Inova Health System Management Team Update September 2007.

Inova Health SystemInova Health System

Management Team UpdateSeptember 2007

Quality and SafetyQuality and Safety

2007

Safety GOAL IAH IFH IFOH ILH IMVH ICCC ICGCC IVNAHH

Year to Date Event Rate 0.07 0.163 0.049 0.144 0.19 0.159 0.038 0.044 0

Clinical Effectiveness

Percent of Core Measures at 100% 75% 68% 44% 75% 50% 63% 60% 70% 70%

Percent of 100K Lives Indicators at Target 100% 75% 75% 75% 34% 100% na na na

Regulatory Readiness

Percent of Monthly Mock Surveys Passed 67% 57% 86% 100% 100% 63% 34% 67% 71%

At or better than 2007 goal

At 50% of goal or better

Less than 50% of the goal

Patient SafetyPatient Safety

No harm/interventionMinor intervention

Moderate intervention

Severe permanent harm

Death

2006%

2007 (ytd) %0%

5%

10%

15%

20%

25%

30%

35%

2006% 2007 (ytd) %

Year over year statistics:Year over year statistics:•Safety events 2006: 44Safety events 2006: 44•Safety events 2007: 32Safety events 2007: 32

•Event related mortality 2006: 29%Event related mortality 2006: 29%•Event related mortality 2007: 16%Event related mortality 2007: 16%

Event Classification2006 vs. 2007

Clinical Effectiveness MeasuresClinical Effectiveness Measures

0%

20%

40%

60%

80%

100%

AMI-ASA on discharge

AMI-Beta Blocker on Discharge

AMI-PCI within 90 min

CHF-ACEI for LVSD

CHF-Discharge InstructionsCAP-Pneumovax

CAP-Timely Antibiotics

100K-Central Line Bundle

100K-VAP Bundle

Q1-07 Q2-07 Q1-06

2006 2007 2006 CMS Benchmarks

IHS Avg. IHS Avg. Top VA National

AMI 10th Avg Avg

Aspirin at Arrival 96% 100% 100% 95% 93%

Aspirin Prescribed at Discharge 94% 93% 100% 92% 90%

ACEI for LVSD 88% 100% 100% 86% 83%

Adult Smoking Cessation Advice Counseling 99% 96% 100% 88% 89%

Beta Blocker Prescribed at Discharge 95% 100% 100% 94% 90%

Beta Blocker at Arrival 94% 100% 100% 91% 87%

PCI Received Within 120 Minutes of Hosp Arrival 75% 88% 60% 55%

CHF

Discharge Instructions 50% 70% 93% 68% 62%

LVF Assessment 91% 98% 99% 87% 84%

ACEI for LVSD 88% 100% 100% 84% 82%

Adult Smoking Cessation Advice/Counseling 64% 67% 100% 88% 83%

PNEUMONIA

Oxygenation Assessment 100% 100% 100% 100% 99%

Pneumococcal Vaccination 52% 83% 94% 72% 71%

Adult Smoking Cessation Advise/Counseling 57% 80% 100% 84% 81%

Initial Antibiotic Received Within 4 Hrs of Hosp Arrival 80% 93% 93% 77% 80%

SIP

Prophylactic antibiotics given within one hour of incision 76% 78% 94% 79% 78%

2006:% Green (Top 10%)=7%% Blue (Average) =40%% Red (Below Avg)=53%

2007:% Green (Top 10%)=44%% Blue (Average) =50%% Red (Below Avg)=6%

Inova Health System

Implementation of "Safety Essentials" - Progress Report

August 2007

IAH IFH IFH IFHC IFH IFOH ILH IMVH ICCC ICGCC IVNA Ambul System*

Safety Essentials Core IHVI Women's HH

Safety Oversight Team 4 4 4 4 4 4 4 4 3 3 4 3 9 of 12

Safety Rounds 4 4 4 4 4 4 4 4 2 3 4 3 9 of 12

Safety Coaches 3 3 3 4 4 4 4 4 2 3 2 2 5 of 12

Safety Huddles 4 4 4 4 4 4 4 4 2 4 4 3 10 of 12

RN staffing at 50th percentile 2 4 3 4 3 4 4 3 na na 4 na 5 of 9

Charge RN out of staffing 3 3 3 3 3 4 4 3 na na 4 3 3 of 10

Charge RN standard report WIP Yes Yes Yes Yes Yes WIP WIP WIP WIP Yes WIP

Medical Staff Transparency 2 3 3 3 3 3 3 3 na 2 na 3 0 of 10

Key

Have not started 1

Planning/initial implementation 2

Partially implemented 3

Fully implemented/operational 4

WIP: Work in progress

% of shifts with Charge RN out of staffing: % of shifts with Charge RN out of staffing: (July 07)(July 07)IAH: 79%IAH: 79%IFH: 61%IFH: 61%IFOH: 90%IFOH: 90%ILH: 96%ILH: 96%IMVH: 38%IMVH: 38%

PeoplePeople

Metric 2007 Q2 Goal 2007 Q2 Results

Net New RN’s (FTEs) 98 131.5

Retention of priority clinical staff with less than 2 years experience

80% 71.8%

Reduce Employee Related Injuries by 33%

313 452

Great Places to Work Satisfaction Score

70%

90 Day Action Plans Employee Pulse Check May

67.6%

GrowthGrowth

Metric Q2 2007

YTD Goal

Q2 2007

YTD Results

Equivalent Admissions 83,950 85,168

Outpatient Surgeries 27,135 27,952

Home Care Visits 57,120 40,848

Resident Days 79,183 77,508

Inova Employee Assistance ProgramEAP achieved a 13.5% increase in overall gross revenue as of 8/1/2007. Sales efforts resulted in 46 new contracts

CommunityCommunity

2007 Q2 Goal 2007 Q2 Result

Philanthropy – Gifts $10,000,000 $8,300,000

Disaster PreparednessCaring is Preparing booklet and dvd sent to all employeesPandemic Flu staff prophylaxis plan in place

• Employee +3 to be treated in event of a disaster or flu• Nex Genesis tracking system in place with training planned

for SeptemberTable top drill planned for 4th quarter

CostCost

Metric Q2 2007

YTD Goal

Q2 2007

YTD ResultSystem-wide EBIDA

Margin 14.5% 15.6%

System-wide Operating Expenses (excluding interest and bad debt) per Equivalent Admission

$9,606 $9,267

Inpatient Trends

Patient SatisfactionPatient SatisfactionExcellent Percentile RankingExcellent Percentile Ranking

Quarter 3 (as of September 17, 2007)Quarter 3 (as of September 17, 2007)

Inpatient Goal Actual

Inova Health System 63 72

Inova Alexandria Hospital 44 25

Inova Fairfax Hospital 66 77

Inova Fairfax Hospital for Children 62 85

Inova Fair Oaks Hospital 81 86

Inova Loudoun Hospital 67 82

Inova Mount Vernon Hospital 61 15

(10525402) Overall, would you rate the quality of care provided as:(10525402) Overall, would you rate the quality of care provided as:

Rankings for All Service Lines by Sample Group in Jul-Sep 07*Rankings for All Service Lines by Sample Group in Jul-Sep 07*

Emergency Department Trends


Quarter 3 (as of September 17, 2007)Quarter 3 (as of September 17, 2007)Emergency Departments Goal Actual



IECC Fairfax 96 51

IECC Loudoun 81 86

IECC Reston 87 61

Inova Fairfax Hospital 63 18

Inova Fairfax Hospital for Children 74 90


Inova HealthPlex 73 61


Inova Loudoun Hospital – peds 61 90




Outpatient Surgery Trends



Outpatient Surgery Goal Actual



Inova Fairfax Hospital - ASC 79 66

Inova Fairfax Hospital – Women’s OR 94 84

Inova Fairfax Hospital - Woodburn 86 40




Inova Loudoun Amb Surgery Center 87 100




Outpatient Radiology Trends



Outpatient Radiology Goal Actual



Inova Fairfax Hospital – CT 50 0

Inova Fairfax Hospital - Diagnostic 50 24

Inova Fairfax Hospital – MRI OP 50 95







Overall Progress Overall Progress

Almost one half (38 of 83) of our departments are meeting or exceeding the systemwide goal for their respective area.

Units above 90Units above 90thth percentile – Q3 td 2007 percentile – Q3 td 2007IHVI – Cardiac Step Down LASC – OP surgery ILH – MedicalIFHC – NICU IFH Cardiac cathHealthPlex – OP radiologyHealthPlex – OP surgery IFH – OP MRI ILH Leesburg – OP radiology IMVH – OP radiology IMVH – OP surgery IFOH – Medical IHVI – PCCU ILH – Obstetrics IAH – Medical 2122 IAH – OP radiologyIAH – Neurovascular IMVH – Rehab 5BIFHC – EDILH – peds ED

Inova Health System Management Team Update September 2007.

Documents

safety events

safety rounds4444444423439

safety coaches3334444423225

safety huddles44444444244310

goal slide

patient safety year

event related mortality

event classification