Marcum and Wallace Memorial Hospital Project HOME (Helpful Opportunities for Medical Care Enhancement)

Transcription

1 Marcum and Wallace Memorial Hospital Project HOME (Helpful Opportunities for Medical Care Enhancement) Network Community Lung Cancer Screening Program An innovative Patient Care Program 1

2 Part II. Quality Issues A. What role does organizational leadership (governance, clinical leadership, administration) play in defining and promoting quality health care in your organization? Board of Directors: The Board of Directors support and have the final authority and responsibility for the flexible, comprehensive, and integrated performance improvement process. The Board of Directors has the ultimate responsibility for assuring the provision of high quality patient care. The Board monitors quality management and performance improvement reports from the following: Quality Improvement Committees Medical Staff Quality Committees Patient Safety Committee Infection Control and Blood Utilization committees Administration: The Administration provides the resources, equipment and personnel reasonably required to maintain and support the quality initiatives at MWMH. The CEO, the executive and management teams are responsible for implementing and supporting quality, utilizing the problem solving process, as well as serving as role models. This is demonstrated by: Providing input in the selection of opportunities for improvement Identifying key customer expectations, Sharing concepts and ideas which empower employees to engage in performance improvement activities. Medical Staff: The Medical Staff is committed to supporting the performance improvement endeavors of MWMH and actively participates in the quality process. The ongoing measurement/review processes for the medical staff includes the following: Ongoing focused review of patient care Infection control Blood Utilization Mortality and Morbidity Monitoring and evaluation of quality and appropriateness of care Patient safety Patient satisfaction Risk management Appropriateness of clinical practice Variances from established patterns of clinical practice Serious adverse event review Trauma Team Performance 2

3 1) The specific definition of quality used by your organization The definition of quality at MWMH is reflected through The Mission Statement which states MWMH in conjunction with the healing mission of Jesus, will provide excellence in health services; respond in a spirit of collaboration to the health needs of the community, especially those of the poor and underserved; be compassionate to those who serve and are served; and be faithful to the spirit and tradition of the Sisters of Mercy. 2) How leadership works together and uses the organization s definition of quality in conjunction with the organization s mission and vision to set quality goals. The commitment to quality is found throughout the Marcum & Wallace Memorial Hospital organization, appearing in the Mission Statement, the Strategic Plan, Vision and Values, allocation of resources, role expectations, reward structures, and performance evaluations. This commitment toward quality is the focus of the Process Improvement Plan. Therefore, inherent in this plan is the ability to provide an ongoing, comprehensive self-assessment system for the organization, which supports and promotes continuous improvement in the quality of patient care. To achieve our quality improvement goals MWMH must answer these questions: Are we doing the right thing? Are we doing things right? Are we certain we do the right things right the first time, every time? 3) How organizational leadership engages the organization s employees, clinical/medical staff, and patients and families in setting goals, evaluating progress, and implementing changes to achieve the defined goals. In 2014, Mercy Health developed a 4-year strategic plan with 6 strategic imperatives. One imperative is Cohesive Care Delivery Network, which focuses on actively works to assure safe, high-quality, cost effective, coordinated care. This strategic imperative is integrated into all areas of the hospital. Departmental quality goals with measurable outcomes are evaluated on an annual basis. Quality goals and indicators are also set/evaluated by the medical staff. We receive input from patients and families through the use of Press Ganey satisfaction surveys and during rounding. Quality is measured on a frequent basis using the following: Administrative rounding Press Ganey survey results Intentional rounding for improved outcomes with staff and patients Patient discharge follow-up phone calls 3

4 B. How does your organization support staff and employee efforts to achieve quality goals? 1) How employees and clinical/medical staff are trained in principles and practice of effective teamwork, communication, relationship management, and how the organization continually evaluates the effectiveness of such training. New employees are required to attend hospital orientation. This orientation sets the foundation for effective teamwork and communication. The employee receives information and instruction on the Mercy Health Promise a quality initiative that strives to provide the patient with an experience and not just a service. In orientation the employee also receives information related to the quality program at MWMH including key hospital initiatives for improving the Patient s Experience. The results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys are shared with staff during orientation and ongoing during departmental staff meetings as well as with the members of the medical staff. In addition, Press Ganey patient experience survey results are shared with the hospital staff including the medical staff members highlighting their individual performance with the various metrics. 2) How personal accountability for job performance is balanced with understanding the causes of harm and errors based on an analytical systems approach. At MWMH each employee is individually responsible to maintain a safe environment for patients. Each employee receives education on the Safecare incident reporting system. This system is used to track occurrences, near misses and concerns. The Medical Staff and Quality Committee provide education to the staff related to evidence-based medicine practices. Quality is included in the employee s annual evaluation and their individual performance is monitored throughout the year. 3) How and with what frequency your organization assesses employee and clinical/medical staff perceptions of the quality and safety culture within your organization. The perception of Quality and Safety at MWMH is assessed through various mechanisms on a regular basis including: Daily administrative rounding Daily feedback from staff during rounding Shift report from the House Supervisor Annual employee survey Using a mandatory computer based testing model known as ilearn Evaluating SafeCare reports on a daily basis Bi-monthly medical staff meetings Quarterly safety committee meetings Administrative Safety Walk Rounds Departmental staff meetings 4

5 Monthly department head meetings Bi-annual AHRQ Safety Culture Survey Bi-monthly Trauma Process Improvement Committee Meeting 4) How and with what frequency your organization assesses employee and medical staff satisfaction with the hospital work environment and the care provided to patients. The work environment and care provided at MWMH is assessed through various mechanisms on a regular basis including: A Physician Survey which asks the physician to rate the hospital in various areas including quality and patient care. MWMH received an overall score of 95/100 in physician satisfaction with the care provided by MWMH Rounding for outcomes on employees and departments Informal daily department walkthrough Annual employee surveys Bi-annual AHRQ Safety Culture Survey C. Describe one clinical or non-clinical hospital process improvement, patient care initiative, or innovative change project. Be sure to address: 1) A description of the project Marcum & Wallace Memorial Hospital (MWMH) Project HOME (Helpful Opportunities for Medical Care Enhancement) Network developed an innovative patient care program in 2014 called the Community Lung Cancer Screening Program. Marcum & Wallace Memorial Hospital is a 25 bed Critical Access Hospital and Level IV Trauma Center located in Irvine Kentucky. The Project HOME Network (PHN) is a rural health network comprised of 14 agencies in two counties. The aim of the network is to improve the health of the community through collaboration with other health care agencies. The Project HOME Network is funded through the Office of Rural Health Policy (ORHP) within the Health Resources Services Administration (HRSA). MWMH is the grantee and fiscal agent for the PHN. In 2013, the United States Preventative Services Task Force (USPSTF) developed recommendations for annual screening for lung cancer with low-dose computed tomography. The screening would target adults ages 55 to 80 years who have a 30 packyear smoking history and currently smoke or have quit within the past 15 years. The recommendation calls for three scans over a two-year period. The initial baseline scan followed by the second and third scans at 12 and 24 months respectively. In a large 5

6 research study it was found that low dose CT scan is superior to a chest x-ray in detecting early lung cancers. It was decided that patients for the lung cancer screening program would be selected in three ways. 1) Each Community Health Center and Rural Health Clinic would review their electronic health record (EHR) for patients that meet the criteria 2) The Health Care Navigator will query each ED navigation patient on whether they meet criteria for screening and 3) Advertisements will be placed in the local newspapers. 2) A description of the operation/process problems, patient care challenge or other factors that drove the improvement project Kentucky has one of the highest death rates from lung cancer in the nation. The area that MWMH serves has an even higher lung cancer death rate. The following table shows the prevalence of lung cancer in the MWMH Project HOME Network counties Lung Cancer Deaths per 100,000 population Kentucky Institute of Medicine (2007) Estill Lee Kentucky Nation 84/100, /100,000 80/100,000 55/100,000 3) The implementation of the project/process including how long did the project take and when was it completed Preparation for project implementation occurred in May of The Project HOME Network Clinical Care Committee reviewed the American Cancer Society recommendation for spiral CT Scanning for lung cancer screening. The current technology at Marcum & Wallace Memorial Hospital (MWMH) was capable of preforming the CT scan as recommended. It was decided by the committee to explore the option of developing and adding a lung cancer screening program for the Project HOME Network patients. The Project HOME Network met with a group of lung cancer specialist from the University of Kentucky Markey Cancer Center (National Cancer Institute Designated Cancer Center). They were very interested in helping us develop a community based comprehensive lung cancer screening program. Those attending the planning meeting were: - Dennis Jones, MD - Director of the Markey Cancer Center - Jamie Studts, PhD - Behavioral Health and Modification Specialists - Timothy Mullett, MD - Chief of CT Surgery University of Kentucky Hospital - Kristine Dameron, MHA Research Director - Michael Brooks, MD - Chief of Oncology Radiology 6

7 - Mark Dignan, PhD - Director of the UK Prevention Center - Cheri Tolle, MHA - UK Markey Center Outreach Coordinator It was decided after the initial meeting to move forward to develop a Community Lung Cancer Screening Program. The program would be based on the draft recommendations of the US Preventative Services Task Force (USPSTF). The USPSTF also recommended that Health Care Navigators be used to provide shared decision making (SDM) with the patient. The idea behind SDM is that there are some risks associated with CT Screening and the patient should be well informed of those risks before making the decision to enter the screening program. In the fall of 2013, preparation was made to start the program. A memorandum of agreement (MOA), protocols, and medical services agreements were established with Marcum & Wallace Memorial Hospital, Project HOME Network and the University of Kentucky Healthcare. An educational program was established for all the providers in the network area. These programs were conducted by UK and Project HOME and included the latest recommendations for CT lung cancer screening. These programs were well attended by all providers in the service area. In addition, The Health Care Navigator received training on shared decision making (SDM) and interviewing skills. 4) What makes the project innovative and significant? Patients living in the rural area can receive high quality, comprehensive lung cancer screening without the need to travel to a large urban hospital. The Community Lung Cancer Screening Program is designed to provide a multidisciplinary approach to lung cancer screening. The program is a collaboration of The Project HOME Network, Marcum & Wallace Memorial Hospital and the University of Kentucky Healthcare. The Project HOME Network provides the Health Care Navigator for shared decision making, the funding source for the screenings and data collection. Marcum & Wallace Memorial Hospital provides the technical screening services using a 64 slice CT scan. Dr. William Witt, the staff Radiologist provides initial interpretation of each screening. UK Healthcare provides technical expertise and quality control interpretation of the screening. In addition, UK Healthcare provides additional testing and treatment if needed. 5) What benefits were realized? As of March 2015, a total of 43 patients have received Shared Decision Making (SDM) and accepted entrance into the program. Of the 43 patients, 41 patients have received initial CT screening, with 30 patients were negative, 9 were suspicious and required further follow-up and two were positive for cancer. Several of the patients have received 7

8 their second CT scan. The patients diagnosed with cancer were referred to the cancer team at the University of Kentucky Markey Cancer Center. In February 2015, the Centers for Medicare/Medicaid Services (CMS) approved low dose CT scan as the standard recommendation for screening for lung cancer. This approval means that lung cancer CT screening will now require all insurances to cover the cost of the screening. In November 2015, Marcum & Wallace Memorial Hospital was designated as a CT Lung Cancer Screening Center by the American College of Radiology. 8