CAMC celebrated National Quality Week by recognizing some very important work and projects. Employees submitted 27 projects for judging. There were nine Quality Award Winners and two Honorable Mentions.
Work process improvement award
Decreasing registration errors in automated procedures lab (APL)
The Automated Procedures Laboratory at Memorial Hospital performs between 10,000 and 12,000 registrations per month for laboratory specimens that are collected at the various LabWorks locations. This project aimed to initiate a workflow to decrease errors throughout the process of registration and ordering tests. Through education and process changes, the errors were decreased from 153 in February 2023 to 39 errors in June 2024.
Clinical Outcomes award
CAMC Baby First GPRA completion
The Baby First team located at the CAMC Family Resource Center has been successful in achieving their goal of greater than 80% completion rate of the 6-month Government Performance and Results Modernization Act form with interview. The addition of an incentive program has positively impacted their engagement and ability to continue rapport with their patients. At the end of September, the completion rate was 91%.
Harm Reduction award
Back to Basics: Improving the fundamental practice of transmission-based precautions
The project aims to enhance compliance with hand hygiene and appropriate use of personal protective equipment (PPE) to prevent infections and protect both patients and health care workers. Using a three-dimensional approach of culture, process and people, the quality project led to significant improvements, with Teays Valley and Women and Children’s hospitals exceeding transmission-based precautions compliance goals at 94% and 93% respectively, and an overall 24% improvement across CAMC.
Harm Reduction award
Leveraging In-process measures of hysterectomy bundle elements to reduce SSI SIR
In 2023, Women and Children’s Hospital saw an increase in the number of hysterectomy surgical site infections (SSI), thus increasing its standard infection rate well above the national benchmark. Through the implementation of an updated bundle approach, enhanced glucose management process to include pre and post operative phases, as well as an improved antibiotic administration process based on current research, there were ZERO abdominal hysterectomy surgical site infections for the first quarter of 2024.
Patient Experience Improvement award
Improving outcomes initiation of the golden hour
The time immediately following birth is known as the Golden Hour when it comes to mother-baby bonding. During this 60-minute uninterrupted period, skin-to-skin contact between mother and baby is critical to promote attachment, reduce stress for both mother and baby and to help baby adapt to life outside of the womb. This implementation has greatly benefited mom and baby with a less stressful transition.
Waste Reduction award
Respiratory driven bronchiolitis and high flow nasal cannula management
Results from a study conducted at CAMC Women and Children’s Hospital shows implementing the evidence-based practice of treating bronchiolitis and promoting an efficient high-flow nasal cannula strategy reduced hospital length of stay and improved operational and clinical outcomes. Education was presented to bedside clinicians and data was collected by daily audit tools to monitor progress in high-flow nasal cannula management.
Sustainment award
Our pathway to improving AMI mortality
The project was developed in 2021 to focus on our acute myocardial infarction (heart attack) mortality patients and improve our performance in comparison to other hospitals in the Premier database. The team started multidisciplinary mortality reviews weekly to address any concerns and gain perspective from various members of the team. As reviews continued, several areas were identified for improvement: coding, proper provider documentation and outpatient palliative/hospice referrals. By continuing these weekly mortality reviews, the performance goal of an observed to expected value of less than 0.92 has been maintained.
Innovation
Quality improvement utilizing CPT II automation
Rules were created that would submit Current Procedural Terminology (CPT®) Category II codes based on documentation without adding additional steps to the providers workflow. Utilization of these codes helps improve our MIPS (Merit-Based Incentive Payment System) reimbursement and our ACO (Accountable Care Organization) shared savings rate.
Financial Improvement award
Meds to beds deliveries
Pharmacy implemented a team (piloted at Memorial Hospital) to focus on Meds-to-Beds patients and are now providing bedside medication delivery and counseling to about 75% of patients being discharged daily