capacity Management Success for Denver Health Medical Center Denver Health A Multidisciplinary Approach to Developing a Highly Reliable Bed Delivery Program Vidant Health (Vidant Medical Center) Alcohol-Impregnated Caps: Are They Effective for Preventing CLABSI? UAB Health System (UAB Hospital) Decreasing Missed Referrals for Aim4Peace Truman Medical Center Hospital Hill Quality Improvement in Cardiac Surgery: An Innovative Systems-Based Multidisciplinary Approach University of South Alabama Health System Impact of Target Stroke on Reducing Door-to-Needle Times University of Louisville Hospital Discharge Before Noon Challenge: Improving Throughput NYU Langone Medical Center Partnering for Organizational Success: A Systematic Approach to Supply and Equipment Remediation After Extensive Water Damage NYU Langone Medical Center How to Use a Web-Based Tool to Collect Data and Track Compliance With Regulatory Requirements UC San Diego Health System Association Between Compliance With Select SCIP Measures and In-House Mortality and Coded Hospital-Acquired Infections UC San Diego Health System Outpatient Hand Hygiene QI Project Stanford Hospital & Clinics We Are All in This Together: Improved Vaccine Charting Using a Computerized Support System Thomas Jefferson University Hospital Oral Care With Chlorhexidine Gluconate: Does It Reduce VAP? Emory University Hospital

American Journal of Medical Quality 29(2S) Reducing Drug Utilization Costs in the Management of Heparin-Induced Thrombocytopenia: An Interdisciplinary Approach Lahey Hospital & Medical Center Intensive Outpatient Utilization of Addiction and Behavioral Medicine Services and Corresponding Reductions in Inpatient Visits in a Teaching Family Medicine Center UCLA Health System (Ronald Reagan UCLA Medical Center) Diabetes Chronic Disease Management: Collaborative Between Community Health and Department of Endocrinology Mayo Clinic in Rochester Building a Framework for Quality Program Integration Between a Hospital and Academic Medical School Children’s Memorial Hermann Hospital Unique Use of Pharmacists and Analytical Tools to Achieve Core Measure Compliance Yale-New Haven Hospital A Near Zero Unindicated Early-Term Delivery Rate Achieved Without Punitive Measures Froedtert & The Medical College of Wisconsin A Standardized Vascular Access Algorithm Reduces Central Line–Associated Bloodstream Infections, Lengths of Stay, and Variations in Outcomes in the Non-ICU Adult Ward Setting Denver Health Direct Access to Physical Therapy: Improved Patient Outcomes for Ambulatory/Musculoskeletal Care University of Wisconsin Hospital and Clinics Stanford Hospital & Clinics Emergency Department Continuous Improvement Journey Stanford Hospital & Clinics A Multidisciplinary Approach to Reducing Surgical Site Infections Cedars-Sinai Medical Center The Evolution of a Regional Anesthesia Team: From Unengaged to Unstoppable Upstate University Hospital Achieving Zero for Central Line–Associated Bloodstream Infection (CLABSI) in a Pediatric ICU Through an Integrated Team Approach Upstate University Hospital Valley of Despair to Top Performer: Children’s Asthma Care at the University of Virginia University of Virginia Health System Face-to-Face Handoff: Improving Transfer to the Pediatric Intensive Care Unit After Cardiac Surgery at the University of Virginia Children’s Hospital University of Virginia Health System