BMC Quality Goals for Fiscal Year 2020 (FY 20)
Reducing Preventable Harm Index (PHI)
PHI is comprised of the 4 major Hospital Acquired Infections (HAIs) with a goal of 1.0 (YTD 0.84):
- Catheter associated urinary tract infection (CAUTI),
- Central Line Associated Bloodstream Infections (CLASBI)
- Hospital acquired Clostridium difficile infections (CDIFF) and
- Methacillin-Resistant Staph aureus bacteremia
The PHI also contains several perioperative/periprocedural complications and “never events” such as falls, pressure ulcers, and iatrogenic pneumothorax. The post-procedural complications followed most closely in internal medicine are venous thromboembolic events, hemorrhage/hematoma and development of acute kidney injury.
This year marks a major change in BMC’s approach to the monitoring and goal setting for HAIs . We are shifting from rates and standardized infection ratios to simply following counts as we try to “chase zero” with the goal of zero events for each floor team. Following infection counts will allow us to assess and respond more quickly as an organization. Goal counts are in the table below.
If your team is following a patient who develops an HAI, please respond to the nurse manager’s request to meet to assist in the preparation of a preventability analysis.
Reducing Mortality
- BMC’s O/E (Observed to Expected) mortality for FY2019 was 0.79 below the goal of <0.84.
- BMC’s O/E Mortality Goal for FY2020 is 0.77 which places BMC in the top 25th percentile nationally in mortality compared to other academic medical centers.
- What can I do?
- Capture severity of illness by documenting all significant conditions in the H&P.
- Engage Serious Illness Support Services for patients who have been identified as being at high risk of mortality in the next 6 months for discussions on advance care planning.
- Refer BMC patients who are Comfort Measures Only patients for inpatient hospice screening.