What is Pneumonia?  Pneumonia is an inflammation or infection of the lungs, most often caused by bacteria or a virus.  The air sacs in the lungs fill with mucous and other liquids.  Because of this, oxygen cannot get into the blood and be carried to the cells of the body.

Pneumonia is the sixth leading cause of death in the United States, accounting for approximately 500,000 hospital admissions annually, and is one of the most common diagnoses leading to admission at Baystate Health (BH) facilities.  National statistics have led the Centers for Medicare and Medicaid Services (CMS) to publicly report pneumonia quality process measures, readmission rates and mortality via hospitalcompare.hhs.gov.  The impact of this disease has helped to keep our quality improvement work related to pneumonia in the forefront.  Several multidisciplinary groups are in place and have collaboratively revised and implemented the comprehensive practice guideline for the management of this patient population.  The guideline decreases practice variation by providing recommendations drawn from recent medical literature. Adoption of the “Opt-Out” model has improved our rates of smoking cessation counseling and immunization.  In the Opt-Out model, the clinician has to actively choose not to apply or prescribe the agreed-on process or intervention.  Typically, selecting to opt-out is more time consuming or difficult than allowing the agreed-on process to occur as part of the flow of work.  Using this model promotes the desired action (the default) to be applied more consistently to a greater number of eligible patients.  Opt-Out is just one of the reliability principles in place to help drive perfect care to every patient, every time.  The concept of a “composite score” has set the bar for delivering optimal care higher than ever before.  The composite score represents overall quality (how well BH facilities reliably provide all appropriate care).   

Highlights

Baystate Medical Center

Care is focused on providing the appropriate evidence-based interventions to every patient, every time.  

• 97% of patients with pneumonia received every recommended intervention, consistent with the HQA benchmark.
• 97% of patients had appropriate antibiotic selection, compared with the HQA benchmark of 100%.
• 97% of patients with pneumonia had a blood culture drawn before antibiotics were given, compared with the HQA benchmark of 100%.
• Feedback loops have been developed to provide timely information to all clinicians if they miss an opportunity to provide optimal care.

Baystate Mary Lane Hospital 

Care is focused on providing the appropriate evidence-based interventions to every patient, every time.  

• Ongoing education, reinforcement and direct feedback are provided to staff so that all pneumonia guidelines are applicable to all patients with either a primary or secondary diagnosis of pneumonia, or with pneumonia diagnosed during an inpatient stay. 
• 90% of patients with pneumonia received every recommended intervention, compared with the HQA benchmark of 97%.
• 93% of patients had appropriate antibiotic selection, compared with the HQA benchmark of 100%.
• 100% of patients with pneumonia had a blood culture drawn before antibiotics were given, consistent with the HQA benchmark.

Baystate Franklin Medical Center

Care is focused on providing the appropriate evidence-based interventions to every patient, every time.  

• 92% of patients with pneumonia received every recommended intervention, compared with the HQA benchmark of 97%.
• 92% of patients had appropriate antibiotic selection, compared with the HQA benchmark of 100%.
• 97% of patients with pneumonia had a blood culture drawn before antibiotics were given, compared with the HQA benchmark of 100%.
• Feedback loops have been developed to provide timely information to all clinicians if they miss an opportunity to provide optimal care.

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