Those who work in the organization are
focused on improving safety and quality
LD.03.06.01

It is relatively impossible for most people to focus on multiple issues simultaneously.  As a result, SETMA has organized teams which allow members of that team to focus on safety and quality in regard to their area of responsibility.  Those teams are:

1. Hospital Care Team
2. Long-Team Care Facility Team - I-Care
3. Quality Improvement Team
4. Information Technology Team
5. HIPAA Compliance Team
6. Nursing Services Team
7. Information Security Team

SETMA has standardized metrics identified through which to evaluate the performance of each of these teams.  We routinely review our processes and outcomes to make certain that quality and safety are being supported.  The following are critical supports required for success in our Performance Improvement and patient safety and quality efforts:

1. Care where the same data base is being used at ALL points of care.
2. A robust EHR to accomplish the above.
3. A robust business-intelligence analytics system, which allows for real-time data analysis at the point of care.
4. A laser printer in every examination room so that personalized evaluational, educational and engagement materials can be provided to every patient at every encounter, with the patient’s personal health data displayed and analyzed for individual goal setting and decision making.
5. Quality metric tracking, auditing and statistical analysis.
6. Public Reporting of quality metric performance by provider name.
7. Quality Improvement initiatives based on tracking, auditing and analysis of metrics.
8. Shared vision among all providers, support staff and administrators - a personal passion for excellence -- which creates its own internalized, sustainable energy for the work of healthcare transformation.
9. Celebratory culture which does not compete with others but continually improves the organization’s own performance, using others as motivation but not as a standard.
10. Monthly peer-review sessions with all providers, to review provider performance and to provide education in the use of electronic tools.
11. Adequate financial support for the infrastructure of transformation.
12. Respect of the personal value of others and the caring for people as individuals.
13. An active Department of Care Coordination and a hospital-care support team which is in the hospital twenty-four hours a day, seven days a week.
14. Aggressive end-of-life counseling with all patients over fifty, and active employment of hospice in the care of patients when appropriate.

The SETMA Model is the foundation of our medical home through which our quality improvement and patient safety and quality efforts are pursued:

• Transitions of Care using PCPI’s 18-point quality measurement set on care transitions.
• Coordination of Care through our Department of Care Coordination which also recommends to The SETMA Foundation those who need our help in paying for their healthcare. In the past three years, the partners of SETMA have given $1.5 million dollars to The Foundation for the support of the care of our patients. Through the Foundation, we have paid for tests, medications, treatments, surgeries, dental care and other care of our patients. None of the Foundation’s money can be paid to or profit SETMA.
• Medication Reconciliation at multiple locations including hospital, emergency department, clinic, nursing home, home health, hospice, etc. In that the same data base is used in all locations, SETMA’s patients receive dozens of instances of medication coordination each year which adds to patient safety.
• The Baton - out of 8,760 hours in a year, the patient is in charge of h is/her care for over 8,700 hours. The patients “plan of care’ and “treatment plan,” with goal setting, education, information and current status of care is “the baton,” which is passed from the provider to the patient to empower the patient to care for himself or herself.

“Often, it is forgotten that the member of the healthcare delivery team who carries the ‘baton’ for the majority of the time is the patient and/or the family member who is the principal caregiver. If the ‘baton’€”the plan of care and treatment plan -- is not effectively transferred to the patient or caregiver, then the patient’s care will suffer.” (James L. Holly, MD)

• Care Coaching - done by 12-30 minute telephone calls, American Diabetes Association (ADA) accredited Diabetes Self Management Education (DSME) and Medical Nutrition Therapy (MNT) Education programs, as well as home v isits by nurses, patients are further engaged with their own care.
• A Team - mu lti-specialty, multi-discipline team which coordinates care, accepts responsibility for patient safety and quality care, and which documents to the same data base, works together to provide outstanding care with documented excellent outcomes. SETMA’s LESS Initiative is the foundation of our wellness program. “LESS” stands for “lose weight, “exercise” and ‘stop smoking.” Completed on all patients seen in the clinic, The LESS gives each patient a weight assessment of BMI, BMR, Body Fat, disease risk of current weight and instructions on how to change the BMR in order to facilitate weight control. The patient also receives a personalized exercise program based on their health, age, heart rate and over all conditions. Exercise programs are modified for diabetes, congestive heart failure and other physical limitations. Finally, every patent, even pediatric are assessed for smoking or exposure to tobacco smoke. Smoking cessation and nicotine addiction educational materials, and, if the patient smokes, an “electronic tickler file,” are generated to trigger a personal telephone call 30-days later to assess progress in stopping smoking.
• SETMA’s use of Clinic Decision Support (CDS) has improved provider performance and outcomes significantly. One element of our EHR deployment is described as “we want to make it easier to do it right than not do it at all.” is illustrated by our population management of infectious diseases. In Texas, 78 diseases are reportable to the State Health Department. There are five categories of the timing requirement of that reporting. SETMA designed a program which is triggered by the placement of one of the reportable diagnoses in the assessment template. When that occurs, the following happens without any further action by the provider:
• The Reportable Disease template has the infectious disease documented. An e-mail is sent to the Department of Care Coordination/  The Department notifies the State either by telephone, e-mail or letter.  The Department notifies the provider that the report has been made.  If there is a confirmatory test, when the result returns it is matched with the assessment and a follow-up report is sent to the State.  Quarterly and annually an audit is completed for all infectious diseases and the incidence of their being reported.

All of this happens without the provider doing anything but making the diagnosis. The same processes take place with our HIV Surveillance Program. All patients 13-64 are screened for HIV. Our EHR has a Screening and Prevention screen which displays the standards of care for preventive and screening care. If the element applies to the patient and has been done, it appears in black. If it applies and has not been done, it appears in red. If it does not apply to this patient, it is in grey. If the HIV testing is red, the provider simply clicks a button and the following happens:

• The test is ordered and the order is sent to the lab.
• A document is printed for the patient to sigh for permission
• The charge is sent to business office
• The screening template is updated to show that the test has been done.

For years SETMA has calculated several Framingham Risk Scores for our patients but in 2010, we expanded that to include all twelve Framingham Risk Calculators. We then added a feature which allows us to tell our patients, “If you make a change, it will make a difference.” In order to do this, we not only calculate the risk scores, but we add a “what if” scenario. The principle risk score shows the patient’s 10-years Cardiovascular Risk and shows the patient’s “relative” heart age. In addition to showing the patient’s actual and relative heart age on the plan of care and treatment plan, SETMA produces five “what if” scenarios. “What if” each element is treated to goal? The “baton” shows the patient how his/her risk and relative heart age will change. The same is done for a 20% improve in each element of the Risk Calculator. As public reporting changes provider behavior, the “what if” scenario can change patient behavior.

SETMA’s EHR and EPM make it possible to complete tasks in seconds which previously took minutes. It also allows us to do in less than a minute audits which once took hours. Because the same data base is used in the hospital, emergency department, nursing home, clinic, hospice, home health, physical therapy and all other points of care, SETMA is able to replace the typical medical record silhouette of a patient with a granular portrait which allows the patients continuity of care to be maintained no matter who is seeing the patient. And, all of this contributes to patient safety.

This has allowed SETMA to eliminate ethnic disparities of care in diabetes and hypertension and to address complex issues of transitions of care and preventable readmissions to the hospital. SETMA’s public reporting of provider performance by provider name has added a transparency to our care delivery, which has encouraged our patients to hold us and themselves accountable for improved outcomes. Our attention to statistical analysis has allows us to move our standard deviations on hemoglobin A1C from 1.98 in 2000 to 1.2 in 2011. It has challenged us to change and improve processes which affect an improvement in outcomes. And, as members of the National Quality Forum, SETMA continues to work to improve health in our practice, in our community, in our region and in our nation.