Partners in Quality: I Have Your Back

Purpose:
Improving HCAHPS, Core measure compliance, and Preventing Hospital Acquired Infections/ Conditions are challenging for every hospital.

Significance:
As hospital reimbursement is affected by HCAHPS, core measures, and HAIs/ HACs, it is critical to develop and implement systems which prevent adverse outcomes or fall outs. Working as a multidisciplinary team, default strategies are developed to prevent human error.

Strategy and Implementation:
Weekly, a large group of department leaders, including nursing and other clinical staff, come together with representatives from the medical staff departments and the quality staff. The purpose of the meeting is to identify opportunities to prevent fallouts and develop failsafe systems to prevent harm to patients and enhance care delivery. The agenda includes: review of current HCAHPS scores by department and by question, review of any hospital acquired infections or conditions, and review of all core measure fall outs. Through a root cause methodology, each case is reviewed to determine what could have been done to eliminate the condition or the compliance fall out. HCAHPS scores are reviewed to determine whether tactics are working or need revision or more hardwiring. For serious fallouts, the teams which provided the care are invited to participate in the problem solving. This is extremely powerful. This group has been active for over 3 years.

Evaluation:
Success is measured on the basis of publicly reported data. Our trends have been very positive, in fact AMI, Pneumonia, and CHF core measures have been at 100%. Ventilator associated pneumonia has been eliminated. New maternal core measures are trending up. We are in top quartile hcahps.

Implications for Practice:
Any hospital can implement this tactic. Pulling collective wisdom, talents and experience from a multidiscipliinary body and promoting a culture of "no-blame" where every professional is responsible for preventing errors no matter where in the processes of care they occur, has tremendous impact .