532682
research-article2014
AJMXXX10.1177/1062860614532682American Journal of Medical QualityPeterson et al
Article
The Power of Involving House Staff in Quality Improvement: An Interdisciplinary House Staff–Driven Vaccination Initiative
American Journal of Medical Quality 2015, Vol. 30(4) 323–327 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614532682 ajmq.sagepub.com
Susan Peterson, MD1,2, Ryan Taylor, MBA3, Melinda Sawyer, MSN, RN2, Paul Nagy, PhD1,2, Lori Paine, MS2, Sean Berenholtz, MD, MHS, FCCM1,2, Redonda Miller, MD, MBA1, and Brent Petty, MD1
Abstract Immunization for influenza and pneumococcal pneumonia were incorporated into The Joint Commission “global immunization” core measure January 1, 2012. The authors’ hospital chose to adhere strictly to guidelines to avoid overvaccination. An immunization order set was created to aid appropriate ordering practices. In spite of this effort, compliance rates remained below the goal. The objective was to improve compliance with inpatient vaccination core measures to >96%. An educational slide set was created and distributed by the Housestaff Patient Safety and Quality Council (HPSQC). A competition was established among departments. Finally, the HPSQC partnered with quality improvement staff to improve communication and optimize concurrent review processes. The average compliance prior to the HPSQC vaccination initiative was 78% for pneumococcal pneumonia and 84% for influenza; average compliance in the months following the intervention was 96% and 97.5%, respectively. This project yielded significant improvement in compliance with vaccination core measures. Keywords patient safety, quality improvement, vaccination, house staff The Housestaff Patient Safety and Quality Council (HPSQC) at the Johns Hopkins Hospital was created in the summer of 2012. The initial vision, derived in part from the efforts of New York-Presbyterian Hospital, was to create house staff driven improvement of patient care and safety and to build capacity among trainees to improve patient-reported outcomes at the lowest possible cost.1,2 Similarly structured councils have been shown to improve outcomes in projects such as medication reconciliation.3 Another goal was to integrate house staff into the hospital’s quality improvement (QI) structure, as has been demonstrated by other similar councils.4 To achieve this vision and goal, the house staff chose an interdisciplinary QI project that was congruent with institutional priorities to focus their efforts. A number of projects were proposed, but the HPSQC identified a notable challenge with compliance with global immunizations for influenza and pneumococcal pneumonia, which became a core measure in 2012 (although vaccination for community-acquired pneumonia patients had been a core measure since 2002). Core measures are a standardized performance measure required by The Joint Commission for the assessment of care delivered and were created in
collaboration with the Centers for Medicare & Medicaid Services (CMS).5 The institution chose to adhere strictly to Centers for Disease Control and Prevention (CDC) guidelines for influenza and pneumococcal vaccination to avoid overvaccination. Patients included in the monthly audits were randomly selected from among all patients discharged for acute inpatient care with a length of stay less than 120 days; these patients were assessed for and offered pneumococcal and influenza vaccination as appropriate. Guidelines for administration of the influenza vaccine for inpatients were straightforward.6 Patients had the influenza vaccination administered unless they were younger than 6 months of age, had an organ transplant during the 1
Johns Hopkins University, Baltimore, MD Johns Hopkins University Armstrong Institute, Baltimore, MD 3 Johns Hopkins Health System, Baltimore, MD 2
Corresponding Author: Susan Peterson, MD, Department of Emergency Medicine, Johns Hopkins University, 5801 Smith Ave Suite 3220, Baltimore, MD 21209. Email: [email protected]
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admission, had a history of Guillain-Barré syndrome within 6 weeks of receiving the influenza vaccine, had a bone marrow transplant or autologous stem cell transplant in the previous 6 months, or had a history of anaphylactic allergy or sensitivity to eggs or thimerosal. Guidelines for pneumococcal vaccination administration for inpatients were more complex; the individuals included patients who were 65 years of age or older or patients 5 to 64 years old with one or more of the following chronic conditions or circumstances: cochlear implant, immunocompromising condition, cerebrospinal fluid leaks, coronary artery disease, congestive heart failure, chronic pulmonary disease, asthma, diabetes, chronic liver disease, renal failure, nephrotic syndrome, functional asplenia, sickle cell disease, multiple myeloma, cigarette smoking, resident of a chronic care facility, Hodgkins lymphoma, malignancy, HIV/AIDS, or taking immunosuppressive agents. Patients who had contraindications to vaccination or who had been vaccinated in the preceding 5 years were not eligible to receive the vaccine.7 Because of the complexities of the vaccination guidelines, a comprehensive electronic order set with mandatory fields for vaccination screening and ordering was created to aid prescribers in appropriate ordering practices in January 2012 and was announced with a general e-mail to hospital prescribers but without specific education for the house staff about the purpose of this order set. Additionally, the QI staff (later described) initiated a concurrent review process in the Department of Surgery in July 2012 and then in the Department of Medicine and Neurosciences in November 2012. These departments were chosen because they were the largest departments with the highest noncompliance rates. Vaccination orders were reviewed on Monday of each week, and providers were contacted if the vaccination order was not completed appropriately. QI staff noted significant challenges contacting the appropriate providers, and in spite of the concurrent review effort, compliance rates for appropriate vaccination of inpatients remained below the institutional goal of >96%. There was significant opportunity for intervention to improve compliance with inpatient vaccination core measures for influenza and pneumococcal pneumonia.
Methods The house staff of the HPSQC initiated this project at a large academic medical center with 1059 licensed beds and more than 48 000 discharges annually. Work by the HPSQC was completed from September 2012 to April 2013. Interventions were agreed on by the members of the HPSQC, which included representatives from the 20 different residency programs practicing in the hospital.
Members of the HPSQC were house staff appointed by their program director. One primary member and one alternate member were chosen by each of the 20 residency programs, with all training years accepted. The council met monthly with anticipated attendance of >70%. HPSQC members were responsible for participating in monthly meetings, communicating the council’s activities to the house staff in their respective programs, and participating in and communicating any relevant information related to the HPSQC project. The leadership of the HPSQC, consisting of the appointed chair, vice chair, and administrative assistant, was responsible for carrying out the agreed-on interventions. A steering committee was composed of 11 hospital leaders drawn from attending physicians, QI leadership, and administration (eg, Vice President for Medical Affairs, Associate Dean for Graduate Medical Education). Outcome measures were hospital-wide percentage compliance with pneumococcal and influenza vaccinations as reported per CMS core measure methodology, described later in this section.7 The preintervention period was January 2012 to November 2012, and the postintervention period was January 2013 to April 2013. The members of the HPSQC agreed on a 3-pronged approach to improve compliance. First, there was inadequate education for the house staff when the order set was created. An educational slide set was created and distributed by the members of the HPSQC to the house staff in their departments. This was done largely by e-mail, although in some departments there was additional review of the material in house staff education conferences; for example, if a particular department frequently experienced failures for a common comorbidity such as asthma. This slide set was customized further for the Department of Pediatrics, whose patients had additional unique criteria for vaccination. This slide set outlined not only how to appropriately order the immunization screen but also gave insight into why it was so important to comply with the standard. Second, a competition was established between departments to reward the department that was most consistently compliant and the one that was most improved by the end of the academic year. The winning departments were rewarded with a celebratory lunch provided by the HPSQC, leveraging the competitive nature of the house staff to aid in improving compliance. At the monthly HPSQC meetings, leadership reviewed the monthly compliance rates and specific failures by department. This focus on results generated valuable solutions to challenges and encouraged members to engage with and on behalf of their fellow house staff in their departments. Lastly, the leadership of the HPSQC partnered with the nursing staff and QI staff to improve communication and optimize a concurrent review process, which was initiated
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Figure 1. Vaccination compliance rates January 2012 to April 2013.
a few months prior to involvement by the HPSQC. The QI staff is composed of nurses assigned to one or more departments who gather quality data for the hospital and work with other hospital staff to implement methods to improve performance. In addition, the chair of the HPSQC met with the Nursing Quality Improvement Committee to garner support and feedback on the council’s efforts. The HPSQC had the expertise to ensure that the reviewers had optimal information on how to contact an ordering physician, helped ensure the calls were being made at time intervals that were appropriate, and helped review and troubleshoot identified failures once every 2 weeks. A feedback hierarchy was established (house staff initially paged twice, followed by the fellow, and finally the attending) and communicated to the broader house staff community. This hierarchy was used to communicate with house staff who were repeatedly noncompliant. Compliance data were collected monthly by the institution in compliance with the CMS core measures methodology. The same method was used both pre intervention (January 2012 to November 2012) and post intervention (January 2013 to April 2013). In brief, after the end of each month, 104 medical record numbers of admitted patients with a length of stay less than 120 days were randomly selected and reviewed by the QI staff to determine compliance. Patients who were excluded from receiving the vaccination were removed from those 104 medical record numbers. The medical records of all remaining patients who met inclusion criteria were reviewed to determine if vaccinations for influenza and pneumococcal pneumonia were appropriately ordered and administered or for the presence of documentation that appropriately
justified why the vaccination was not given (eg, patient refusal). These data were aggregated to determine monthly compliance.7,8 χ2 Analysis was completed utilizing StataCorp, version 12.1 statistical software (StatCorp LP, College Station, TX). This analysis was completed in 2 ways. The first analysis was completed comparing the 4 months before and after December, the month of the house staff interventions. Because there was concern that this may not account for seasonal differences, the analysis also was completed comparing the applicable months from January 2012 to November 2012 (before the intervention) and then January 2013 to April 2013.
Results In the 11 months leading up to the HPSQC vaccination initiative, compliance for pneumococcal pneumonia immunization averaged 78%. Influenza vaccination compliance over that same time period was 84%. On initiation of the HPSQC’s 3-pronged approach, compliance improved from 86% in November 2012 to 98% in December 2012 for pneumococcal pneumonia vaccination and 94% to 95% for influenza vaccination for the same months. These gains continued in the following months, ultimately reaching 100% compliance with pneumococcal vaccination and 99% compliance with influenza vaccination. The average compliance in the months following the intervention was 96% for pneumococcal pneumonia vaccinations and 97.5% for influenza vaccinations. Figure 1 demonstrates the change in compliance rates and the timing of interventions. It should be
Downloaded from ajm.sagepub.com at Stockholm University Library on August 11, 2015
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noted that a new clinical building was opened in April 2012, and there was a notable decrease in compliance at that time. The χ2 analysis comparing the 4 months before and after the intervention was statistically significant for both pneumococcal vaccination (P = .001) and influenza vaccination (P = .002). The χ2 analysis comparing all data collected before and after the intervention was even more statistically significant, with a P value of
research-article2014
AJMXXX10.1177/1062860614532682American Journal of Medical QualityPeterson et al
Article
The Power of Involving House Staff in Quality Improvement: An Interdisciplinary House Staff–Driven Vaccination Initiative
American Journal of Medical Quality 2015, Vol. 30(4) 323–327 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860614532682 ajmq.sagepub.com
Susan Peterson, MD1,2, Ryan Taylor, MBA3, Melinda Sawyer, MSN, RN2, Paul Nagy, PhD1,2, Lori Paine, MS2, Sean Berenholtz, MD, MHS, FCCM1,2, Redonda Miller, MD, MBA1, and Brent Petty, MD1
Abstract Immunization for influenza and pneumococcal pneumonia were incorporated into The Joint Commission “global immunization” core measure January 1, 2012. The authors’ hospital chose to adhere strictly to guidelines to avoid overvaccination. An immunization order set was created to aid appropriate ordering practices. In spite of this effort, compliance rates remained below the goal. The objective was to improve compliance with inpatient vaccination core measures to >96%. An educational slide set was created and distributed by the Housestaff Patient Safety and Quality Council (HPSQC). A competition was established among departments. Finally, the HPSQC partnered with quality improvement staff to improve communication and optimize concurrent review processes. The average compliance prior to the HPSQC vaccination initiative was 78% for pneumococcal pneumonia and 84% for influenza; average compliance in the months following the intervention was 96% and 97.5%, respectively. This project yielded significant improvement in compliance with vaccination core measures. Keywords patient safety, quality improvement, vaccination, house staff The Housestaff Patient Safety and Quality Council (HPSQC) at the Johns Hopkins Hospital was created in the summer of 2012. The initial vision, derived in part from the efforts of New York-Presbyterian Hospital, was to create house staff driven improvement of patient care and safety and to build capacity among trainees to improve patient-reported outcomes at the lowest possible cost.1,2 Similarly structured councils have been shown to improve outcomes in projects such as medication reconciliation.3 Another goal was to integrate house staff into the hospital’s quality improvement (QI) structure, as has been demonstrated by other similar councils.4 To achieve this vision and goal, the house staff chose an interdisciplinary QI project that was congruent with institutional priorities to focus their efforts. A number of projects were proposed, but the HPSQC identified a notable challenge with compliance with global immunizations for influenza and pneumococcal pneumonia, which became a core measure in 2012 (although vaccination for community-acquired pneumonia patients had been a core measure since 2002). Core measures are a standardized performance measure required by The Joint Commission for the assessment of care delivered and were created in
collaboration with the Centers for Medicare & Medicaid Services (CMS).5 The institution chose to adhere strictly to Centers for Disease Control and Prevention (CDC) guidelines for influenza and pneumococcal vaccination to avoid overvaccination. Patients included in the monthly audits were randomly selected from among all patients discharged for acute inpatient care with a length of stay less than 120 days; these patients were assessed for and offered pneumococcal and influenza vaccination as appropriate. Guidelines for administration of the influenza vaccine for inpatients were straightforward.6 Patients had the influenza vaccination administered unless they were younger than 6 months of age, had an organ transplant during the 1
Johns Hopkins University, Baltimore, MD Johns Hopkins University Armstrong Institute, Baltimore, MD 3 Johns Hopkins Health System, Baltimore, MD 2
Corresponding Author: Susan Peterson, MD, Department of Emergency Medicine, Johns Hopkins University, 5801 Smith Ave Suite 3220, Baltimore, MD 21209. Email: [email protected]
Downloaded from ajm.sagepub.com at Stockholm University Library on August 11, 2015
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American Journal of Medical Quality 30(4)
admission, had a history of Guillain-Barré syndrome within 6 weeks of receiving the influenza vaccine, had a bone marrow transplant or autologous stem cell transplant in the previous 6 months, or had a history of anaphylactic allergy or sensitivity to eggs or thimerosal. Guidelines for pneumococcal vaccination administration for inpatients were more complex; the individuals included patients who were 65 years of age or older or patients 5 to 64 years old with one or more of the following chronic conditions or circumstances: cochlear implant, immunocompromising condition, cerebrospinal fluid leaks, coronary artery disease, congestive heart failure, chronic pulmonary disease, asthma, diabetes, chronic liver disease, renal failure, nephrotic syndrome, functional asplenia, sickle cell disease, multiple myeloma, cigarette smoking, resident of a chronic care facility, Hodgkins lymphoma, malignancy, HIV/AIDS, or taking immunosuppressive agents. Patients who had contraindications to vaccination or who had been vaccinated in the preceding 5 years were not eligible to receive the vaccine.7 Because of the complexities of the vaccination guidelines, a comprehensive electronic order set with mandatory fields for vaccination screening and ordering was created to aid prescribers in appropriate ordering practices in January 2012 and was announced with a general e-mail to hospital prescribers but without specific education for the house staff about the purpose of this order set. Additionally, the QI staff (later described) initiated a concurrent review process in the Department of Surgery in July 2012 and then in the Department of Medicine and Neurosciences in November 2012. These departments were chosen because they were the largest departments with the highest noncompliance rates. Vaccination orders were reviewed on Monday of each week, and providers were contacted if the vaccination order was not completed appropriately. QI staff noted significant challenges contacting the appropriate providers, and in spite of the concurrent review effort, compliance rates for appropriate vaccination of inpatients remained below the institutional goal of >96%. There was significant opportunity for intervention to improve compliance with inpatient vaccination core measures for influenza and pneumococcal pneumonia.
Methods The house staff of the HPSQC initiated this project at a large academic medical center with 1059 licensed beds and more than 48 000 discharges annually. Work by the HPSQC was completed from September 2012 to April 2013. Interventions were agreed on by the members of the HPSQC, which included representatives from the 20 different residency programs practicing in the hospital.
Members of the HPSQC were house staff appointed by their program director. One primary member and one alternate member were chosen by each of the 20 residency programs, with all training years accepted. The council met monthly with anticipated attendance of >70%. HPSQC members were responsible for participating in monthly meetings, communicating the council’s activities to the house staff in their respective programs, and participating in and communicating any relevant information related to the HPSQC project. The leadership of the HPSQC, consisting of the appointed chair, vice chair, and administrative assistant, was responsible for carrying out the agreed-on interventions. A steering committee was composed of 11 hospital leaders drawn from attending physicians, QI leadership, and administration (eg, Vice President for Medical Affairs, Associate Dean for Graduate Medical Education). Outcome measures were hospital-wide percentage compliance with pneumococcal and influenza vaccinations as reported per CMS core measure methodology, described later in this section.7 The preintervention period was January 2012 to November 2012, and the postintervention period was January 2013 to April 2013. The members of the HPSQC agreed on a 3-pronged approach to improve compliance. First, there was inadequate education for the house staff when the order set was created. An educational slide set was created and distributed by the members of the HPSQC to the house staff in their departments. This was done largely by e-mail, although in some departments there was additional review of the material in house staff education conferences; for example, if a particular department frequently experienced failures for a common comorbidity such as asthma. This slide set was customized further for the Department of Pediatrics, whose patients had additional unique criteria for vaccination. This slide set outlined not only how to appropriately order the immunization screen but also gave insight into why it was so important to comply with the standard. Second, a competition was established between departments to reward the department that was most consistently compliant and the one that was most improved by the end of the academic year. The winning departments were rewarded with a celebratory lunch provided by the HPSQC, leveraging the competitive nature of the house staff to aid in improving compliance. At the monthly HPSQC meetings, leadership reviewed the monthly compliance rates and specific failures by department. This focus on results generated valuable solutions to challenges and encouraged members to engage with and on behalf of their fellow house staff in their departments. Lastly, the leadership of the HPSQC partnered with the nursing staff and QI staff to improve communication and optimize a concurrent review process, which was initiated
Downloaded from ajm.sagepub.com at Stockholm University Library on August 11, 2015
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Figure 1. Vaccination compliance rates January 2012 to April 2013.
a few months prior to involvement by the HPSQC. The QI staff is composed of nurses assigned to one or more departments who gather quality data for the hospital and work with other hospital staff to implement methods to improve performance. In addition, the chair of the HPSQC met with the Nursing Quality Improvement Committee to garner support and feedback on the council’s efforts. The HPSQC had the expertise to ensure that the reviewers had optimal information on how to contact an ordering physician, helped ensure the calls were being made at time intervals that were appropriate, and helped review and troubleshoot identified failures once every 2 weeks. A feedback hierarchy was established (house staff initially paged twice, followed by the fellow, and finally the attending) and communicated to the broader house staff community. This hierarchy was used to communicate with house staff who were repeatedly noncompliant. Compliance data were collected monthly by the institution in compliance with the CMS core measures methodology. The same method was used both pre intervention (January 2012 to November 2012) and post intervention (January 2013 to April 2013). In brief, after the end of each month, 104 medical record numbers of admitted patients with a length of stay less than 120 days were randomly selected and reviewed by the QI staff to determine compliance. Patients who were excluded from receiving the vaccination were removed from those 104 medical record numbers. The medical records of all remaining patients who met inclusion criteria were reviewed to determine if vaccinations for influenza and pneumococcal pneumonia were appropriately ordered and administered or for the presence of documentation that appropriately
justified why the vaccination was not given (eg, patient refusal). These data were aggregated to determine monthly compliance.7,8 χ2 Analysis was completed utilizing StataCorp, version 12.1 statistical software (StatCorp LP, College Station, TX). This analysis was completed in 2 ways. The first analysis was completed comparing the 4 months before and after December, the month of the house staff interventions. Because there was concern that this may not account for seasonal differences, the analysis also was completed comparing the applicable months from January 2012 to November 2012 (before the intervention) and then January 2013 to April 2013.
Results In the 11 months leading up to the HPSQC vaccination initiative, compliance for pneumococcal pneumonia immunization averaged 78%. Influenza vaccination compliance over that same time period was 84%. On initiation of the HPSQC’s 3-pronged approach, compliance improved from 86% in November 2012 to 98% in December 2012 for pneumococcal pneumonia vaccination and 94% to 95% for influenza vaccination for the same months. These gains continued in the following months, ultimately reaching 100% compliance with pneumococcal vaccination and 99% compliance with influenza vaccination. The average compliance in the months following the intervention was 96% for pneumococcal pneumonia vaccinations and 97.5% for influenza vaccinations. Figure 1 demonstrates the change in compliance rates and the timing of interventions. It should be
Downloaded from ajm.sagepub.com at Stockholm University Library on August 11, 2015
326
American Journal of Medical Quality 30(4)
noted that a new clinical building was opened in April 2012, and there was a notable decrease in compliance at that time. The χ2 analysis comparing the 4 months before and after the intervention was statistically significant for both pneumococcal vaccination (P = .001) and influenza vaccination (P = .002). The χ2 analysis comparing all data collected before and after the intervention was even more statistically significant, with a P value of
