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Henry Ford Task Force Reduces Catheter-related Bloodstream Infections in Hemodialysis Patients

The Henry Ford Medical Group in Detroit has a large dialysis program with high-risk patients; about 80 to 100 of these patients per month use a hemodialysis catheter for vascular access. Despite attempts to reduce catheter-related bloodstream infections (CRBSI) over a 3-year period, rates remained well above the national benchmark of 3.1/100 patient months. To address this issue, the Catheter Bacteremia Task Force was formed, involving Nephrology, Pharmacy Services, Infectious Diseases, Infection Control, and the Dialysis Administrator. This Task Force included the expertise and key leadership needed to make any potential intervention successful. The protocol involved instilling a gentamicin/trisodium citrate solution into the catheter lumen after each patient’s dialysis session.

Use of the antibiotic lock protocol decreased the average rate of CRBSI by almost 85%, avoiding an estimated 69 infections. The protocol was spread to three other dialysis units, resulting in a 24.5% reduction in mortality for dialysis patients. This improvement initiative reduced infections to below the national benchmark and reduced hospitalizations and unnecessary vascular access procedures which also translated into significant cost-savings.

For this innovative work, Henry Ford Health System won the Innovations in Healthcare Award in recognition of excellence in chronic kidney disease prevention and treatment.

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313-876-8709
Dangell1@hfhs.org
www.henryfordhealth.org

Henry Ford Health System’s ‘No Harm Campaign’ Reduces Harm and Saves Lives

The “No Harm Campaign” at Henry Ford Health System (HFHS) in Detroit integrates national, local, and homegrown efforts into one system-wide initiative to reduce harm. With an ambitious goal to decrease harm events system-wide by 50% from 2008-2013, the No Harm Campaign focuses on enhancing the culture of safety, improving the quality and clarity of clinical communications, identifying top causes of harm overall and at individual points on the continuum of care, and redesigning care to eliminate common causes of harm.

HFHS uses a broad definition of harm: any unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization or that results in death. Such injury is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital.

Harm reduction is measured by a comprehensive set of 27 measures across six categories: infection-related, medication-related, procedure-related, care delivery, employee, and other types of harm. These harm measures, comprised of hundreds of medical codes, combine to create a unique aggregate global harm score. The global harm score for each hospital overall and by category is transparent to all stakeholders within the system in an effort to create and spread best practices for harm reduction across the system.

From January 2008 through December 2011, the combined inpatient harm rate system-wide decreased by 31% and system-wide mortality rate decreased by 18%. This reflects a reduction of 169 harm events/month even while adding a new hospital and increasing the total number of patient days in the period measured. Cost-savings of the No Harm Campaign are estimated to total $10 million over a 4-year period, a savings of 8-9% each year in costs.

Read More

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313-876-8709
Dangell1@hfhs.org
www.henryfordhealth.org

Obstetrical Care Improvements Increased Quality and Reduced Costs

In reviewing its data, Intermountain found that there were a “golden few” clinical processes that made up the bulk of care that the system delivers. Just 104 clinical processes accounted for 95 percent of all of Intermountain’s care delivery. Eleven percent of these related solely to obstetrics. Intermountain realized that it could have a bigger impact on quality overall by focusing on this area because of the sheer numbers of obstetrical patients, so it developed care protocols that resulted in fewer elective induced labors, cesarean sections, while reducing overall costs.


How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts

Adapted from the article by Brent C. James and Lucy A. Savitz is available at: http://content.healthaffairs.org/content/30/6/1185.full.html

Since the late 1980s, Intermountain Healthcare of Utah and Idaho has applied a process management philosophy that maintains the best way to reduce costs is to improve quality. To implement this philosophy system-wide, Intermountain created data systems and management structures that increased accountability and drove quality improvement. It also achieved significant cost savings by measuring, understanding, and managing variation among clinicians in providing care.

In reviewing its data, Intermountain found that there were a relative “golden few” clinical processes that made up the bulk of care that the system delivers. Just 104 clinical processes—roughly 7 percent of the 1,400—accounted for 95 percent of all of Intermountain’s care delivery. Eleven percent related solely to obstetrics. Intermountain realized that it could have a bigger impact on quality overall by focusing on this area because of the sheer numbers of obstetrical patients.

Induction of early labor has been associated with higher rates of complications for both mothers and newborns, so, in 2001, Intermountain’s pregnancy, labor, and delivery leadership decided to focus on the induction of early labor as a target for improvement. The team created a shared baseline and a standardized electronic checklist that identified when elective induction is medically appropriate. The protocol was deployed across the entire Intermountain system, which performs more than 32,000 deliveries each year. If the patient met the criteria, the induction proceeded; if not, the nurses informed the attending obstetrician that it could not proceed without approval from the chair of the obstetrics department or a specialist in high-risk pregnancies.

The new protocol helped reduce rates of elective induced labor, unplanned cesarean sections, and admissions to newborn intensive care units. Elective inductions that were not clinically appropriate fell from 28 percent to less than 2 percent of all inductions. Intermountain’s overall rate of deliveries by cesarean section is now 21 percent, while the national rate is approaching 34 percent. There were cost efficiencies as well. Intermountain estimates that the elective induction protocol reduces health care costs in Utah by about $50 million per year. If applied nationally, it would lower health care delivery costs by about $3.5 billion annually.

Intermountain implemented other evidence-based quality improvement initiatives that resulted in enhanced patient safety, better outcomes, and lower overall costs.

Keywords: care teams, care management, care coordination, communication, electronic medical record, EMR, evidence-based medicine, health information technology, Intermountain Healthcare, induced labor, obstetrics, Salt Lake City, Utah, safety, treatment, value

FOR MORE INFORMATION:

Dave Green
Communications Manager
Intermountain Healthcare
36 South State Street
Salt Lake City, UT 84111
tel. 801.442.2844
dave.green@ihc.com
www.ihc.com

HealthPartners: Closing the Gap in Health Care Disparities (Colorectal Cancer)

Colorectal cancer deaths are 48 percent higher among African-Americans than among whites, according to the US Department of Health & Human Services. As a result, HealthPartners developed customized interventions aimed at reducing disparities in colorectal cancer screening rates for African-American patients.


More than ten years ago, HealthPartners began groundbreaking work to close a gap in health care and ensure that care and service is of equally high quality for all populations, regardless of a patient’s race or ethnicity, preferred language, private insurance or public program. To identify and address these disparities, HealthPartners leaders established the Cross Cultural Care and Service Task Force in 2001, and, in 2003, the health system developed a plan to collect self-reported patient demographic data to assist in creating strategies and tactics to improve care and service for our patients.

Reduction of colorectal cancer screening disparities for African-American patients

Colorectal cancer deaths are 48 percent higher among African-Americans than among whites, according to the US Department of Health & Human Services. As a result, HealthPartners developed customized interventions aimed at reducing disparities in colorectal cancer screening rates for African-American patients.

In 2009, based on new national guidelines and guidelines from the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative, HealthPartners expanded the eligible population for colorectal cancer screening to include African-Americans and Native Americans at age 45 instead of 50, which added more than 1,000 HealthPartners patients who needed screening.

To screen additional patients and to close the gap, HealthPartners developed several customized interventions, including:

  • Using the race information provided by patients and the electronic medical record to automatically generate reminders to African-American and Native American patients and providers to have colorectal screening beginning at age 45
  • Telephone outreach to patients who were eligible for screening
  • The option of a fecal immunochemical (FIT) test, an evidence-based alternative to colonoscopy. The electronic medical record provides a shared decision making tool for our provider to offer the FIT test for patients who prefer it over colonoscopy.

These interventions are saving lives by improving screening disparities by payer (as a measure of socioeconomic differences) and by race. HealthPartners has seen a 27 percent improvement in colorectal screening rates for African American patients since implementation. Even with the population expansion, HealthPartners screening rates continue to rise rapidly, and are already above the 2010 HEDIS 50th percentile rankings.

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Kaiser Permanente’s Healthy Bones Program Results in Reduction in Hip Fractures

According to recent information from the National OsteoporosisFoundationand the Office of the Surgeon General, osteoporosis is a major medical problem. The disease currently affects 8million women and 2 million men in the United States. Kaiser Southern California has a fully integrated Healthy Bones Program in place at all eleven of its medical centers. Using its electronic medical records system is capable of tracking dual X-ray absorptiometry scans, fragility fractures, and the medications used to treat or prevent osteoporosis, Kaiser’s multidisciplinary team prevented 970 hip fractures in calendar year 2007 (2544 hip fractures were predicted and the actual number was 1574), a reduction of 38.1%.

Excerpts from The Journal of Bone and Joint Surgery article:
http://www.ejbjs.org/cgi/content/full/91/Supplement_6/79

“According to recent information from the National OsteoporosisFoundationand the Office of the Surgeon General, osteoporosis is a major medical problem. The disease currently affects 8million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated1.5 million individuals in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of 18 billion dollars. With the rapidly aging U.S. population, the problem of osteoporosis is now reaching epidemic proportions. There are 75 million baby boomers entering the stage in their lives when they are most at risk for osteoporosis. One-half of all women and one-third of all men will sustain a fragility fracture during their lifetime.

Knowledge That What the Orthopaedic Surgeon Does Improves Bone Health

The literature has shown that orthopaedic surgeons have not done enough to aggressively diagnose and treat osteoporosis. It is important for orthopaedic surgeons to know that an aggressive osteoporosis disease-management program can decrease the rate of osteoporosis-related hip fractures by 25% to 50%. One such program is described below.

Background of the Kaiser Southern California Healthy Bones Program

Kaiser Southern California (Kaiser SCAL) is a health-maintenance organization in Southern California that is made up of eleven medical centers with 3.2 million members. Kaiser SCAL has an electronic medical records system that is capable of tracking dual X-ray absorptiometry scans, fragility fractures, and the medications used to treat or prevent osteoporosis. Kaiser SCAL has a fully integrated Healthy Bones Program in place at all eleven of its medical centers. The Healthy Bones Program was established by having orthopaedic surgeons serve as champions in a large multidisciplinary team comprised of healthcare providers from the following disciplines: endocrinology, family practice, internal medicine, rheumatology.

Results

Since the SCAL Healthy Bones Program was adopted, we have seen our annual dual X-ray absorptiometry scan utilization rate rise from 21,557 per year in 2002 to 78,262 per year in 2007, a 263% increase. The annual dual X-ray absorptiometry scan utilization rate in men was 1549 in 2002, and it increased to 15,700 per year by 2007, a 914% increase. The annual number of patients receiving anti-osteoporosis medications rose from 33,208 per year in 2002 to 84,155 per year in 2007, a 153% increase. The annual number of men who received anti-osteoporosismedications in 2002 was 2663, and that number increased to 9310 a year by 2007, a 250% increase. There was a large variation in the reduction in hip fracture rates at the eleven SCAL medical centers during the study period. The reduction in hip fracture rate varied from 31.0% to 54.3%. The overall hip fracture rate reduction was 38.1%. That translated into preventing 970 hip fractures in calendar year 2007 (2544 hip fractures were predicted and the actual number was 1574).

Keywords: Osteoporosis, Kaiser Permanente Southern California, Healthy Bones, electronic medical records, orthopaedic, bone loss, hip fractures, bone loss, multidisciplinary team

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Kaiser Permanente’s Joint Replacement Registry Improves Patient Outcomes While Reducing Costs

Within the US, over 600,000 total hip and total knee replacements are performed each year. By the year 2030, that number is projected to exceed 4 million. Annual hospital costs associated with these procedures are projected to exceed $65 billion by 2015. The projected increases in the demand for total joint replacements and the costs associated with these procedures will challenge our already overburdened US health care system. Kaiser Permanante’s Total Joint Replacement Registry helps its surgeons and patients make informed decisions about which implant to use or in which patients the risks and potential costs of failure make surgery unwise.


Excerpted from The Permanente Journal article:

“Within the US, over 600,000 total hip and total knee replacements are performed each year. By the year 2030, that number is projected to exceed 4 million. Annual hospital costs associated with these procedures are projected to exceed $65 billion by 2015. Although patients who undergo total joint arthroplasty (TJA) are often of retirement age, recent studies have shown that patients below age 65 represent 35-45% of all TJA recipients in the US. As TJA is marketed more as a lifestyle operation than as a final option to retain mobility for end-stage arthritis, the proportion of patients below age 65 may increase.

The projected increases in TJA demand and the costs associated with these procedures will challenge our already overburdened US health care system. One potential method to address this pending crisis is through comparative safety and clinical effectiveness research aimed at reducing the need for TJA revision surgery. Registries are one example of clinical effectiveness studies that can help surgeons and patients make informed decisions about which implant to use or in which patients the risks and potential costs of failure make surgery unwise. These studies can also identify the relative value of TJA over alternative treatments or the effectiveness of one implant brand or design over another. Although implants vary widely in cost, there is little evidence to support the use of new, more expensive designs instead of more established, traditional designs.

The goals of the Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) are: 1) to monitor revision, failure, and rates of key complications (e.g., infection, venous thromboembolic disease such as blood clots and embolism, and mortality); 2) to identify patients at risk for poor clinical outcomes following TJA; 3) to identify the most effective techniques and implant devices (best practices and implant constructs); 4) to track implant usage and costs; and 5) to monitor and to support implant recalls and advisories in cooperation with the US Food and Drug Administration.”

Link to full journal article: http://xnet.kp.org/permanentejournal/sum08/joint-replacement.html

Keywords: clinical effectiveness, total hip replacements, total knee replacements, joint replacement, total joint replacement registry, total joint arthroplasty, TJA, Kaiser Permanente, KP, Southern California, registries

For More Information:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Information Technology Supported Care Teams Significantly Improve Care for Patients with Heart Disease

Kaiser Permanente Colorado has significantly reduced the mortality rate for patients with heart disease, which is the nation’s number one killer for both women and men. Using team-based medical best practices and computer-supported care registries, doctors and clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent. Coronary Artery Disease is the dangerous buildup of plaque inside the coronary arteries. Cardiac mortality refers to all deaths related to heart events.


Excerpt from Kaiser Permanente case study:
http://xnet.kp.org/future/ahrstudy/032709cardiac.html

“Kaiser Permanente Colorado has significantly reduced the mortality rate for patients with heart disease, which is the nation’s number one killer for both women and men. Using team-based medical best practices and computer-supported care registries, doctors and clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent. Coronary Artery Disease is the dangerous buildup of plaque inside the coronary arteries. Cardiac mortality refers to all deaths related to heart events.

The ability of clinical care teams to coordinate their efforts in cardiac care is greatly enhanced by the availability of electronic health information—which provides instant access to patient information—and evidence-based clinical care guidelines and protocols.”

Keywords: CAD, care coordination, care teams, cardiac care program, chronic care, collaborative care, colorado, communication, coronary artery disease, electronic medical record, evidence-based medicine, health information technology, integrated care, Kaiser Permanente, KP Healthconnect, patient support, population health, preventive care, safety, treatment, value

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Depression Care Curbs Rate of Suicides at Henry Ford

A quality improvement initiative for the Health Alliance Plan members who receive care at Henry Ford Medical Group resulted in dramatically bringing down the rate of suicide in its 200,000 patient population. Over 9 consecutive quarters, there were no suicides among the patients of the Perfect Depression Care Program of the Behavioral Health Services division of Henry Ford, in stark contrast to the 230 suicides expected in an average population of 100,000. The goal of the initiative was to completely redesign care delivery around the six aims outlined in the Institute of Medicine’s Crossing the Quality Chasm report–safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—in order to reduce the number of suicides to zero. The belief held by the program is that perfect depression care would result in no suicides—not just a reduced risk of suicide.


Excerpted from:
Depression Care Effort Brings Dramatic Drop in Large HMO Population’s Suicide Rate
Tracy Hampton, PhD
JAMA. 2010;303(19):1903-1905.
http://jama.ama-assn.org/content/303/19/1903.extract

“While physicians and other health care workers may not be ableto predict which of their patients will attempt suicide, theycan implement preventive strategies that markedly lower therisk of such tragedies. Now, one pioneering program has demonstratedthe importance of pursuing 2 key approaches at once: carefullyassessing patients for risk of suicide and adopting measuresto reduce the likelihood that a patient will attempt suicide.

The example comes from a quality-improvement initiative that succeeded in substantially bringing down the rate of suicide in a population of about 200 000 members of a large health maintenance organization (HMO). Through the second quarter of last year, the Perfect Depression Care program of the Behavioral Health Services (BHS) division of the Henry Ford Health System resulted in 9 consecutive quarters without any suicides, a dramatic contrast to the annual rate of 89 suicides per 100,000 members at baseline and approximately 230 suicides per 100,000 individuals expected in a patient population . . .”

Keywords: care team; depression; Henry Ford Health System; Michigan; Perfect Depression Care Program; prevention; quality improvement; rate of suicide;

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313-876-8709
Dangell1@hfhs.org
www.henryfordhealth.org

New Tools Empower Patients to Make Decisions

Studies show that if patients are given information about all of the options available to treat their condition in a palatable manner, they are much happier with their medical decision and the outcome. Patients also tend to choose less aggressive treatments. This can improve patient safety and health outcomes while bringing down the cost of care. At any given time, between 20,000 and 30,000 Group Health patients are considering a preference-sensitive procedure. To assist their patients and doctors in making treatment decisions, the health system uses tools such as videos to involve and inform their patients.


New Tools Empower Patients to Make Decisions, by Michael Soman, MD, April 19, 2010
http://ghcview.org/?p=110

Sometimes science does not have all the answers. Treatments for conditions from back pain to breast cancer sometimes involve weighing different options with pros and cons for each. Often these treatment decisions are best determined by the patient’s preference as she weighs the impact on her life of surgery, pain, and daily functioning.

At Group Health we have identified a list of preference-sensitive conditions and have begun a more formalized approach to involving the patient in these treatment decisions. Part of experience for patients is watching a carefully balanced video presentation developed with scientific rigor by the Foundation for Informed Medical Decision Making. In a video for cardiology, a patient learns the pros and cons of getting angioplasty. In general surgery, another video educates breast cancer patients about the differences in lumpectomy versus mastectomy.

Patients are encouraged and given time to fully discuss all of their questions and concerns with their doctor. It is a decision made together – shared between patient and doctor. This, unfortunately, is a very different experience in many doctors’ offices and hospitals across the country where patients can feel rushed and under some pressure to follow the doctor’s orders. Although most doctors mean well, surgeons tend to promote the treatment that they feel they do well – and that supports their business.

Studies show that if patients are given all the information in a palatable manner, they are much happier with their decision and the outcome. Patients also tend to choose less aggressive treatments. This can improve patient safety and health outcomes while bringing down the cost of care.

At any given time, between 20,000 and 30,000 Group Health members are considering a preference-sensitive procedure. Researcher David Arterburn from the Group Health Research Institute is carefully tracking the results of this program, looking at improvements in the patient experience as well as whether the process reduces the number of more aggressive treatments.
We don’t whether these new tools will reduce costs at Group Health. But we know from our experience at Group Health that ensuring patients are fully informed and involved in decisions about their care is worth the investment of materials and time.

Keywords: care coordination, communication, David Arterburn, Foundation for Informed Decision Making, Group Health Cooperative, Group Health Research Institute, integrated delivery system, medical home, patient support, physician primary care, shared decision making, treatment, value, Washington

FOR MORE INFORMATION:

Stephen Tarnoff, MD
Associate Medical Director, Strategy & Business Development
Group Health Cooperative
320 Westlake Ave. N., Suite 100
Seattle, WA 98109-5233
tel.206.448.5006
tarnoff.s@ghc.org
www.ghc.org

Diabetic Care Management at Intermountain Healthcare

Diabetes is the sixth leading cause of death by disease in the US. But caring for diabetic patients is remarkably simple. Most health care providers understand what needs to be done to keep diabetics well, but it is difficult and time-intensive to get the patient to participate in the process — and it’s easy for things to fall through the cracks. To care effectively for diabetic patients, a care management model must be put in place and followed consistently in order to keep diabetic patients healthy. Intermountain Healthcare’s system makes it easier for the health provider and the patient to do the right thing.


Diabetic Care Management at Intermountain Healthcare Diabetes is the sixth leading cause of death by disease in the US. But caring for diabetic patients is remarkably simple. Most health providers understand what needs to be done to keep diabetics well, but it is difficult and time-intensive to get the patient to participate in the process — and it’s easy for things to fall through the cracks. To care effectively for diabetic patients, a care management model must be put in place and followed consistently in order to keep diabetic patients healthy. Here’s how Intermountain Healthcare does it:

  1. When a diabetic patient is identified (in one of its 140 clinics, 21 hospitals, or among its 400,000 health plan members), this is noted in Intermountain’s advanced computerized electronic patient record.
  2. This electronic record then follows the patient wherever they go in the Intermountain system and identifies them to caregivers as diabetic.
  3. Patient education is provided in the physician office as well as in regular, consistent mailings. Care managers (typically nurses) are assigned to help individual diabetic patients and make outreach phone calls.
  4. Most of Intermountain’s hospitals and large clinics offer diabetic education classes as well as diabetic educators who visit the patients in their hospital room. There are multiple Diabetes Education Centers that have more than 20,000 patient visits each year.
  5. Patients are strongly encouraged and frequently reminded to get tests and screenings related to their diabetes. This helps them keep their blood sugar in control and avoid other complications.
  6. Intermountain’s health plan sends quarterly diabetes reports to physician offices listing the names, screening statuses, and lab results of diabetic patients. If patients have not been filling their diabetic medication prescriptions, the physician is notified so he can follow up with the patient. This report also allows physicians to see how his/her diabetes patient management compares to other physicians.
  7. Clinical teams of physicians, nurses, pharmacists, diabetes educators, and computer specialists meet monthly to measure and refine the process.

How does diabetic care at Intermountain compare to the U.S.? Two examples:

  • Intermountain ranks above the national average in getting patients to do annual extensive HbA1c (blood sugar) testing, with 90 percent participating appropriately.
  • Only 22 percent of Intermountain patients have poor HbA1c control compared to the national average of 29 percent. Poor control can contribute to a variety of other health problems.

It’s important to note that it’s unlikely any health care organization will achieve perfection. Much of this process depends on personal involvement by the patient, and some patients are more motivated than others.

Keywords:care teams, care management, care coordination, communication, diabetes, electronic medical record, EMR, evidence-based medicine, health information technology, Intermountain Healthcare, Salt Lake City, Utah, safety, treatment, value

FOR MORE INFORMATION:

Dave Green
Communications Manager
Intermountain Healthcare
36 South State Street
Salt Lake City, UT 8411
tel. 801.442.2844
dave.green@ihc.com
www.ihc.com