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Board Report December 2007

Sunshine Memorial Hospital


Quality Report
K e y Q u a l i t y I m p r o v e m e n t I n i t i a t i v e s

Reducing Days in A/R Timely


The “Timely Money Team” came together in December of 2006 to work on improving the Discharge Timely
hospital’s days in A/R. Evaluation revealed that a number of activities impacted the hos-
Coding
Summary First
pital’s A/R days. The six most influential were the timeliness with which the doctor com-
pleted his or her discharge summary, the timely submission of charges, the submission of
Billing
a clean claim the first time, the timely billing of the primary claims, the timely billing of
secondary claims and the timeliness of getting self pay bills out the door. Multiple quality Timely Days in AR Timely
improvement plans were initiated in the different departments that impact billing. A new Charges Secondary
dictation system that allows practitioners to dictate discharge summaries from anywhere Billing
helped significantly in the timeliness of discharge summaries. Changes in how bills get Timely
moved between “billing buckets” has helped. The hospital’s days in A/R has dropped Clean
Claims Self-Pay
from 76 to 37 in 9 months. The goal is to achieve 30 days and hold it. Billing

Days in A/R
D is char ge S ummar y T imelin ess R at e

Discharge Summary Completion


90 90%

80%

70%

80 60%

New 50%

70 Dic- 40%

30%

20%

60 10%

0%
T m
i e ly
S u b ms
io n o C
f h a rg e s
1 2 3 4 5 6 7 8 9 10 11 12

50 Clean Claims
1 2 0%

40 1 00%

8 0%

30 6 0%

4 0%

20 2 0%

0%

1 2 3 4 5 6 7 8 9 1 0 1 1 1 2

10 C h a rtC o d n
i g R a te

Timeliness of Coding
0 120%

1 2 3 4 5 6 7 8 9 10 11 Coding
12 100%

Training 80%

Tm
i e lin e s s B iln g R a t e f o r S e c o n d a r y C a
l im s 60%

40%
T im e lin e s s B illin g R a te o n P rim a ry C la im s
Timely Billing for Primary Claims Timely Billing for Secondary Claims 20%
120%
1 2 0%
0%

1 2 3 4 5 6 7 8 9 10 11 12
100%
1 00%

Timeliness Submission of Charges C le a n C la im R a te

80%
New Sys- 8 0%
100%

90%

tem for 80%


60%
moving 6 0% 70%

40%
bills into 60%

50%

the secon-4 0%
40%

20% dary billing 30%

bucket 2 0% 20%

10%
0%
1 2 3 4 5 6 7 8 9 10 11 12 0%
0% 1 2 3 4 5 6 7 8 9 10 11 12

1 2 3 4 5 6 7 8 9 10 11 12

Timely Billing for Self-Pay Claims


Tm
i e lin e s s B iln g R a t e f o r S e fl - P a y C la im s

New System for moving bills into


10 0 %

90%
the self-pay billing bucket
80%

70%

60%

50%

40%

30%

20%
The Efforts of the “Timely Money” Team
10 %

0%
1 2 3 4 5 6 7 8 9 10 11 12
Thanks for a Job Well Done!
B o a r d R e p o r t P a g e 2

K e y O p p o r t u n i t i e s f o r i m p r o v e m e n t

One of our major QI initiatives this year


Medication Error Rate
looks to reduce our medication error rate. As
chart one shows, we have made good and
0.14%
steady progress. In our initial review of our
0.12%
data we found that 82% of all our errors were
0.10%
0.08%
related to transcription and omission errors.
0.06%
We have focused on QI plans directed at cor-
0.04% recting the systems issues that generate these
0.02% two categories of errors. We have seen a
0.00% steady decline in both types of errors. In No-
vember and December we had no errors at-

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tributed to the omission of a medication. The


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Se nursing and pharmacy staff have done a great
Transcription Errors Omi ssi on Er r or s
job in making our QI goal of reduced medica-
120.00%
100.00%
70.00%
tion errors happen.
60.00%
80.00% 50.00%
40.00%
60.00% 30.00%
40.00% 20.00%
10.00%
20.00%
0.00%
0.00%
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Hospital Acquired Infection Rate

Hospital acquired infections is a major area of national 6.00%


focus because of the number of people who die from 4.00%
them every year. Our nosocomial infection rate is well 2.00%
below the national rate of 5.2 and we have no patients 0.00%
who have experienced harm.

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Smoking Cessation Instructions Our hospital is participating in a national CMS pro-


ject that looks at hospital performance in several
120.00% important areas of patient care. Our hospital is sub-
100.00% mitting data for three of these indicators. In review-
80.00%
ing our data from this national project we found that
we did very poorly in documenting education for
60.00%
our patients who smoke on the importance of and
40.00% opportunities to quit smoking. For this year this has
20.00% been an important nursing and physician QI oppor-
0.00%
tunity.
C u r r e n t Q I I n i t i a t i v e s
Maintenance 1. Putting in a new handicapped accessible entrance on the north side of the building
to accommodate patients that must now park on that side of the building because
of increased patient volumes.
2. Currently working with consultant to determine how to reduce energy costs
through more energy-efficient lighting.
3. Working with outside contractor to increase emergency room parking by 15 park-
ing places.
4. Preparing new clinic location for opening in 65 day.
5. Working with town to get additional hospital signs installed.
.Dietary 1. Working to implement a selection menu that has more culturally diverse foods as
42% of our patient population is of Hispanic descent.
2. Participating in walking tours on Fridays to try and isolate out why patients score
the food below desired levels.
Housekeeping 1. Trying out new floor products in an attempt to make floor wax to last longer and
improve floor appearance.
Nursing - General 1. Adopted waterless handwashing system to increase staff likelihood of washing
hands and reduce risk of hospital acquired infection.
2. Working with Cardiopulmonary and Medical Staff to improve patient teaching for
smoking cessation.
3. Working to improve patient satisfaction with response to request for pain medica-
tions.
4. Working with Pharmacy and the Medical Staff to reduce transcription and omis-
sion errors.
Patient Satisfaction 1. Currently implementing a new patient satisfaction survey that will allow better
information from the different patient care areas.

Emergency Room 1. Working to improve documentation of Gloscow evaluations on trauma patients


before transfer.
2. Working as part of a multidisciplinary team to reduce wait times that patients
perceive to be problematic.
3. Working with lab to reduce wait times for lab results when the lab staff must be
called in from home.
Medical Staff 1. Working to improve documentation of time on all progress notes and orders.
2. Working to reduce use of non-approved abbreviations.
3. Working to improve patient perceptions of physician willingness to listen to what
the patient has to say about condition and concerns
4. Working with radiology to improve documentation of rational for requesting radi-
ology procedures.
5. Working with Nursing and Cardiopulmonary to improve patient teaching for
smoking cessation.
Radiology 1. Purchased 16 slice CT scanner. Operational date is 9/07.
2. Working with physicians to improve documentation of rational for requested radi-
ology procedures.
Laboratory 1. Working to improve patient satisfaction with wait times for morning outpatient
blood draws.
2. Currently implementing a computerized stat value reporting system.
Rehabilitation Services 1. Revising scheduling and work flow systems to accommodate getting new patients
scheduled within 48 hours of call.
2. Working with physicians to improve completeness of orders for rehabilitation to
reduce delays for patients.
Admissions 1. Working to reduce patient frustration with numerous phone interruptions during
admission process
2. Working with ED to have admission process initiated within 10 minutes of patient
arrival.
B o a r d R e p o r t P a g e 4

K e y P a t i e n t S a t i s f a c t i o n F i n d i n g s
Would you recommend this hospital to family and friends?
Woul d Y ou R e c omme nd T hi s H os pi t a l t o Fr i e nds a nd Fa mi l y

120%

100%
In April we implemented a
major guest relations program
80%
and service recovery program.
This last quarter we have seen
60%
Surge in
agency staff
a significant improvement and
40%
due to nursing stabilization in the question on
20% resignations our patient satisfaction survey.
The stabilization of staff has
0%

1 2 3 4 5 6 7 8 9 10 11 12
helped.

A Job Well Done!!!!!


If there was a staff member who went out of his or her way to make your experience great, who was it?
Susan Keefer, RN, Medical Surgical Unit
Jeff Matthews, Radiology Technologist
Kathy James, Social Worker
Would you use this hospital for your next inpatient visit?
Woul d Y ou U s e T hi s H os pi t a l f or Y our N e x t I npa t i e nt V i s i t

101%
In April we implemented a
100%
major guest relations program
99%
and service recovery program.
98%
Over the past two quarters we
97%
have seen an improvement an
96%
stabilization in the area. The
95%

94%
stabilization of staff has
93%
helped.
92%

91%

1 2 3 4 5 6 7 8 9 10 11 12

Areas of Priority
Did you see or experience anything that you felt could be unsafe? If yes, what was it?
I had two medication errors while I was in the hospital. It would seem to me that this would be less likely to
occur if I had had the same nurse giving me my medications. While I saw the same nurses every day, every
day I had a different nurse giving me my medications,
The locks on my bed did not work well and it would move when I would get in and out unless I was careful.
The water in my bathroom was really hot. If an old person were to be in that room I bet it would be easy for
them to make the mistake of not testing the water and burning themselves.

Quality Improvement Opportunities

If there is something we could have done to make your experience better, what was it?
It would have helped me to sleep if the nurses could have been quieter at the desk at night.
The space in which I was receiving physical therapy was so small that patients were bumping into one another.
The woman in the bed next to me liked to watch TV until the early hours of the morning and I could not sleep. The
hospital should have rules about how late the TVs can stay on.
My family complained that the parking lot was dark because so many light bulbs were blown out and made them feel
unsafe leaving the hospital at night.
P a g e 5 S u n s h i n e M e m o r ia l

P a t i e n t S a t i s f a c t i o n
-2 -1 Current Quality Improvement
Month Month Opportunity
Admission

1. Timeliness of admission process 4.2 4.7 4.8

2. Courtesy of staff 4.7 4.7 4.95

3. Efficiency of admission process 4.3 4.4 4.2 Comments about numerous telephone inter-
ruption for staff during admission process
Room

1. Pleasantness of room 4.4 4.5 4.5 Comments about darkness of rooms

2. Cleanliness of room 4.6 4.8 4.8

3. Temperature of room 4.5 4.6 4.2 Comments about swings in temperature

4. Noise level 4.8 4.8 4.9

5. Courtesy of staff who came into your room 4.9 4.9 4.9

Meals

1. Quality of food 4.1 4.4 4.3 No specific complaints but quality of food
consistently scores poorly. Dietary currently
conducting patient interviews to determine
plan
2. Temperature of food 4.5 4.6 4.4 To be addressed as part of above plan. Pri-
mary comments associated with breakfast
3. Assistance you received with your meals 4.9 4.7 4.9

4. Explanation you received if you had a special diet 4.8 4.9 4.9

Staff

1. Friendliness and courtesy of staff 4.9 4.8 4.9

2. Willingness of staff to offer assistance 4.8 4.6 4.85

3. Staff’s attitude towards your requests 4.8 4.9 4.85

4. How well staff kept you informed 4.3 4.7 4.65 No specific complaints. Included on walking
round assessments to determine what could
be done to improve this score
5. Teamwork displayed by the staff who cared for you 4.7 4.7 4.95

6. Timeliness of response for pain medication 4.3 4.1 4.3 Nursing, pharmacy and medical staff working
on improvement plan.
Physician

1. Time the physician spent with you 4.5 4.7 4.65 Referred to medical staff

2. Physician’s concern for your questions and worries 4.2 4.4 4.63 Referred to medical staff

3. Friendliness and courtesy of physicians involved in your care 4.4 4.4 4.5 Referred to medical staff

4. Skills of physicians involved in your care 4.9 4.9 4.92

5. Physician willingness to listen to information you have to share about your 4.3 4.4 4.35 Referred to medical staff
condition or illness
Discharge

1. Extent to which you felt ready for discharge 4.75 4.8 4.85

2. Involvement of your family in discharge planning 4.7 4.65 4.75 Referred to nursing for plan development
Board Report December 2007

Q u a l i t y A s s u r a n c e R e a d i n e s s

Activities
Billing Days in Receivable are at 37 days. Nine months ago we were at 78 days. Opportunities for improvement
continue to be addressed. The goal is 30 days.

Brentwood Clinic
Cardiopulmonary
Central Supply Spore strips indicated sterilization problems with primary sterilizer. New parts installed. Repaired within
8 days. Out-sourced sterilization to Friendly Hospital until fixed.

Dietary Water temperature on dishwasher does not reach required temperatures due to age. Implemented plan for
chemical sanitization that meets state guidelines. New dishwasher is in capital budget for next year.

Emergency Room Potential EMTALA problem with confusion between ER and OPs identified on State survey. Policies and
procedures established to address issue.

Housekeeping
Human Resources
Infection Control
Laboratory Laboratory did not pass proficiency testing in two areas. Corrective action plans submitted to the state
and accepted. Will monitor closely until resolution is certain.

Nursing –Acute State deficiency for sterile technique in the preparation of IV medications and leaving medication unat-
tended in an unlocked medication cart in patient care areas that could be accessed by patients. QI plans in
place.

Obstetrics
Oncology
Maintenance Mixing valve failed on primary water line making water temperature control difficult. New value in-
stalled with 48 hours.

Material Management
Nuclear Medicine
Pharmacy
Radiology
Rosewood Clinic Sample drugs are not being managed according to procedure. QI plan in place and in compliance within 3
days. Fire extinguishers not checked last month. QI plan in place. Checked immediately and placed on
Maintenance checklist.

Rehab Services
Swing Bed
Safety Numerous firewall penetrations identified by the Fire Marshall. QI plan in place to have repaired within
30 day.

Surgical Services Physician #012 did not have H&P done prior to start of cases for 3 cases last month. Addressed through
physician peer review. A new checklist has been developed and the charts will be screen before the start
of all cases and cases won’t start without H&Ps.

Ultrasound
Utilization Review
Hospital Compare
Submissions
Trauma Registry
Submissions

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