Clinical Analytics & Decision Reporting

Success Stories

Health Catalyst

Comprehensive Approach to CAUTI Prevention Leads to Dramatic Reduction in Infections

Despite being common, healthcare-associated infections are potentially deadly and carry a significant financial cost. Of healthcare associated infections, catheter-associated urinary tract infections (CAUTI) are one of the most common, despite most instances of CAUTI being preventable.
As CAUTI was determined to be one of the top five influential factors in the publicly report quality scores, Piedmont Healthcare looked to data for more visibility into factors that were contributing to CAUTI rate in an effort to permanently reduce the number of infections. By engaging staff for compliance with CAUTI prevention best practices, Piedmont has seen sustainable improvements.
Results:

50.2 percent relative reduction in CAUTI standardized infection ratio (SIR). This translates to 37 fewer patients with infections than expected.
6.7 percent relative improvement in insertion bundle compliance.
Maintenance bundle compliance improved dramatically, with nearly a three-fold increase in the percentage of patients receiving the maintenance bundle.

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Labor and Delivery Transformations Lower Costs and Improve Care

One in three women delivers via cesarean in the U.S., and more than 90 percent of them have repeat operations in subsequent deliveries. Despite numerous evidence-based guidelines and established best practices for labor and delivery, clinical care varies widely for many practices. Labor and delivery care varied at Thibodaux Regional Medical Center, causing the organization to look for ways to standardize care.
To better understand variations in care, and opportunities to reduce its cost, the labor and delivery care transformation team at Thibodaux Regional used the Health Catalyst Labor and Delivery Advanced Application as well as the Financial Management Explorer application, which integrates data from billing and costing, and creates snapshots of current financial metrics.
Informing and educating providers with provider-specific data in conjunction with redesigned workflow, standardized supplies, and new, standardized protocols enabled the labor and delivery care transformation team at Thibodaux Regional to experience cost savings and improved outcomes, including:

24.4 percent relative reduction in the cost of care for uncomplicated vaginal delivery. Projected annual cost savings of $266,067.
22 percent relative reduction in the cost of care for cesarean deliveries. Projected annual cost savings of $346,856.

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Standardized Best Practices Improve Elective Colon Surgery Outcomes

Nationally, readmission within 90 days after colorectal surgery occurs in about one in four patients, at a cost of approximately $9,000 per readmission. Committed to improving its clinical and financial outcomes, MultiCare, an integrated healthcare delivery system in the Pacific Northwest, decided to focus an improvement effort on elective colorectal surgery when it recognized that patient population had a high opportunity for improvement in both clinical outcomes and cost.
Effectively using its existing quality improvement methodology and Collaborative structure, MultiCare leveraged the work of the Enhanced Recovery After Surgery (ERAS) Society and identified and implemented standardized best practice care routines and interventions that would benefit this population. By using the information in the Enterprise Data Warehouse and analytics applications to monitor clinical outcomes and compliance, and leveraging technology in the EHR to provide decision support and order sets at the point of care, MultiCare was able to significantly improve the clinical outcomes for these patients.
Results:

19 percent reduction in readmission rates.
22 percent reduction in length of stay.
85 percent reduction in infections related to colorectal surgery.

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How Allina Engaged Clinicians and Analytics to Improve Influenza Vaccination Rate

Influenza, a contagious respiratory illness spread by droplets, can lead to hospitalization and even death. Millions of people get influenza each year, hundreds of thousands are hospitalized, and thousands to tens of thousands die from influenza related causes each year. The key to preventing a devastating outbreak is vaccinating enough people that an outbreak is unlikely.
When Allina Health identified that its own rates for influenza vaccination were lower than desired, the health system studied data gleaned from its EHR and an Analytics Platform from Health Catalyst, which includes a Late-Binding™ Enterprise Data Warehouse and broad suite of analytics applications, to understand its true current vaccination performance. The data revealed that changes were in order, which Allina put in place through clinician feedback, engagement, and education.
Results:

4.8 percentage point improvement in influenza vaccination rate, exceeding the Healthy People 2020 goals for vaccination.

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Combatting Opioid Abuse with Data-Driven Prescription Reduction

Each day, 91 Americans die from an opioid overdose. Historically, illegal opioids, such as heroin, were the primary contributing factor to overdoses. Today, it is well understood that a driving force for opioid abuse is prescriptions, which contribute significantly to the overdose epidemic.
Following a series of adverse outcomes related to opioid misuse within the community, Allina Health sought to evaluate how it managed acute non-cancer pain in the outpatient setting, particularly among opioid-naïve patients. By leveraging the Health Catalyst Analytics Platform, including the Late-Binding™ Data Warehouse and broad suite of analytics applications, Allina Health obtained data on prescribing patterns and identified several opportunities to reduce the number of opioids prescribed.
Results:

980,527 fewer opioid pills prescribed in the outpatient setting in 2016, a 12 percent relative reduction.
1,079 fewer patients (with acute or chronic pain) receiving eight or more opioid pill prescriptions over 12 months, a 10.3 percent relative reduction.
13,391 fewer patients receiving opioid prescriptions for more than 20 pills, a 13 percent relative reduction.

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Successfully Sustaining Sepsis Outcomes

Increasingly, high-functioning healthcare organizations are recognizing the challenge of sustaining results following successful clinical improvement initiatives. Sepsis is a major driver of mortality in the U.S. In fact, it is estimated that up to half of all hospital deaths are linked to sepsis. After executing a successful strategy to improve outcomes for patients with sepsis, Piedmont Healthcare was determined to sustain those critical reductions in mortality, length of stay, and cost.
The health system “hardwired” process changes into the EHR, monitored performance compliance via a well-developed analytics application, and fostered strong leadership on the frontlines to champion a culture of continuous improvement. In the second year of its latest sepsis improvement effort, Piedmont was able to not only sustain, but also to further improve upon its first-year improvement results.
Second-year results:

14.2 percent reduction in mortality for severe sepsis and septic shock translating to 68 lives saved in one year.
30.7 percent improvement in number of patients receiving calculated fluid target.
$1.2 million saved in one year from decreased variable cost.

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Driving Down Costly COPD-related Readmissions with NOREADMITS Bundle

Nationally, approximately 700,000 hospitalizations occur each year with the principle diagnosis of Chronic Obstructive Pulmonary Disease (COPD), with one in five patients being readmitted within 30 days. Even with a national cost for each COPD readmission costing between $9,000 and $12,000, evidence-based measures that improve patient outcomes and decrease COPD readmissions are largely lacking.
When reviewing organizational performance for 30-day all cause readmission, MultiCare Health System identified COPD as one of the top two readmission diagnoses, along with a rate higher than expected. This prompted the organization to take action. MultiCare implemented a NOREADMITS bundle, using the Health Catalyst Analytics Platform and integrating performance measures for each element of the bundle, resulting in:

16.5 percent reduction in readmission rate.

Approximately 34 fewer patients with COPD readmitted each year, saving an estimated $360,000 annually based on national benchmarks.

95 percent of COPD patients were assessed for readmission risk.
Two-fold increase in COPD order set utilization.

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Collaborative Partnerships and a Three-System Approach to Driving Healthcare Transformation

Healthcare organizations are among the most complex forms of human organization ever attempted to be managed, making transformation a daunting task. Despite the challenges associated with change, Texas Children’s Hospital identified that it needed to evolve into a data-driven outcomes improvement organization.
Texas Children’s embarked on a journey to transform care, building a three-systems approach—analytics, best practice, and adoption—designed to develop a data-driven quality improvement organization that could achieve outcomes improvement expediently and at scale across the entire organization. Texas Children’s leadership knew that the foundation for clinical systems integration would be meaningful, actionable data. That realization prompted the organization to implement the Health Catalyst Analytics Platform including a Late-Binding™ Data Warehouse (EDW) and a broad suite of analytics applications.
After deploying the analytics platform supported by multidisciplinary quality improvement teams, Texas Children’s was able to improve patient outcomes related to the following:

35 percent relative decrease in hospital-acquired conditions (HACs).
44 percent relative decrease in LOS for patients with Diabetic ketoacidosis (DKA).
30.9 percent relative reduction in recurrent DKA admissions per fiscal year.

 

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How Texas Children’s Turned Child Diabetes Management into a Community Cause

Patients with diabetes are at a high risk for infections and substantial complications, including the risk of death from infections. Further, social determinants in these patients’ communities have a tremendous influence on their health.
Texas Children’s Hospital, ranked as one of the top four Best Children’s Hospitals by U.S. News & World Report, recognized that there were gaps in diabetes care coordination in the community—where the majority of a child’s diabetes management takes place. The hospital initiated a coordinated community response, aided with an analytics platform, which is setting the standard for community management of pediatric diabetes.
Results

4 percent relative improvement in the percentage of patients with diabetes who received the influenza vaccine.
3 percent relative improvement in pediatric provider diabetes knowledge.
90 percent of patients now have individualized school packets developed and available in the EHR.

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Systematic Improvement of Diabetes Care in the Inpatient Setting

Texas Children’s Hospital is improving the care delivery of its patients with diabetes, one of the most common diseases in school-aged children. How? Powered by dedicated improvement teams and analytics, they have focused on order utilization, timeliness of IV and subcutaneous insulin administration, length of stay (LOS), establishing a diabetic care unit (DCU), educating core diabetic nurses (CDNs), frontline staff adoption, and more.
Care delivery improvements include the following:

94 percent of patients with diabetic ketoacidosis (DKA) are assigned to diabetic care unit.
17 percent relative increase in patients with DKA receiving an evidence-based evaluation and order sets.
19 percent relative increase in patients with DKA receiving IV insulin within one hour of order.
50 percentage point improvement in the percentage of patients transitioning to SubQ insulin in less than four hours after medical readiness.
44 percent relative decrease in LOS for patients with DKA.

 

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DKA Risk Prediction Tool Helps Reduce Hospitalizations

Each year, more than 12,700 pediatric patients are diagnosed with diabetic ketoacidosis (DKA), a life threatening complication of diabetes. Texas Children’s Hospital sought a way to accurately predict risk of DKA in time for care team members to intervene before these patients suffered a severe episode.
The health system ultimately formed a multidisciplinary high risk diabetes team to devise pre- and post-discharge strategies, and DKA risk prediction tools aided by the Health Catalyst Analytics Platform built using the Late-BindingTM Data Warehouse.
Results:

30.9 percent relative reduction in recurrent DKA admissions per fiscal year.
90 percent of all patients with new onset type 1 diabetes at the Medical Center Campus have a documented RIPGC in their medical chart.
100 percent of patients with type 1 diabetes have a risk index for DKA documented every 6 months.

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Improving Population Health for Children with Diabetes

Diabetes is the most common chronic illness for children living in developed countries. Leaders at Texas Children’s Hospital wanted to take a more data-driven approach to population health management for children with diabetes. They created a Care Process Team (CPT) to pursue outcomes improvements related to diabetic ketoacidosis (DKA) since data from the EDW revealed that 64% of diabetes patients discharged had this life-threatening condition.
After the CPT achieved their initial goal of improving care for patients admitted to the hospital with DKA, they set out to implement larger improvements that would benefit the entire population of diabetes patients.
By empowering CPT members, leveraging data to drive decisions, and implementing new interventions effectively, the Diabetes CPT members have improved population health for patients with diabetes across all settings of care. Below are a few of the most significant results.

44 percent relative decrease in LOS for patients with DKA.
30.9 percent relative reduction in recurrent DKA admissions per fiscal year.
34.4 percent relative improvement in the percentage of patients with diabetes who receive the influenza vaccine.

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Analytics Support the Delivery of Effective Diabetes Self-Management Education

Effectively educating pediatric and adolescent patients and families to self-manage diabetes is a critical part of diabetes care. Leaders at Texas Children’s Hospital, one of the top four children’s hospitals in the country, recognized that diabetes self-management education that incorporates national standards and empowers patients can improve clinical outcomes and quality of life. While diabetes education has always been important to Texas Children’s, the education provided to patients was varied, no organizational standards existed, and tracking the effectiveness was not possible.
To address these challenges, Texas Children’s created an Education Care Process Team (CPT) that focused on: developing a standard education curriculum based on national guidelines, creating consistent education materials, leveraging powerful analytics to identify potential learning gaps and customize patient goals, and investing in the professionals who deliver education.
As a result of these efforts, Texas Children’s achieved the following:

Implementation of a standard diabetes education curriculum.
100 percent of diabetes educators are now CDEs.
70.7 percent of patients with diabetes have had an education visit with a CDE, and the hospital is on track to achieve its goal of 80 percent within the year.

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Improving Diabetic Care in the Ambulatory Environment

Diabetes is the most common life-threatening, chronic illness in children who live in developed countries. With effective management of diabetes, children with diabetes can live long, healthy, and active lives.
Texas Children’s Hospital believes that diabetes patients and their families are most successful in managing their disease if they receive standardized, family-centered, multidisciplinary care in both inpatient and outpatient settings.
Texas Children’s created a new Clinic Care Process Team (CPT) which developed a comprehensive approach to standardizing diabetes care by automating best practice alerts that help clinicians recognize the need for testing, so they order labs more quickly.
Within one month of implementation Texas Children’s saw measurable improvements:

Screening percentages for each test improved to >80 percent.
28.2 percent relative improvement in the percentage of patients receiving recommended annual thyroid-stimulating hormone (TSH) testing, with current performance greater than 90 percent.
23 percent relative improvement in the percentage of patients receiving recommended annual lipid testing, with current performance greater than 90 percent.
54.1 percent relative improvement in the percentage of patients receiving annual retinal examinations, with current performance at 94 percent.
Patient satisfaction is on an upward trend.

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From the Boardroom to the Bedside—Using Analytics to Drive a Culture of Continuous Improvement

Tracing its roots back nearly 120 years, Mission Health has a vision to provide world-class care to western North Carolina and beyond—even as the entire healthcare profession experiences a disruptive upheaval. Mission determined to meet these external changes by making a big change of its own: embracing a culture of continuous improvement.
Mission subsequently engaged physicians and other clinicians to increase process improvement skills, while expanding access to meaningful data via an analytics platform from Health Catalyst.
Results:

20 percent improvement in compliance with severe sepsis; 32 percent reduction in mortality rates; 58 percent increase in sepsis detection.
7 percent reduction in LOS for bowel surgery patients.
34 percent improvement in heart failure LVEF assessment rates.
20 percent increase in “on time” starts as result of OR dashboard.

 

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Using Value to Prioritize and Guide Analytics Investments

With the advent of analytics, hospitals have new access to high quality, reliable data. In turn, this can fuel any number of outcomes improvement projects, but hospitals have finite resources to expend on these initiatives. A process is needed to identify which ones will deliver the highest value and best align with the hospital’s overarching priorities.
To balance the demand for analytics support of improvement projects Mission Health designed a prioritization tool that has helped them identify the right projects to approve–while keeping stakeholders more engaged than ever in improving outcomes for patients.
To date, 80 percent of 55 approved projects have met or exceeded their initial targets. Actual realized targets include:

32 percent reduction in sepsis mortality
20 percent improved compliance with the sepsis care process
7 percent reduction in LOS for bowel surgery patients

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How to Significantly Reduce Sepsis Mortality

Up to 50 percent of all hospital deaths in the United States are linked to sepsis. That sepsis mortality statistic was not lost on Piedmont Healthcare, a system of six hospitals and more than 100 physician and specialist offices across greater Atlanta and North Georgia. Sepsis accounted for half of Piedmont’s mortality rate, despite years of progress in sepsis care.
Piedmont leaders recognized that they needed an innovative quality improvement methodology to spread best practices and sustain improvement, supported by an accessible source of timely, reliable, and actionable information. They therefore implemented a “core and spread” team structure to promote enterprise-wide adoption of best practices. The health system also deployed a sepsis prevention analytics application to deliver performance insight to all levels of the organization, and discovered a high correlation between better patient and financial outcomes and the number of bundle elements the patient received.  Being able to tie outcomes to interventions, along with the incorporation of nurse driven protocols, resulted in sustained practice change and greater engagement from physicians, nursing and frontline staff, all the way to the Board level.
As a result, Piedmont achieved the following impressive outcomes:

5.8 percent reduction in mortality for all patients with severe sepsis and septic shock, translating to 26 lives saved in one year.
2.5 percent reduction in total inpatient length of stay (LOS).
8.2 percent reduction in variable cost per case, equating to $4.3 million saved in one year.

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How to Reduce Clinical Variation and Improve Outcomes While Demonstrating a Positive ROI

Clinical variation can be frustrating for patients and their families, often leaving the impression that healthcare team members are not on the same page and don’t agree on the plan for the patient’s diagnosis or treatment. It is also costly—the Institute of Medicine estimates that $265 billion (30 percent) of healthcare spending is waste that directly results from clinical variation.
To reduce unwanted variation, Texas Children’s Hospital invested considerable resources to develop clinical standards tools, including evidence-based order sets; however, demonstrating the effectiveness and utilization of those guidelines, pathways, and order sets had been daunting. To that end, Texas Children’s deployed an analytics platform from Health Catalyst to aggregate and analyze the data needed to perform both of these critical functions.
Results:

$2,401 reduction in cost per patient with order set utilization, and an 8.4-day difference in average length of stay (LOS).
$15 million reduction in total direct variable costs in Fiscal Year 2015, $32 million anticipated reduction in Fiscal Year 2016 at the current order set usage rate, and a potential $64 million annual reduction with a hypothetical 80 percent order set usage rate.
1,629 percent return on investment (ROI).

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Reducing HAC Rates to Keep Kids Safe and Healthy

Hospital-acquired conditions (HACs)—such as central line-associated blood stream infections (CLASBIs) and pressure ulcers (PUs)—cause harm and adversely affect patients’ lives, while also increasing hospital length of stay (LOS) and total hospital costs. In fact, each case of CLABSI alone costs up to $55,000 to treat and makes health systems vulnerable to reimbursement penalties.1
Children’s Hospital of Wisconsin (CHW), a nationally ranked pediatric center with two hospitals and a surgery center, recognized that reducing the rate of HACs in its facilities would require major systematic changes. CHW’s approach to transforming care to prevent HACs included cultural changes with an emphasis on staff education and engagement and a new governance structure to support the initiative. These changes were powered by high-tech tools and quicker access to new types of data that CHW didn’t have in the past.
The hospital’s implementation of its comprehensive and collaborative HAC reduction plan has resulted in measurable quality of care improvements and cost reductions, including:

$1.6 million savings realized to date as a result of a 30 percent reduction in the overall number of HACs
23 percent reduction in central line-associated blood stream infections (CLABSIs)
74 percent reduction of pressure ulcers (PUs)
68 percent reduction in venous thromboembolisms (VTEs)

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Evidence-Based Care Process Model Reduces SSIs and Readmissions

The consequences of poor-quality surgical care are significant for both hospitals and patients. Consider the following: One in four patients having a colon re-section is readmitted within 90 days, costing U.S. healthcare approximately $300 million a year and negatively affecting the lives of tens of thousands of patients and their families.
In 2013, Mission Health, North Carolina’s sixth-largest health system, identified opportunities to improve clinical outcomes for its bowel surgery patients. With a vision of achieving the best outcome for each patient, Mission set goals to reduce length of stay (LOS), decrease readmissions, and reduce surgical site infections (SSIs) for its bowel surgery patients.
Mission recognized that care process models (CPMs) were key to making it easier for clinicians to deliver the best care to patients by doing the right thing consistently. The health system therefore organized a multidisciplinary improvement team charged with developing and implementing an evidence-based CPM for bowel surgery. In support of this effort, Mission leveraged technology and analytics to encourage clinician adoption of the CPM and to deliver performance insights.
Through these efforts, Mission has achieved impressive improvements in bowel surgery care:

92 percent reduction in colorectal surgery SSI rates
28.5 percent reduction in mortality
10.6 percent reduction in 30-day readmissions
4.4 percent reduction in LOS
8.5 percent reduction in cost per case

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Patient-Centered LOS Reduction Initiative Improves Outcomes, Saves Costs

U.S. hospital stays cost the health system at least $377.5 billion per year. In today’s value-based care environment, hospitals are under increasing pressure to avoid patient harm and maintain quality while also lowering costs. Reducing hospital length of stay (LOS), especially as it relates to avoiding unnecessary hospital-acquired conditions (HACs), is a primary indicator of a hospital’s success in achieving these goals.
El Camino Hospital, a 395-bed multi-specialty community hospital in Mountain View, Calif., places a high priority on keeping patients safe. However, when it came to its goal of reducing LOS, leaders recognized that they faced some major challenges, including:

The complexity of implementing a multi-layered, multi-disciplinary approach to improving the patient discharge process.
Identifying what issues were contributing the most to increased LOS so that they could be addressed.

By implementing analytics and protocols that provide access to actionable data, the LOS reduction team was able to identify patients at high risk for increased LOS so that they could develop and track critical interventions. El Camino’s patient-centered approach to tackling LOS reduction also included multi-disciplinary cooperation, leadership buy-in, and additional resources to enhance discharge care coordination.
This innovative, systematic approach resulted in not only a better than anticipated reduction in ALOS of 7.8 percent, but also:

14.8 percent reduction in readmissions
55 percent reduction in healthcare acquired conditions (HACs)
32 percent reduction in incidence of AHRQ patient safety indicators (PSIs).
$2.2 million projected annual cost savings

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How an IDS Standardized Care for Women While Increasing Market Share

One in three pregnant women give birth via cesarean section in the United States, which is more than double the rate the World Health Organization (WHO) recommends. And instead of decreasing, the overall C-section rate in Washington State increased 73 percent from 1996 to 2009. C-section rates are just one area of maternal care where our practice in the U.S. lags behind the science and knowledge of best practice. MultiCare Health System believes that all of its female patients should experience the same high-quality care across its integrated delivery system. The health of the next generation depends on it.
MultiCare recognized that it had to standardize care across its system to meet quality standards, improve its patients’ experiences and outcomes, and maintain its market share. The health system launched a Women’s Collaborative, the sole purpose of which was to improve clinical care and patient outcomes for women’s services systemwide.
By working with clinicians to implement standards of care, and using analytics to measure performance, the Women’s Collaborative achieved the following:

NTSV (low-risk, rst-time mother) C-section rate 9 percent less than the national average and already below the 2022 national goal of 23.9 percent
Six-point increase in market share for inpatient OB/GYN services
Improvements in care delivery:

63 percent reduction in episiotomy rate

11 percent reduction in SSI rate for C-sections
14 percent reduction in 3rd or 4th degree perineal laceration rate
Non medically indicated induction rate consistently less than a quarter of one percent
6.7 percent reduction in the percentage of abdominal hysterectomies

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Sepsis: The Impact of Timely, Trustworthy Data and a Systemwide Approach to Care Improvement

For patients with the severest form of sepsis, the chance of survival decreases by 7.6 percent for every hour that antimicrobial treatment is delayed. Coordinated team work and the speed with which recognition, diagnosis, and treatment of sepsis occur are critical. Health systems across the country have discovered that by successfully engaging clinicians in driving and maintaining best practice interventions they are able to save lives and improve patient outcomes. At Piedmont Healthcare, the work of educating clinicians on the importance of following sepsis care best practices had been done. The missing pieces were a well-resourced, systemwide improvement team to improve sepsis care, and a concise way to view and give timely feedback on performance based on accurate, trusted data. To fill in these missing pieces, Piedmont created a cross-representative sepsis improvement team and enabled tracking for compliance to best practices with an analytics application from Health Catalyst. Within just three months of deploying the Sepsis Improvement Application, Piedmont has accomplished significant improvements in efficiency—and completely won trust in the data. Piedmont has already identified early indications of patient outcome improvements. Initial achievements of its sepsis improvement team include deploying systemwide visibility into sepsis care performance and best practices compliance, improved acknowledgement of first alert by 19 percent across the system, and a reduction in manual data collection by 97 percent.

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Calculating the ROI of Diabetes Care Improvement

Texas Children’s Hospital has dedicated itself not only to successfully improving diabetes mellitus (DM) outcomes, but also to developing a framework for measuring the ROI of its performance improvement efforts. Texas Children’s tackled its DM initiative with a combination of technology investments and new organizational models, including an enterprise data warehouse (EDW) and analytics platform, a clinical care process team model for improving the quality and cost of care, and a diabetic care unit (DCU) staffed by a highly specialized, highly trained group of providers. Health system leaders also worked with the business school at Rice University to develop a model for measuring ROI that focused on easily quantifiable drivers. The results of this effort include substantially improved quality of care for DM patients, an increase in net revenue by a projected $232,000 annually, and an estimated ROI of 53 percent.

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The Improvement Methodology From Thibodaux That TJC Calls “Best Practice”

Thibodaux Regional Medical Center has always excelled in delivering quality care to its patients, but a fundamental tenet of its culture is continuous improvement.
Driving that continuous improvement is a methodology The Joint Commission called “best practice in how to use data and get physicians engaged.” This quality improvement methodology centers around a three-systems care transformation model that includes best-practice care protocols, analytics, and rapid time-to-value analytics application development and frontline clinician adoption.

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