Identifying gaps, barriers, and solutions in implementing pressure ulcer prevention programs.

BACKGROUND: Patients continue to suffer from pressure ulcers (PUs), despite implementation of evidence-based pressure ulcer (PU) prevention protocols. In 2009, Joint Commission Resources (JCR) and Hill-Rom created the Nurse Safety Scholar-in-Residence (nurse scholar) program to foster the professional development of expert nurse clinicians to become translators of evidence into practice. The first nurse scholar activity has focused on PU prevention. Four hospitals with established PU programs participated in the PU prevention implementation project. PU PREVENTION IMPLEMENTATION PROJECT: Each hospital's team completed an inventory of PU prevention program components and provided copies of accompanying documentation, along with prevalence and incidence data. Site visits to the four participating hospitals were arranged to provide opportunities for more in-depth analysis and support. Following the initial site visit, the project team at each hospital developed action plans for the top three barriers to PU program implementation. A series of conference calls was held between the site visits. YEAR 1 PROJECT RESULTS: Pressure Ulcer Program Gaps and Recommendations. The four hospitals shared common gaps in terms of limitations in staff education and training; lack of physician involvement; limited involvement of unlicensed nursing staff; lack of plan for communicating at-risk status; and limited quality improvement evaluations of bedside practices. Detailed recommendations were identified for addressing each of these gaps. these CONCLUSIONS: Recommendations for eliminating gaps have been implemented by the participating teams to drive improvement and to reduce hospital-acquired PU rates. The nurse scholars will continue to study implementation of best practices for PU prevention.

Maximize Reimbursement and Minimize Risk Under the Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) and the Quality Payment Program (QPP).

The Congress recently passed legislation to repeal the Sustainable Growth Rate Formula and replace it with the Medicare Access and Children Health Plan Reauthorization Act's Quality Payment Program. The Quality Payment Program is designed to move physician payment from a volume-based to a value-based methodology. There are two pathways of payment that diverge and are differentiated by managing risks or managing rewards. The Merit-based Incentive Payment System (MIPS) is a competitive payment system that is budget neutral and results in defined winners and losers with potential losses/gains in payments from 4% in 2019 to 9% in 2022. Characteristically, this is not dissimilar to the Sustainable Growth Rate Formula of days past but with quality measures applied. The second pathway is that toward Alternative Payment Models (APMs) that allow clinicians to participate in payment models that that provide rewards for higher-quality, lower-cost care with entry bonuses as high as 5%. The Virginia Cardiac Services Quality Initiative, a well-known regional quality collaborative, was awarded a federal grant as a Support and Alignment Network 2.0 in September 2016. As an awardee, the Virginia Cardiac Services Quality Initiative is offering, free of charge, educational support to clinicians to understand the Medicare Access and Children Health Plan Reauthorization Act, MIPS, and APMs. These support services will include on-site education, continual evaluation, and guided transformation of practices to move from MIPS, a very competitive and possibly very difficult system for Society of Thoracic Surgeons members, toward Advanced APMs, where they can self-direct their measurement and rewards, allowing success financially under the Medicare Access and Children Health Plan Reauthorization Act.

Measuring the quality of nursing care to Alzheimer's patients.

Facilities that provide care to Alzheimer's disease patients are under unrelenting pressure to document the quality of nursing care they provide to various stakeholders. Unfortunately, little consensus exists nor is guidance given as to how to measure the quality of nursing care. Regulations and standards exist but are seldom translated into systematic outcome measures that assist nurses and facilities to measure, report,and manage the quality of care they provide to residents in general and Alzheimer's patients in particular. This article offers practical ad-vice on conceptualizing quality of nursing care to Alzheimer's patients and the selection of outcome measures to collect, analyze, use, and re-port quality of nursing care data.

Quality improvement for stroke management at the Cleveland Clinic Health System.

BACKGROUND: The Cleveland Clinic Health System established a stroke quality improvement (QI) initiative across its nine hospitals. IMPLEMENTING THE STROKE QI INITIATIVE: A stroke QI team took a three-pronged approach to QI: professional education, public education, and hospital process improvements. Its activities and subsequent data analysis needs were divided into four cycles (1999-2003). All data were provided to the stroke QI team and then to the Medical Operations Council to review results, consider data integrity issues, and plan dissemination. The dissemination of performance results permitted broad organizational responses to facilitate improvement. Improvement activities included professional education, public awareness, process improvement, focused data collection with routine feedback, protocol refinement, and coordination of clinical personnel within and between hospitals. RESULTS: The frequency of brain hemorrhagic complications decreased by more than half, from 13.4% to 6.4%; the rate of intravenous tissue plasminogen activator use increased from 1.5% to 3.9% of all stroke patients; and protocol deviations were reduced from 33% to 17%. DISCUSSION: The keys to this initiative's success were the health system's leadership's support, physicians' engagement via multidisciplinary project committees at the health system and hospital levels, and flexibility in implementing locally tailored process interventions.

Cleveland Clinic Health System: A comprehensive framework for a health system patient safety initiative.

The Cleveland Clinic Health System (CCHS) is committed to the enhancement of patient safety throughout the CCHS. This article describes the CCHS patient safety initiative, the development, objectives, strategies, goals, and activities.

Quality improvement and tissue-type plasminogen activator for acute ischemic stroke: a Cleveland update.

BACKGROUND AND PURPOSE: A systematic audit of intravenous tissue-type plasminogen activator (tPA) use and stroke outcomes in Cleveland, Ohio, during 1997-1998 demonstrated higher rates of symptomatic intracranial hemorrhage (ICH) than reported in the National Institute of Neurological Disorders and Stroke (NINDS) trial. We now report updated results of intravenous tPA use in the Cleveland Clinic Health System (CCHS). METHODS: A stroke quality improvement program was initiated in the 9-hospital CCHS in 1999. A retrospective chart review for all stroke patients with primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes 434 and 436 admitted to the 9 hospitals from June 1999 to June 2000 was used to determine outcomes of patients treated with intravenous tPA. RESULTS: Intravenous tPA was given to 18.8% of patients arriving within 3 hours of symptom onset. Protocol deviations occurred in 19.1% of patients given intravenous tPA. The symptomatic ICH rate was 6.4%. CONCLUSIONS: Since 1997, intravenous tPA use has increased, while the rates of symptomatic ICH and protocol deviations have decreased in the CCHS. The CCHS symptomatic ICH rate is now similar to that reported in the NINDS trial. These improvements occurred after initiation of a stroke quality improvement program.

Utilization of intravenous tissue plasminogen activator for acute ischemic stroke.

BACKGROUND: Intravenous tissue plasminogen activator (tPA) is the only approved therapy for acute ischemic stroke, although only 2% of patients with stroke receive intravenous tPA nationally. OBJECTIVE: To determine the rate of tPA use for stroke in the Cleveland, Ohio, community and the reasons why patients were excluded from thrombolysis treatment. DESIGN: Retrospective cohort study. SETTING: Community. Subjects Patients admitted because of stroke to the 9 Cleveland Clinic Health System hospitals from June 15, 1999, to June 15, 2000. MAIN OUTCOME MEASURES: Utilization of intravenous tPA and reasons for ineligibility. RESULTS: There were 1923 admissions for ischemic stroke in the 1-year period. Of these, 288 (15.0%) arrived within the 3-hour time window, and approximately 6.9% were considered eligible for tPA. The most common reasons for exclusion among patients arriving within 3 hours were mild neurologic impairment and rapidly improving symptoms. The overall rate of tPA use among patients presenting within 3 hours was 19.4%, and the rate of use among eligible patients was 43.4% (n = 56). The use of tPA did not differ significantly according to race or sex. CONCLUSIONS: Only 15% of patients arrived within the 3-hour time window for intravenous tPA, making delay in presentation the most common reason patients were ineligible for i.v. thrombolysis. Neurologic criteria were the second most common group of exclusions. Overall tPA use was low, but it was used in nearly half of all patients with no documented contraindications. Intravenous tPA use in a community setting can compare favorably with the rate of use seen in academic medical settings.

Introducing the quality Institute of the Cleveland Clinic Health System.

Several quality measurement needs surfaced when the Cleveland Clinic Health System (CCHS) was formed, including a need for standardized measurement of clinical processes and outcomes, patient satisfaction, critical care, and patient safety. The Quality Institute (QI) facilitates system teams to address these issues, manages selection of measurement tools, collects and analyzes performance data, coordinates presentations, and presents team findings. The QI manages the CCHS performance improvement plan and coordinates activities designed to accomplish priority goals, in collaboration with multiple CCHS teams and the regional and hospital staffs. The most important outcome of the QI's operations is improved care, as demonstrated through objective measurement. Other outcomes include external recognition and funding; implementation of standardized measurement systems, data management activities, and production of quarterly reports; increased internal recognition; completion of several education programs; acceptance of data by payers and plans; and participation in attainment of Joint Commission on Accreditation of Healthcare Organizations network accreditation.