Georgia Hospital Association - PHA

Situation

Hospital core measure performance is publicly reported by the Hospital Quality Alliance (CMS & AHA), The Joint Commission, Georgia Hospital Quality Check, and Georgia Hospital Price Check.

Hospital performance nationally and in Georgia is lowest for pneumonia vaccination, and hospitals are striving to improve implementation in this area.

The Partnership for Health and Accountability is the statewide patient safety program for hospitals in Georgia. Through the collaborative efforts of member hospitals tools are provided to look at entire spectrum of health care delivery to:

• Promote safety and quality throughout all aspects of the hospital
  
• Provide a mechanism for peer-review accountability without blame
  
• Disseminate best practices
  
• Educate and support hospitals for Core Measure improvements
  
• Share information with the public through the quarterly Hospital Relative Quality Index that generates a composite measure of hospital quality and patient safety

Solution

The two hospitals highlighted below are just two examples of how hospitals have demonstrated significant improvements in the rates of pneumonia vaccinations by using some of the tools provided by PHA including:

• The annual PHA Quality & Patient Safety awards are a national model for collaborative efforts to improve Patient Safety, and winning solutions are showcased at the annual Patient Safety Summit
  
• Quarterly Hospital Relative Quality Index uses composite measures for process and outcome measures, and selected Patient Safety Indicators so hospitals view their progress and standing
  
• PHA Staff consulting, site visits, and QIO collaboration
  

One hospital used the state immunization registry – GRITS - to identify patients receiving their pneumonia vaccine which eliminated one key barrier – the staff time required to determine if vaccination was necessary. Other strategies included:

• Stickers on charts to identify patients needing the vaccine
• Medical and administrative leadership support
  

The second hospital went from increasing the composite ACM score from 57% to 94% in just 2 years. A key element to their success was designating 1 staff person to monitor core measure data and work with clinical leaders to develop and implement tools for improvement. A Medical Director who took an active role in following up with the physicians contributed to the gains made.

Better Health Lower Costs

Hospitals working together through a voluntary statewide approach have improved Georgia performance statewide. Results from individual hospital gains and shared learnings have increased the mean for all core measures. In addition, the variation for all measures has been reduced.