Page 22 - Hoag Orthopedic Institute 2015 Outcomes Report

PERFORMANCE IMPROVEMENT
Ongoing Performance Improvement (PI) initiatives at HOI are at work throughout the enterprise. HOI uses Lean Six Sigma, a proven strategy to increase patient satisfaction, reduce errors, reduce waste and activities that do not add value, and streamline everyday processes to maximize the organization’s productivity. HOI’s leadership team has undergone Lean Six Sigma training to create organization-wide cultural change and sustain Lean practices.
FALL PREVENTION
All patients at HOI are considered at risk for falls. HOI team members realized that the applications for fall prevention were very generalized and did not meet HOI’s specific needs. A multidisciplinary Falls Committee was created to specifically identify actions that would keep HOI patients safe. Subsequently, the committee developed and launched a safety initiative with these elements:
• A patient/family education falls video was created and can be accessed from the television in the patient’s room.
• Pre-op staff provides fall prevention guidelines to the patient and family.
• Patients and families read the guidelines while waiting to have surgery.
• Staff inquire whether this education on fall prevention has been read and understood.
• A staff RN verifies that this education was provided.
Since implementation of these measures in FY14, there was less than one fall per 1,000 patient days. Reassessment of fall risk and prevention
is an ongoing priority.
IMMUNIZATION IMPROVEMENT
Influenza and pneumonia (PNA) vaccinations
are two clinical care processes reported to Centers for Medicare & Medicaid Services (CMS). Compliance with these core measures is publicly reported, and the measures serve as quality indicators for HOI. The value-based purchasing CMS incentive program has included flu vaccination as a clinical care process measure for FY 2016. In order to receive full points
for this measure in the 2016 VBP program, HOI needs to meet the CMS benchmark of 98.9 percent compliance.
HOI’s goal is to be 100 percent compliant with influenza and pneumonia vaccinations. As of October 2014, HOI had a compliance rate of 98.6 percent for flu vaccinations and 97.2 percent compliance for PNA.
A review of immunization fallouts (noncompliance) for FY 2014 showed opportunities in documentation, patient screening, registration and coding.
Immunization screening of these patients, previously done on paper, is now done electronically. Staff education was provided to reinforce the screening process, and visual reminders to aid in compliance were posted.
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