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Quality Improvement Initiatives
Continuous Improvement has been a way of doing business at NMC for years. It started out as a management development topic and has become how we go about daily life. As a community hospital, we must always search out better ways to do things in order to remain a viable, vital organization. We are constantly looking to improve patient care, enhance patient satisfaction, increase employee safety, operate with greater efficiency, and achieve better outcomes. The uniform format of the Act 53 report card calls for descriptions of three new quality improvement projects. We are pleased to provide overviews of these efforts: Reducing the time from Abnormal Mammogram to the time of tissue diagnosis, Preventing Infection: "the CLEAN" initiative, and STEMI Heart Attack Collaboration.
Project Name: Reducing the time from Abnormal Mammogram to the time of tissue diagnosis
Situation/Description:
NMC performs approximately 1430 diagnostic mammograms each year. As part of the hospital’s efforts to improve turn around times from the time an abnormal mammogram has been identified to the time that a tissue diagnosis has been rendered, a sub team of the hospital’s Cancer Committee came together to analyze the process. Clinical staff members from the Diagnostic Imaging Department, Process Improvement Department, Pathology Department and Surgical Services assessed the current workflow and identified areas for improvement.
Project Goals/Measures:
In November of 2008, the team came together to assess the baseline data from the time an abnormal mammogram was identified to the time a tissue diagnosis was determined. They found that average turn around times were remarkably variable, with an average range running at about 4 weeks. The goal of the team was to develop a new pathway which would result in a reduction of overall turn around time to 7 days and develop a system that would provide patients with critical information about their tests in much less time. The goal in addition to creating efficiencies was to increase patient and provider satisfaction and reduce patient stress due to wait times.
Intervention Description:
The team began by assessing baseline turn around time data and flow charting the current work flow processes. They identified barriers to the system, which included numerous phone calls to offices for appointments, scheduling barriers, and multiple appointment types which added days and sometimes weeks to the process. The team then defined the ideal state, which would effectively cut out approximately ten unnecessary steps and would reduce overall turn around times by about 2 weeks, bringing the overall assessment/diagnostic time down to 7 days or less.
The team also met with various stakeholders, including primary care physicians and general surgeons to test the new algorithm and elicit feedback from them. The proposed changes were welcomed by the providers and all were in agreement to proceed with a test of change.
Evaluation and Results:
The team has continued work on a number of changes which have dramatically improved turn around times from an average of 4 weeks, now down to 17 days. Some examples include:
- immediate call backs to primary care physicians and surgeons from the radiologists to hand off a report of abnormal mammogram results right away.
- Scheduling changes in the Diagnostic Imaging Department which has allowed for next day Stereotactic biopsy appointments should the patient wish to schedule those quickly.
- Updated education materials have been developed for patients and these are provided to them at the time of their initial visit in DI.
- Implementation of an Oncology Case Management position to facilitate patient flow through the cancer care process and care plan.
While these improvements show an impressive reduction in turn around times, more work is needed to further reduce the time frames to the ultimate goal of 7 days. Focus will be placed on appointment scheduling systems in physician offices as well as further improvements in DI to facilitate scheduling of tests and reporting results.
Contact Information:
Jane Catton, RN, BScN, MHA
Chief Quality Officer/Director of Process Improvement
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
(802) 524-1205 * (802) 524-1250 fax * jcatton@nmcinc.org
Peter Burke, MD
Pathologist Medical Director
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
(802) 524-1074 * (802) 524-1098 fax * pburke@nmcinc.org
Project name: Preventing Infection – “the CLEAN initiative”
Situation Description:
NMC’s surgical site infection rate is less than the national average (typically below 1%, with a national average of approximately 2.6% - see more by following this link), an achievement NMC is very proud of and our staff works very hard to maintain. Part of that emphasis has been an improvement effort targeted at hand hygiene throughout the organization.
At a May 2006 joint meeting of the Infection Control Practitioners from Vermont’s hospitals and members of the Vermont Program for Quality Health Care, a collaborative multi-faceted emphasis on hand hygiene was discussed. This effort included a review of policies, staff self-assessments, a review of employee and patient survey data, direct observation of practices, and ultimately, improvement efforts based on the findings.
Project Goals & Measures:
Data from the initial observations for hand hygiene compliance, done by VPQHC, found NMC units at 31%, 65%, and 100% compliance – compared to a national average of 40%. Data from the self-assessments and the patient satisfaction report provided additional support for an improvement effort. The hope was a well-planned intervention would allow NMC to achieve the goal of significantly increasing observed compliance with hand hygiene initially to well beyond -- possibly doubling -- the national rate of 40%, on its way to 100% compliance.
Intervention Description:
The review of the policies showed NMC had strong policies in place – the need for additional staff training and increased awareness was then selected for attention. “CLEAN” (NMC’s hand hygiene improvement program) was implemented. It’s components are; 1. Cultivate an atmosphere where it’s encouraged to remind one another about hand hygiene, 2. Learn the specifics about the appropriate times and ways to perform hand hygiene, 3. Exhibit what was learned, 4. Assess the need for additional dispensers of hand hygiene products, 5. eNumerate hand hygiene compliance through direct observation and monitoring volume of hand hygiene products used. Signage was developed and now rotates through the patient care areas and staff areas to maintain fresh awareness of the importance of proper hand hygiene and the steps in that process. A segment on the importance of hand hygiene was introduced into the yearly staff Inservice program. Presentations were made at department meetings to clarify the policy and work through the logistical challenges presented on busy patient care units. In addition, the topic was reinforced through material in the hospital newsletter (including a hand hygiene quiz), installation of additional hand sanitizer stations throughout the hospital, and through discussions with the physicians on the Medical Staff.
Evaluation & Results:
In 2009 the overall Hand Hygiene compliance rate was 92.3% up from 88.5% in 2008 and 65% in 2006! That is a 27.3% increase in over 3 years!
In addition to these dramatic improvements, is an overall increase in the use of hand sanitizers across the organization. In 2009 we used 64 cases of hand sanitizer compared to 36 cases in 2006. That is an 80% increase in use hospital wide, and certainly a great measure of improved overall hand hygiene compliance around the departments through out the hospital. As we know, many infections can be prevented by simply washing our hands. Given our current low infection rate and excellent compliance with hand hygiene principles demonstrates our commitment to patient safety at NMC!
Contact Information:
Pam Bonsall
Infection Control Practitioner
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
524-8481 * 524-1250 (fax) * pbonsall@nmcinc.org
Project Name: STEMI Heart Attack Collaboration Project
Situation Description:
Living in rural Vermont doesn’t have to mean feeling isolated and without access to high tech health care services. In times of medical crisis, the ability of a community hospital to get patients the care they need can be critical. NMC has worked closely and collaboratively with Fletcher Allen Health Care in Burlington to ensure that patients in northwestern Vermont have appropriate access to care. In 2007, the hospitals began work together to reduce “door to balloon time” for patients with a particular type of heart attack.
Project Goals & Measures:
“ST Elevated Myocardial Infarctions” (STEMI) are among the most dangerous of heart attacks, given their sudden onset and deadly implications. For these patients especially, time is of the essence. NMC’s Emergency Department has worked with Fletcher Allen’s Cardiology to implement a specialized STEMI Protocol – which calls for patients experiencing that type of heart attack in northwestern Vermont to be assessed, diagnosed, and stabilized at NMC, transferred to Burlington, and into the FAHC Cardiac Catheterization Lab within 90 minutes, which is the national standard for hospitals with a Cardiac Cath lab of their own.
Intervention Description:
Beginning in the fall of 2006, work began behind the scenes to set the stage for implementation of the STEMI protocol at NMC. Dr. Prospero Gogo, a Fletcher Allen Cardiologist with Courtesy (consulting) privileges at NMC and part-time office hours on the NMC campus, began conversations about STEMI with Dr. Marc Kutler of NMC’s Emergency Department.
Collaboration takes effort from all parties involved, including Fletcher Allen, NMC, and the area ambulance squads:
- Early on, Fletcher Allen’s Cardiology department made a commitment and put into practice immediately taking calls from NMC’s Emergency Department to reduce call-back time for these time sensitive patients.
- Working together, a STEMI documentation tool was created that included all of the protocol information onto one sheet of paper that follows through the entire process. This includes demographics, nursing documentation, physician orders, and transfer documentation.
- Individuals presenting to the Emergency Department with a potential STEMI diagnosis are never removed from the ambulance stretcher to save valuable time in the process prior to transporting the patient to FAHC’s Cardiac Catheterization Lab.
Evaluation & Results:
In 2007, NMC’s average time from arrival at NMC’s Emergency Department to an open artery at Fletcher Allen was just 88 minutes—including drive time to travel 27 miles between facilities along I-89—according to data collected by Harold L. Dauerman, MD, Director of Cardiovascular Catheterization Laboratories, Professor of Medicine University of Vermont/Fletcher Allen. Dr. Dauerman and Dr. Marc Kutler review every STEMI case that occurs to review the process and the timeframes to be able to address any issues that may have arisen.
In 2009, NMC transferred 20 patients to FAHC for treatment of STEMI. Our average ‘Door to transfer Time’ was 39 minutes for these patients and our overall average ‘Door to FAHC time” was 85 minutes, including a 30 minute drive from St. Albans to Burlington. In one year we have reduced our overall “Door to FAHC time” by an additional 3 minutes, down from 88 mins in 2008 to 85 minutes in 2009. We continue to exceed national benchmark goals of 90 mins using our STEMI protocol for our patients. When every minute counts in the treatment of heart attacks, NMC is leading the way. Saving patients and reducing harm!
This amazing collaborative approach is a prime example of both organizations’ unquestioned commitment to saving lives. When every minute makes a difference, this effort is truly a life saver in northwestern Vermont.
Contact Information:
Molly Grismore, Emergency Department Nurse Manager
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
524-4307 * 524-1053 (fax) * mgrismore@nmcinc.org
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