Posted: June 25, 2014

Getting Practical About Improving Quality


Responding to the increasing demands for integrating quality, an interprofessional Orthopaedic total joint arthroplasty team used a dashboard to display key performance indicators as a driver to improve value, quality, and patient safety in a mid-western academic medical center. Using a structured, monthly meeting agenda, the team uses the dashboard data to assess, plan, implement, and evaluate performance improvement opportunities. The process has proved successful and contributed to a number of dramatic improvements in the quality, safety, and efficiency of care as well as patient satisfaction. In January 2012, an interprofessional University of Iowa Hospitals and Clinics team came together to evaluate and improve patient satisfaction, care processes and outcomes using individualized dashboards to display key performance indicators. The process of identifying specific indicators led to the formation of our Orthopaedic quality team. The dashboard has become the principal guide for our team's quality and performance improvement initiatives in the total joint replacement surgery patient population. The dashboard was implemented in response to the new demands of health reforms and changes in public reporting. Data is obtained from various sources including: United HealthSystem Consortium, American College of Surgeons National Surgical Quality Program, CMS, Value Based Purchasing, Press Ganey, HCAHPS, Joint Commission, and US News and World Report. The dashboard key performance indicators provide clear direction for quality improvement initiatives, functional needs, patient satisfaction, financial impact, and standardizing patient care protocols. Key performance indicators display financial metrics, patient satisfaction survey results, measures of efficiency, effectiveness, and quality of services provided, and measures that identify the infrastructure needed to foster growth and improvement. The dashboard includes the following: case mix index, length of stay, postoperative complications, 30-day readmissions, discharge status, blood utilization rates, documentation practices and core measure compliance rates. The dashboard data is updated prior to the standing monthly meeting where individual and group data is presented, clearly labelled and unblinded. The team recognized that complete transparency and non-judgmental discussion are vital to ensure maximum performance in the pre-defined indicators. Individual best performers are recognized and looked to for leadership in standardizing care delivery. We bring together surgical faculty, nurses, quality healthcare professionals, infection preventionists, clinical leaders, ARNPs, PAs, PT/OT, Health Coach, and patient satisfaction coordinator to review data, individual cases, and evidence around best practices. As a result, a number of protocols have been standardized including: pain management, tranexamic acid, blood transfusion, deep vein thrombosis prophylaxis, and documentation practices. The dashboard concept led to improved quality, value, and patient safety in care delivery of Orthopaedic total joint replacement surgery patients. It contributed to a number of dramatic improvements in the quality, safety, and efficiency of care as well as patient satisfaction from calendar year 2012 to 2013: Reduction in the 30-day all-cause readmission rate from 5.8% to 4.6%. Increase in the number of total cases from 66 cases per month to 72 cases per month. Decrease in mean ICU days from 2 days to 1.5 days, or $922,320 savings in reduced hospital stay. Decrease in complication rate decreased from 0.023 to 0.019. Reduction in Agency for Healthcare Research & Quality safety indicator triggers from a mean of 1 per month to 0 for the last 6 months. Decrease in mortality index decreased from 0.54 to 0 for 10 consecutive months. Increase in surgeon aggregate HCAHPS percentiles, currently higher than comparison groups. Improved Joint Commission's Surgical Care Improvement Project hip arthroplasty measure from 98.8% to 100%. Implementation of a standardized pain protocol order set in Epic to address patient satisfaction on pain management. Implementation of a standardized blood management protocol including tranexamic acid and presurgical anemia screening. Reduction in percent of cases that received blood transfusion decreased from 14% to 8%, and the total number of blood product units transfused among all cases from 0.42 to 0.2. Improved documentation practices with the case mix index increasing from 2.3 to 2.5 in November 2013. Our estimated financial savings so far are over $9 million. Due to the success of the Orthopaedic team, other services such as cardiac, vascular, thoracic, heart and lung transplant surgery teams have begun replicating the dashboard concept.


Team Based and Interprofessional Approaches to Quality, Value and Patient Safety, 2014 IQ Meeting


Aldijana Avdic, BSN, RN, PBMS, CPHQ, University of Iowa Roy J. and Lucille A. Carver College of Medicine

Nicolas O. Noiseux, MD, University of Iowa Roy J. and Lucille A. Carver College of Medicine

Nancy Krutzfield, MS, RN, University of Iowa Roy J. and Lucille A. Carver College of Medicine

Denise Peck, ARNP, University of Iowa Roy J. and Lucille A. Carver College of Medicine