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Hospital Clinical Quality Improvement

General resources

Minnesota Hospital Comparison Rates Value-Based Purchasing Measures. Value-based purchasing measures graphs from the January 2012 release of Hospital Compare, showing all Minnesota hospitals' performance, as well as national and state averages. (44-page PDF)

Minnesota Hospital Comparison Rates Value-Based Purchasing Measures. Value-based purchasing measures graphs from the December 2011 release of Hospital Compare, showing all Minnesota hospitals' performance, as well as national and state averages. (39-page PDF)

Hospital Consumer Assessment of Healthcare Providers and Systems. HCAHPS provides a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care that enables valid comparisons to be made across all hospitals.

The CAHPS Improvement Guide. Resources from the Agency for Healthcare Research and Quality for improving the patient experience, identifying the best areas for improvement, and implementing interventions.

Why Not the Best? Quality improvement tools and resources from The Commonwealth Fund, including an interactive map explorer and a function for comparing hospitals and creating reports.

Clinical topics

Acute myocardial infarction

Every year, nearly one million people suffer a heart attack (acute myocardial infarction or AMI). AMI is among the leading causes of hospital admission for Medicare beneficiaries, age 65 and older.

Common Failures and Best Practices. Scientific evidence indicates that these process of care measures represent the best practices for the treatment of AMI. (3-page Word doc)

Falls

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care. Nearly one million patients fall in U.S. hospitals each year. This online toolkit can help hospitals reduce falls that occur during a patient’s hospital stay. The Toolkit addresses hospital readiness, program management, choosing fall prevention practices, implementation, measurement, and sustainability.

Healthcare associated infections

Collaborative Healthcare Associated Infections Network (CHAIN)

Heart failure

Heart failure is the most common hospital admission diagnosis in patients age 65 or older, accounting for more than 700,000 hospitalizations among Medicare beneficiaries every year. It is associated with severe functional impairments and high rates of mortality and morbidity.

Common Failures and Best Practices. Scientific evidence indicates that these process of care measures represent the best-practices for the treatment of heart failure. (2-page Word doc)

High blood pressure

According to the Minnesota Department of Health, nearly 67 million American adults have high blood pressure, and half of them do not have it under control. In Minnesota, one-quarter of adults in 2011 were reported to have high blood pressure. Hypertensive heart disease caused by high blood pressure contributed to the deaths of nearly 6000 Minnesotans. Uncontrolled high blood pressure is a major contributor to heart disease and stroke, two of the leading causes of death in the U.S. and Minnesota.

High Blood Pressure in Minnesota. A fact sheet developed for patients by the Minnesota Department of Health. Provides information on risk factors for high blood pressure, how well is it being controlled, disparities in high blood pressure, and more. (2-page PDF)

Pneumonia

Community acquired pneumonia is a major contributor to illness and mortality in the United States, causing 4 million episodes of illness and nearly one million hospital admissions each year.

Common Failures and Best Practices. Scientific evidence indicates that these process of care measures represent the best practices for the treatment of community-acquired pneumonia. (2-page Word doc)

Surgical care improvement project (SCIP)

Hospitals can reduce the risk of complications like wound infection or blood clots in surgery patients by giving the right treatments at the right time. For example, studies show a strong association of reduced incidence of post-operative infection with administration of antibiotics within the one hour prior to surgery. After the incision is closed, however, studies show that prolonged administration of prophylaxis with antibiotics may increase the risk of certain other infections at no additional benefit to the surgical patient.

Common Failures and Best Practices. Scientific evidence shows that these process of care measures represent the best practices for preventing complications after certain surgeries (colon surgery, hip and knee arthroplasty, abdominal and vaginal hysterectomy, cardiac surgery (including coronary artery bypass grafts (CABG)) and vascular surgery). (3-page Word doc)

Improving SCIP Measures: Ridgeview Medical Center’s Story. Presented by Ridgeview Medical Center staff: B.J. Buckland, RN, MS, director emergency and surgical services; Sarah Urtel, RHIA, MHA, executive director of strategy and organizational effectiveness; Chris Vos, RN, BS, infection control preventionist; and Beth Schnabel, RN, surgical services business manager. (52-minute Webinar)

SCIP Measures: Past, Present & Future. Presented by Dale Bratzler, DO, MPH, president and CEO, Oklahoma Foundation for Medical Quality. (55-minute recorded Webinar)

CMS National Patient Safety Initiative for Surgical Care: Ongoing Opportunities for Improvement. Presented by Dale Bratzler, DO, MPH, President and CEO, Oklahoma Foundation for Medical Quality. (60-minute Webinar) Handout (23-page PDF)

Collaborative Effort at Grand Itasca Improves SCIP Rates. As a participant in the national Surgical Care Improvement Program (SCIP), Grand Itasca Clinic and Hospital in Grand Rapids, Minnesota, has been working to improve documentation on discontinuing antibiotics within 24 hours after surgery─one of seven SCIP measures. (1-page PDF)

CentraCare Health System-Long Prairie Develops Successful Surgical Improvement Processes. CentraCare, a Long Prairie hospital in central Minnesota, has been participating with Stratis Health in the national SCIP initiative to improve health care quality around surgical processes. Its team approach to solving problems and improving processes has well exceeded expectations. (1-page PDF)

Sepsis

Surviving Sepsis Campaign. Read about the Surviving Sepsis Campaign to reduce mortality from severe sepsis and septic shock by using of evidence-based guidelines for care, improving diagnosis and treatment, and educating health care professionals. Sepsis remains an epidemic disorder with an unacceptably high death rate and devastating long-term effects. (See guidelines for managing sepsis below.)

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. This document is the third edition and update of guidelines last published in 2008. (58-page PDF)

VTE

Venous Thromboembolus (VTE) Prevention & Treatment. This compilation of information and resources from the Institute for Healthcare Improvement is designed to help organizations establish risk assessment, prevention, and links to treatment for VTE. (3-page PDF)