Performance Improvement Initiatives Research Articles

Non-battle Emergency Department Utilization of the First Modular Army Field Hospital Prototype in Support of Operation INHERENT RESOLVE.

The 2010-2011 withdrawal from Iraq included the closure of all fixed-facility military medical resources. Operation INHERENT RESOLVE, the United States-led counter-terrorism mission in Iraq and Syria, subsequently commenced in 2014. With increasing combat operations, the 28th Combat Support Hospital deployed to Iraq to support that mission as a limited footprint unit prototyped after the new modular Army Field Hospital. We describe the non-battle utilization of the emergency medical treatment section. We prospectively collected data for this project as part of a performance improvement initiative to track healthcare utilization to guide emergency medical treatment section staffing. The project took place at a combat support hospital near Baghdad, Iraq from July 2016 through January 2017. During this time, the emergency department (ED) averaged 3.5 visits per day totaling 675 non-battle encounters. Most (84.6%) were U.S. military personnel with a median age of 32 (IQR 26-38). The most common procedure performed was point-of-care ultrasound (n = 33). Most patients (96.9%) underwent discharge from the ED. Of the 21 subjects admitted, 6 were for surgical intervention and the remaining for medical or observational indications. The most common chief complaints were musculoskeletal (31.1%, n = 210), respiratory (15.3%, n = 103), and dermatologic (12.0%, n = 81). Non-battle injuries and illnesses were the predominant reason for ED utilization. Most subjects were discharged back to duty with relatively low-resource utilization. Few visits required procedural interventions.

Qualifications and Skills Required for Performance Improvement: A Content Analysis of Job Postings.

Healthcare reform and the implementation of a national quality strategy in the United States have increased emphasis on quality improvement. Additionally, as healthcare organizations focus on value, they are paying more attention to quality in the context of cost and seeking to address these concerns through various performance improvement initiatives. Given the importance of these initiatives, this study analyzed the improvement job positions posted by U.S. healthcare organizations, specifically with respect to the qualifications and skills required. The author conducted a content analysis of improvement job postings using an inductive approach to capture and categorize core information about each posting and a deductive approach to evaluate skills required for selected job areas. The results show that healthcare organizations have invested in a breadth of improvement positions across all levels of the organization. Many positions are tied to strategic initiatives. The greatest number of positions posted were in the performance improvement area, followed by quality improvement, process improvement, Lean, Six Sigma, and Lean Six Sigma. These research results may be useful to healthcare organizations for strategic resource planning purposes and to educators and professional associations to target programs that offer students and members the opportunity to gain needed qualifications and skills.

Fine-Needle Aspiration Utilization for Malignant Thyroid Neoplasms in the Community Hospital Setting: A Quality Improvement Study.

Thyroid nodules are increasingly common. Although guidelines have been published, it is unclear whether recommendations for the use of fine-needle aspiration (FNA) and ultrasonography are followed. To evaluate the impact of a quality improvement initiative regarding utilization of FNA and ultrasonography before resection of malignant thyroid neoplasms at a community-based hospital. A retrospective medical record review of patients who received thyroidectomy with histologically proven malignant thyroid neoplasms at a community-based teaching center in the Midwest in 2014 revealed inconsistent use of FNA and ultrasonography per national guidelines. Thus, a quality improvement initiative was conducted using the PDSA (Plan, Do, Study, Act) method and included both an intradepartmental outreach effort and an interdisciplinary hospital cancer committee presentation. To determine the success of the initiative, medical records were reviewed from January 1, 2015, through July 1, 2016 (after the initiative) and compared with findings from 2014 (before the initiative). The medical records of 366 patients were reviewed over a 2.5-year period, and 23 records (12 in 2014 and 11 in 2015-2016) met the inclusion criteria. In 2014, FNA was performed on 58% of patients before operative management of thyroid malignancy. After the quality improvement initiative, FNA was performed on 100% of patients before operative management of thyroid malignancy (P=.0155). Before the quality improvement initiative, 75% of patients undergoing an operation for malignant thyroid neoplasms underwent preoperative ultrasonography, compared with 100% after the initiative (P=.0753). A performance improvement initiative that used the PDSA framework effectively influenced physician adherence to national guidelines for thyroid neoplasms.

“EVEN LISTENING IS GOOD”: COMPARING AN ACTIVE AND PASSIVE PARTICIPATION OF FAMILIES IN MULTIDISCIPLINARY ROUNDS

SESSION TITLE: Improving Patient Care Through System Change SESSION TYPE: Original Investigations PRESENTED ON: 10/10/2018 02:30 pm - 03:30 pm PURPOSE: Studies have shown that keeping open information with families not only improves satisfaction but also improves the overall performance outcome of an Intensive Care Unit (ICU) [1]. It was therefore hypothesized that if a patient’s family was given the chance to be either actively or passively involved in the multidisciplinary rounds (MDRs), their satisfaction can be measured objectively. Searching of literature shows that we are the first to compare between active (AP) and passive participation (PP) of families in MDRs. METHODS: This observational study was performed in a 40 bed Cardio-Vascular ICU of a tertiary care center. Data was collected from the each weekday morning’s formal MDRs involving an intensivist, a bedside nurse, unit manager, a pharmacist, a dietician, a social worker, a respiratory therapist, a physical therapist and a chaplain. No patient identifying data were collected or preserved. A patient’s case is discussed, with recent updates, by the bedside nurse or an intensivist. Families are allowed to observe this discussion and are provided the opportunity to actively ask any questions. A total of 266 beds were rounded with 121 families present. Out of the 121 families present during the rounds, 73 scores were retained after they satisfy all inclusion questions. A five point satisfaction score is developed depending on understanding of the plan of the care for the day as well as overall goal of the treatment, opportunity to ask questions, opportunity to raise concerns and on the doctors’ communication skills. RESULTS: Out of 73 scores, 34 were from families that were active in the rounds (AP group) and 39 were from families that only passively listened to the discussion of providers (PP group). STATA © biostatistic software is used to satisfy sample size in each arm to obtain mean, histogram, power of 80%, equal variance, level of significance of .05 (Type 1 error) with standard deviation estimated using sample T-distribution. Z for 95% Confidence Interval (CI) = 1.96, 95% CI of difference: -0.3393 <0.333< 1.0053 (Wald), t= 0.971; df= 33; p= 0.83066 (left p: 0.1693; two sided: 0.3386). CONCLUSIONS: As we failed to reject our null hypothesis, we concluded that even passive participation ensures significant family satisfaction. Structured and family-centered MDRs designed to address all aspects of patient care may answers all concerns family might have. The presence of entire ICU team reinforce families of the best care. CLINICAL IMPLICATIONS: Effective communication with patients' families is an important determinant of ICU outcome measures. Involvement of families either actively or passively in MDRs can be used as a key to obtain these parameters. Further studies are needed to objectively measure a family-centered patient care.Ref.: Roland P, et al - Visitation in critical care: process and outcomes of a performance improvement initiative. J Nurs Care Qual. 2001;15(2):18–26 DISCLOSURES: No relevant relationships by Samantha DeLuca, source=Web Response No relevant relationships by Sahar Fatima, source=Web Response No relevant relationships by Tina Lam, source=Web Response No relevant relationships by Iqbal Ratnani, source=Web Response Speaker/Speaker's Bureau relationship with Sunovian Please note: $5001 - $20000 Added 11/20/2017 by Salim Surani, source=Web Response, value=Honoraria Advisory Committee Member relationship with Astra Zeneca Please note: $5001 - $20000 Added 11/20/2017 by Salim Surani, source=Web Response, value=Consulting fee

Defining Proficiency for The Society of Thoracic Surgeons Participants Performing Thoracoscopic Lobectomy

Parameters defining attainment and maintenance of proficiency in thoracoscopic video-assisted thoracic surgery (VATS) lobectomy remain unknown. To address this knowledge gap, this study investigated the institutional performance curve for VATS lobectomy by using risk-adjusted cumulative sum (Cusum) analysis. Using The Society of Thoracic Surgeons General Thoracic Surgery Database, the study investigators identified centers that had performed a total of 30 or more VATS lobectomies. Major morbidity, mortality, and blood transfusion were deemed primary outcomes, with expected incidence derived from risk-adjusted regression models. Acceptable and unacceptable failure rates for outcomes were set a priori according to clinical relevance and informed by regression model output. Between 2001 and 2016, 24,196 patients underwent VATS lobectomy at 159 centers with a median volume of 103 (range, 30 to 760). Overall rates of operative mortality, major morbidity, and transfusion were 1% (244 of 24,189), 17.1% (4,145 of 24,196), and 4% (975 of 24,196), respectively. Of the highest-volume centers (≥100 cases), 84% (65 of 77) and 82 % (63 of 77) (p= 0.48) were proficient by major morbidity standards by their 50th and 100th cases, respectively. Similarly, 92% (71 of 77) and 90% (69 of 77) (p= 0.41) of centers showed proficiency by transfusion standards by their 50th and 100th cases, respectively. Three performance patterns were observed: (1) initial and sustained proficiency, (2) crossing unacceptability thresholds with subsequent improved performance; and (3) crossing unacceptability thresholds without subsequent improved performance. VATS lobectomy outcomes have improved with lower mortality and transfusion rates. The majority of high-volume centers demonstrated proficiency after 50 cases; however, maintenance of proficiency is not ensured. Cusum provides a simple yet powerful tool that can trigger internal audits and performance improvement initiatives.

External benchmarking of trauma services in New South Wales: Risk-adjusted mortality after moderate to severe injury from 2012 to 2016

BackgroundTrauma centres and systems have been associated with improved morbidity and mortality after injury. However, variability in outcomes across centres within a given system have been demonstrated. Performance improvement initiatives, that utilize external benchmarking as the backbone, have demonstrated system-wide improvements in outcomes. This data driven approach has been lacking in Australia to date. Recent improvement in local data quality may provide the opportunity to engage in data driven performance improvement. Our objective was to generate risk-adjusted outcomes for the purpose of external benchmarking of trauma services in New South Wales (NSW) based on existing data standards. MethodsRetrospective cohort study of the NSW Trauma Registry. We included adults (>16 years), with an Injury Severity Score >12, that received definitive care at either Major Trauma Services (MTS) or Regional Trauma Services (RTS) between 2012-2016. Hierarchical logistic regression models were then used to generate risk-adjusted outcomes. Our outcome measure was in-hospital death. Demographics, vital signs, transfer status, survival risk ratios, and injury characteristics were included as fixed-effects. Median odds ratios (MOR) and centre-specific odds ratios with 95% confidence intervals were generated. Centre-level variables were explored as sources of variability in outcomes. Results14,452 patients received definitive care at one of seven MTS (n = 12,547) or ten RTS (n = 1905). Unadjusted mortality was lower at MTS (9.4%) compared to RTS (11.2%). After adjusting for case-mix, the MOR was 1.33, suggesting that the odds of death was 1.33-fold greater if a patient was admitted to a randomly selected centre with worse as opposed to better risk-adjusted mortality. Definitive care at an MTS was associated with a 41% lower likelihood of death compared to definitive care at an RTS (OR 0.59 95%CI 0.35-0.97). Similar findings were present in the elderly and isolated severe brain injury subgroups. ConclusionsThe NSW trauma system exhibited variability in risk-adjusted outcomes that did not appear to be explained by case-mix. A better understanding of the drivers of the described variation in outcomes is crucial to design targeted locally-relevant quality improvement interventions.

Use of Lean and Related Transformational Performance Improvement Systems in Hospitals in the United States: Results From a National Survey

The health care system in the United States is costly with high variance in quality. There is growing interest in transformational performance improvement initiatives, such as the Lean management system, to eliminate waste and inefficiency and improve quality of care for patients. A national survey of all 4,500 short-term acute general medical/surgical and pediatric hospitals in the United States was fielded between May and September 2017 by the Survey Data Center of the American Hospital Association. Responses were received from 1,222 hospitals (27.3% response rate). Sixty-nine percent (69.3%) reported use Lean or related Lean plus Six Sigma or Robust Process Improvement approaches. Not-for-profit hospitals, hospitals located in metro/urban areas, those belonging to a system/network, and those with 100-399 beds were most likely to be engaged in these activities and for an average of 5.2 years. However, only 12.6% (n = 102) of hospitals reported being at a mature hospitalwide stage of implementation. The degree of maturity, leadership commitment, daily management system use, and training were each positively associated with reported positive performance outcomes. A majority of hospitals have adopted Lean-based transformational performance improvement approaches but with wide variance in the degree of implementation. It takes time for Lean to gain traction. The length of time doing Lean is positively associated with implementation progress and reported positive performance impacts. The extent to which Lean has an organizationwide performance impact awaits further research that links the variables in this study with objective cost and quality measures.

The STELAR ICU: Leveraging Electronic Health Record Data to Foster Research and Optimize Patient Care

Electronic health records (EHR) combined with robust data collection systems can be used to simultaneously drive research and performance improvement initiatives. Our Smart, Transformative, EHR-based Approaches to Revolutionizing the Intensive Care Unit (STELAR ICU) consists of a framework of five best practices that make optimal use of objective data to guide clinicians caring for the sickest patients in our quaternary center. Our strategy has relied on an accessible data infrastructure, standardizing without protocolizing care, using technology to increase patient contact and time spent at the bedside, continuously re-evaluating performance in real-time, and acknowledging uncertainty by using electronic data to provide probabilistic weight to clinical decision-making. These strategies blur the lines between research and quality improvement, with the aim of achieving truly stellar patient outcomes.

The Role of Trauma Video Review in Optimizing Patient Care.

Trauma video review allows for monitoring of performance improvement initiatives, leadership skills, system process issues, and guideline compliance. Despite the well-documented benefits, there are persistent barriers to its use including patient privacy concerns, cost, and provider anxiety. Optimizing implementation by ensuring that informed consent processes are in place, as well as a structured peer review process, can help trauma centers overcome these hurdles. Trauma video review is a unique and beneficial tool that helps tie patient care to quantifiable data, as well as serves as a platform for education opportunities.

Medication Reconciliation: A Necessary Process for Patient Safety

Medication Reconciliation: A Necessary Process for Patient Safety

Facilitating Adoption of an Electronic Documentation System.

Best practice recommends the integration of clinical documentation into the hospital electronic health record to support safe, efficient, and timely patient care. A major barrier to successful adoption and optimization of computerized documentation systems is user satisfaction. The purpose of this descriptive, performance improvement initiative was to implement and evaluate user satisfaction with an electronic documentation system to facilitate successful adoption. The Clinical Procedure Flowsheets application was implemented in a geriatric extended care unit of a large healthcare system. Rogers' Diffusion of Innovation and Davis' Technology Acceptance Model were used to guide system adoption and improve user experience of the innovation. The Perceived Usefulness and Perceived Ease of Use questionnaire was distributed to 24 nursing staff working in the unit 9 weeks after implementation. Results indicated that respondents perceived the Clinical Procedure Flowsheets as easy to use and useful in accomplishing their documentation tasks. The overall mean satisfaction score of 72.17 (SD, 12.13) implied a strong level of user acceptance. The positive perception of the nursing staff in the geriatric extended care unit suggests a high probability of system use that can enhance the documentation of patient care. Further research is recommended to evaluate factors related to system adoption and user satisfaction.

Should interventions to reduce variation in care quality target doctors or hospitals?

Interventions to reduce variation in care quality are increasingly targeted at both individual doctors and the organisations in which they work. Concerns remain about the scope and consequences for such performance management, the relative contribution of individuals and organisations to observed variation, and whether performance can be measured reliably.This study explores these issues in the context of the English National Health Service by analysing comprehensive administrative data for all patients treated for four clinical conditions (acute myocardial infarction, hip fracture, pneumonia, ischemic stroke) and two surgical procedures (coronary artery bypass, hip replacement) during April 2010–February 2013. Performance indicators are defined as 30-day mortality, 28-day emergency readmission and inpatient length of stay. Three-level hierarchical generalised linear mixed models are estimated to attribute variation in case-mix adjusted indicators to individual doctors and hospital organisations.Except for length of stay after hip replacement, no more than 11% of variation in case-mix adjusted performance indicators can be attributed to doctors and organisations with the rest reflecting random chance and unobserved patient factors. Doctor variation exceeds hospital variation by a factor of 1.2 or more. However, identifying poor performance amongst doctors is hampered by insufficient numbers of cases per doctor to reliably estimate their individual performances. Policy makers and regulators should therefore be cautious when targeting individual doctors in performance improvement initiatives.

Road to Home Program: A Performance Improvement Initiative to Increase Family and Nurse Satisfaction With the Discharge Education Process for Newly Diagnosed Pediatric Oncology Patients [Formula: see text

Families of children, adolescents, and young adults with a new oncology diagnosis must absorb knowledge and skills needed to care for their child at home during a period of emergent hospitalizations and intense medical interventions. Effective nurse-led teaching and discharge planning begun at diagnosis can prepare families to safely care for their child following discharge, and be a source of satisfaction. The objective of this performance improvement initiative was to increase family and nurse satisfaction with new diagnosis education and discharge. Using standard performance improvement techniques, family and nursing stakeholder satisfaction with current processes was assessed. Working from established best practice and literature review; The Road to Home was designed and implemented. This novel, comprehensive program includes a visual, interactive display of required education based on the Children's Oncology Group Family Handbook© and hospital specific discharge materials; standardized teaching, tools and documentation for nursing; and caregiver discharge tool kits. Stakeholder input guided improvement strategies throughout the phases of implementation. Sustained increases in family and nurse satisfaction resulted from each phase. The Road to Home program is established for all families of newly diagnosed oncology patients and is meeting goals of increased family and nurse satisfaction with discharge education.

Are university rankings useful to improve research? A systematic review.

IntroductionConcerns about reproducibility and impact of research urge improvement initiatives. Current university ranking systems evaluate and compare universities on measures of academic and research performance. Although often useful for marketing purposes, the value of ranking systems when examining quality and outcomes is unclear. The purpose of this study was to evaluate usefulness of ranking systems and identify opportunities to support research quality and performance improvement.MethodsA systematic review of university ranking systems was conducted to investigate research performance and academic quality measures. Eligibility requirements included: inclusion of at least 100 doctoral granting institutions, be currently produced on an ongoing basis and include both global and US universities, publish rank calculation methodology in English and independently calculate ranks. Ranking systems must also include some measures of research outcomes. Indicators were abstracted and contrasted with basic quality improvement requirements. Exploration of aggregation methods, validity of research and academic quality indicators, and suitability for quality improvement within ranking systems were also conducted.ResultsA total of 24 ranking systems were identified and 13 eligible ranking systems were evaluated. Six of the 13 rankings are 100% focused on research performance. For those reporting weighting, 76% of the total ranks are attributed to research indicators, with 24% attributed to academic or teaching quality. Seven systems rely on reputation surveys and/or faculty and alumni awards. Rankings influence academic choice yet research performance measures are the most weighted indicators. There are no generally accepted academic quality indicators in ranking systems.DiscussionNo single ranking system provides a comprehensive evaluation of research and academic quality. Utilizing a combined approach of the Leiden, Thomson Reuters Most Innovative Universities, and the SCImago ranking systems may provide institutions with a more effective feedback for research improvement. Rankings which extensively rely on subjective reputation and “luxury” indicators, such as award winning faculty or alumni who are high ranking executives, are not well suited for academic or research performance improvement initiatives. Future efforts should better explore measurement of the university research performance through comprehensive and standardized indicators. This paper could serve as a general literature citation when one or more of university ranking systems are used in efforts to improve academic prominence and research performance.

Improving Performance of Mammographic Breast Positioning in an Academic Radiology Practice.

The purpose of this project was to achieve sustained improvement in mammographic breast positioning in our department. Between June 2013 and December 2016, we conducted a team-based performance improvement initiative with the goal of improving mammographic positioning. The team of technologists and radiologists established quantitative measures of positioning performance based on American College of Radiology (ACR) criteria, audited at least 35 mammograms per week for positioning quality, displayed performance in dashboards, provided technologists with positioning training, developed a supportive environment fostering technologist and radiologist communication surrounding mammographic positioning, and employed a mammography positioning coach to develop, improve, and maintain technologist positioning performance. Statistical significance in changes in the percentage of mammograms passing the ACR criteria were evaluated using a two-proportion z test. A baseline mammogram audit performed in June 2013 showed that 67% (82/122) met ACR passing criteria for positioning. Performance improved to 80% (588/739; p < 0.01) after positioning training and technologist and radiologist agreement on positioning criteria. With individual technologist feedback, positioning further improved, with 91% of mammograms passing ACR criteria (p < 0.01). Seven months later, performance temporarily decreased to 80% but improved to 89% with implementation of a positioning coach. The overall mean performance of 91% has been sustained for 23 months. The program cost approximately $30,000 to develop, $42,000 to launch, and $25,000 per year to maintain. Almost all costs were related to personnel time. Dedicated performance improvement methods may achieve significant and sustained improvement in mammographic breast positioning, which may better enable facilities to pass the recently instated Enhancing Quality Using the Inspection Program portion of a practice's annual Mammography Quality Standards Act inspections.

Facilitating Focused Process Improvement Efforts in Home Health Agencies to Improve Utilization Outcomes Effectively and Efficiently

The aim of this study was to identify a smaller set of clinical practices most associated with the utilization outcomes of the home health agencies. A secondary data analysis approach was adopted using the publicly accessible Home Health Compare repository as the main data source; the control variables such as rurality, agency size, and median income levels were obtained from other public data repositories. Checking for fall risks and starting care in a timely manner were most associated with hospital readmissions. These two practices and treating patients for pain are most associated with the emergency room visit rates. The results provide additional guidance to home health agencies in their prioritized and focused performance improvement initiatives to improve their utilization outcomes.

Modelling manufacturing employees’ performance based on a system dynamics approach

Employee performance is a key factor for the success of any modern organization. Employees are an asset that cannot be imitated by the competition, and therefore should be considered the most valuable resource. Unfortunately, they are also the hardest to control. Previous studies in manufacturing organizations have proven this. Performance improvement initiatives with a wide range of approaches are used in an attempt to improve employee performance. Motivation or organizational commitment are some examples of such programmes. However, the clear majority do not focus on the bigger picture. A conceptual model through system dynamics of the factors that affect employee performance and the different improvement initiatives is presented in this paper.

61 Donors Per Million

Background Practice and results vary widely between hospitals, and often between institutions in the same healthcare system. This state contains eight hospitals representing six healthcare systems, including two transplant centers and two level 1 trauma centers, serving a population of approximately 952,000. Prior to the Initiative, there was not one centralized forum for facilitating sharing of best practices or collateral learning. Identification and adherence to a single set of best demonstrated practices across multiple health systems can raise donation rates. Aim To launch and leverage a statewide performance improvement initiative to increase organ and tissue donation across every hospital by reducing variability and standardizing practice within and among each of the hospital systems. Methods Historic hospital development strategy encompassed proactive, comprehensive education, routine case follow up, relationship building practices, and multidisciplinary Donation Councils, as well as other methods, at each hospital in the state. Ten years of data showed an average conversion rate of 57%. To optimize the process and outcomes, the OPO partnered with various state professional organizations, each health system, and the state department of health to “Create and Sustain a Culture Where Optimal Donation Practices and Collaboration Are Embraced, Resulting in a Sustained Organ Donation Rate of At Least 65%”. The OPO and hospitals together implemented a concentrated, multi-faceted approach, championed by a core group of approximately 50 multidisciplinary clinicians and administrators representing 8 hospitals. Improvements focused on timely referral, planned and collaborative family conversations about donation, hard-wired case reviews and mutual critique, and a bolstered education schedule for members of the health care teams. The core group convened quarterly to exchange information and compare experience and results, ensure standardization, and engage in collaborative learning. Between each quarterly meeting, members of the core group were responsible for instituting new practices and ensuring adherence to best practice at their home institutions. Results Unprecedented statewide increases in donation were observed: achievement of a 62% conversion rate during the initiative compared to 57% over the previous ten years. Conclusion A strategic, multi-faceted, and collaborative performance improvement initiative, supported by the state legislature, state nurses association, state medical society and academy of medicine, and owned by each hospital and health system, achieved never-before-seen results. Early, continuous, and active recruitment and engagement of hospital and professional organization partners by the OPO is what made these outcomes possible.

First Year Experience of a Quaternary Medical Center with Heart Failure Bundled Payment

Background: The Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) initiative is an alternative payment model designed to link payments for multiple services received during an episode of care. The goal is to achieve higher quality and greater coordination of care at a lower cost to CMS. Inova Fairfax Hospital joined the BPCI Model 2 program for heart failure effective October 2015, assuming both upside and downside risk for a 90-day episode of care. Cost targets for each of the 3 heart failure MS-DRGs (291–293) were established based on 2009–2012 Medicare spending. Performance improvement initiatives included nurse navigators (inpatient and post-acute), enhanced order sets (ED, hospital, home health), physician documentation education, and skilled nursing facility network development. While our institution achieved cost savings during the first year, we sought to better understand the factors responsible for this success and opportunities for improvement. Methods: Eligible patients likely to be billed to a heart failure MS-DRG, excluding ESRD, were identified at admission and followed for 90 days post discharge. CMS paid claims were analyzed to study episode cost performance compared to baseline, including readmissions, skilled/acute rehab, home health, outpatient procedures, and home infusion therapies. Results: There were 298 episodes of care: 48.7% were billed MS-DRG 291 (high acuity) and 51.3% were billed MS-DRG 292 or 293 (low acuity). We successfully reduced skilled/acute rehab utilization from 30% to 23% and 90-day readmissions from 34% to 31%, achieving a 1% savings from our cost target. Overall, 73% of episodes were breakeven or favorable, with high acuity patients less likely to achieve savings compared to low acuity patients (64% vs 82%) and 7% of episodes exceeded target by a cost of $30,000 or more, with drivers including readmissions, extended skilled/acute rehab stays, elective TAVR, planned ICD implants or replacements, and high cost home infusion therapies. Conclusions: During the first year of participation, cost savings were primarily driven by reductions in skilled/acute rehab utilization and readmissions, while care for high acuity patients was more likely to result in economic losses. Quaternary referral centers participating in BPCI for heart failure are vulnerable to negative cost performance due to providing medically complex care for heart failure patients.

Assuring Sustainable Gains in Interdisciplinary Performance Improvement: Creating a Shared Mental Model During Operating Room to Cardiac ICU Handoff.

To understand sustainability and assure long-term gains in multidisciplinary performance improvement using an operating room to cardiac ICU handoff process focused on creation of a shared mental model. Performance improvement cohort project with pre- and postintervention assessments spanning a 4-year period. Twenty-six bed pediatric cardiac ICU in a tertiary care children's hospital. Cardiac surgery patients admitted to cardiac ICU from the operating room following cardiac surgery. An interdisciplinary workgroup overhauled our handoff process in 2010. The new algorithm emphasized role delineation, standardized communication, and creation of a shared mental model. Our "I-5" mnemonic allowed validation and verification of a shared mental model between multidisciplinary teams. Staff orientation and practice guidelines were revised to incorporate the new process, visual aids were distributed and posted at each patient's bedside, and lapses/audit data were discussed in multidisciplinary forum. Audits assessing equipment and information transfer during handoff were performed 8 weeks following implementation (n = 29), repeated at 1 year (n = 37), 3 years (n = 15), and 4 years (n = 50). Staff surveys prior to implementation, at 8 weeks, and 4 years postintervention assessed satisfaction. Comprehensiveness of information transfer improved in the 4 years following implementation, and staff satisfaction was maintained. At 4 years, discussion of all elements of information transfer was 94%, increased from 85% 8 weeks following implementation and discussion of four or more information elements was 100% increased from 93%. Of the 73% of staff who completed the survey at 4 years, 91% agreed that they received all necessary information, and 87% agreed that the handoff resulted in a shared mental model. Our methods were effective in creating and sustaining high levels of staff communication and adherence to the new process, thus achieving sustainable gains. Performance improvement initiatives require proactive interdisciplinary maintenance to be successful long term.