Hello, my name is Jennifer Boyce and I am a supervisor heart and vascular outcomes quality nurse for Waukesha Memorial Hospital. Today I will be presenting information on bridging LAAO registry data and quality improvement. The objectives of this presentation are to show how our facility is using data from the LAAO registry dashboard and the steps that our facility Waukesha Memorial Hospital takes to implement change using this data to drive quality improvement activities. I have no disclosures. The goals of this presentation are to have you identify ways to use the data from the LAAO dashboard to implement change and be able to recommend one example on implementing and using data for quality improvement activities at your facility. I would like to start out by telling you a little bit about Waukesha Memorial Hospital. We are located in Waukesha, Wisconsin, about 20 miles west of Milwaukee. Our hospital is part of the Pearl Healthcare System. We are surrounded by a great local community. We began implanting the Watchman device in quarter one of 2019 and our annual volume has been between 40 to 64 cases per year. We presently have two physicians at our facility that implant the Watchman device. At Waukesha Memorial Hospital, interdisciplinary communication and transparency of patient outcomes and events is key to our program's success. We have a very broad list of people that receive our LAAO registry and hospital dashboard reports to include physicians, hospital leadership, and supporting program staff and departments. We feel it is important that the people that interact with our patients and have a direct impact on our outcomes be included in our communications. We also do a lot of education with the team on the LAAO dashboard metrics as some of these categories are quite broad. Having all members of the team that care for these patients understand what we collect and what makes a patient event a fallout assists with the prevention of additional fallout events and improves the care that our patients receive. It also assists with everyone knowing how the care we provide to our patient compares to other facilities performing left atrial appendage implants by comparing our data to the registry national benchmarks. We are very transparent with our patient outcomes and registry data. Having the LAAO registry dashboard helps us to identify trends in our data that should be used to focus our quality improvement efforts. It also allows us to look ahead of the published reports at our patient events so we don't have to wait to take action when needed. I am the quality nurse specialist for our team and I am responsible for all data abstraction, reporting, hospital dashboard updates, and presentations. We also have a Watchman nurse coordinator that assists with patient workup, communications, scheduling patient appointments, and providing patient education and resources as needed. This coordinator, along with help from other supporting staff, completes the patient's six-month, one-year, and two-year follow-up calls. We come together as a team quarterly to review our LAAO registry dashboard data and to allow a forum for team discussions and to create action plans for performance improvement activities. Participants of the quarterly data review include the implanting physicians, hospital leadership, the director and manager of heart and vascular outcomes, supporting electrophysiology physicians, our Watchman coordinator, and other supporting team members. After providing an overall review of our LAAO registry dashboard outcomes, I will highlight two areas of program strength or positive data trends and also two areas of opportunities to consider and focus process improvement efforts. The implanting physicians and team members are responsible for making and implementing changes to improve our outcomes. Now we'll take a look at how Waukesha Memorial Hospital captures, reports, and communicates our LAAO registry dashboard data. I have created dashboard fallout tracking reports for the in-hospital dashboard metrics and separate fallout tracking reports for the 45-day, six-month, one-year, and two-year follow-up periods. As some of the dashboard metric categories are broad, this helps to identify what are the events in each metric that have caused a fallout. The dashboard metric definitions are shown on this report and a brief description of the patient events that have caused a dashboard metric fallout are also recorded. It can be a little tedious to complete these fallout tracking reports, but it will save a tremendous amount of time when working on presentations or evaluating fallout events. It makes the data very usable and keeps others in the loop to the events and patients causing fallouts for the dashboard. This report also provides what the unpublished dashboard results will be, which allows the team to continue to work on the most current performance improvement activities that are needed. I have also created LAAO registry tally reports. These reports are color-coded to give a quick visual on the results of our published outcomes, what we are doing well at, and what do we need to do better on. This report assists with compiling all of the published reports for a better understanding of what our results are now and how they compare to our historical outcomes. It will show if our performance improvement activities help to improve certain outcomes or if they presently and historically are still needing additional review. It is also a great way to see how the overall registry dashboard benchmarks have changed over time. If the benchmarks from all facilities are improving, we are hopefully seeing the same improvement results. It can assist with showing if the benchmark results adjust with the release of new device technologies or fallout definition updates. As with the fallout tracking reports, there is a separate tally report for the in-hospital outcome metrics and all of the follow-up periods. The fallout and tally reports are emailed to designated physicians, leadership, and our watchman implant coordinator on a quarterly basis. These are sent when the quarterly registry reports are emailed and when our hospital LAAO registry dashboard is updated and emailed to the team. Having the fallout definition clearly stated on the fallout report gives designated team members access in looking at the events that cause fallouts while being able to identify patient and event details. This report provides patient name and medical record number to allow for additional case review of the events causing the fallout when needed. With the fallout definition clearly stated, it helps to build confidence of the team to know that events are not being over-coded and they are being captured correctly. It also helps in the tracking of the events for the broader dashboard metrics like major complications to know if the fallouts in this category are related to the same or various events. Again, transparency to all is important to our program's success and team environment. So let's take a look at the Waukesha Memorial Hospital LAAO registry dashboard. I know this is something that you cannot clearly see, but I wanted to provide a visual of how our LAAO registry dashboard formatting looks. The dashboard formatting continues to change as we acquire more data, and I am continually looking at the best ways to display our data on our dashboard. The top portion of the dashboard, which we will look at more closely, is our in-hospital metrics. Below that section, we have two follow-up dashboard categories that we will also take a closer look at. Because certain follow-up categories will capture fallout events that occur during the hospital stay from when the device was implanted or from the previous follow-up period, showing in-hospital and follow-up outcomes displayed in a vertical fashion by quarter assists with knowing at what stage the events are occurring. The last four rolling quarter results on the dashboard for each category is color-coded to assist with visualizing our current performance results. We use the 50th, 75th, and 90th registry benchmark percentiles as our threshold target and stretch goals. These goals are updated on an annual basis using the current registry reports. I report all data as it is available at the end of a quarter once gathered, and do not wait for the published report to update our hospital dashboard. I use the LAAO registry dashboard from the NCDR to complete our hospital dashboard. By showing the data when the quarter is finalized allows us to monitor our data in real time and catch events and trends as they occur. I also want to mention as we review the following slides that the dashboard data is not reflective of our actual results that have been put together for demonstration purposes only. Now let's take a look at the in-hospital metrics on our LAAO registry dashboard. These are the current LAAO registry dashboard metrics that we use on our hospital dashboard. Again, the threshold target and stretch goals are obtained from the LAAO registry reports and are updated annually. Metrics where the 50th, 75th, and 90th registry percentiles are all the same will display a target value only. Results for these categories will be colored green if meeting or better than the target value or red if below the listed value. Numerator and denominators are shown for each category to assist with understanding the number of fallout events. In some categories, because our case volume is lower, one fallout can be enough to trigger a result that is below the 50th percentile for that metric. It is important for the team to be aware of how many events we are having and helps with targeting and focusing our improvement activities. At our quarterly team data review meetings, we will review the dashboard in detail. I review with the team the definitions and events that go into the registry's broader categories for team understanding of what events in these categories will cause a fallout. The definition of major complications is shown here with all of the events that are captured in this metric. The in-hospital dashboard section shows the last three rolling years of our data. This allows being able to see the in-hospital fallout events in a vertical fashion to the 45-day, six-month, one-year, and two-year follow-up periods. When we meet as a team to review our dashboard outcomes, we look at all of the in-hospital metric fallout events that have occurred in the last four rolling quarters. We will review the specific patient events that have caused a fallout for this category. Being able to see the previous rolling two years' worth of data also provides a visual to how the most recent four quarters of data compares to the number of fallout events from the previous two years. Next we will review the LAAO registry follow-up metrics and data tracking. After reviewing the in-hospital metrics, we focus our review on the follow-up metrics section of the dashboard. We review at each meeting the follow-up periods that we track for the registry and the allowable timeframes for each of these follow-up periods. The two follow-up categories that we presently track on our dashboard are stroke, systemic embolism or mortality, and bleeding event any. The follow-up period results are shown in a vertical fashion by quarter under the in-hospital metrics to assist with visualizing when the events have occurred. One example of this benefit is in watching our follow-up bleeding events. Because there are medication adjustments at certain periods, we are hoping to see the number of fallout events decrease when oral anticoagulants and Plavix are stopped. The dashboard results and timing of bleeding events will help us to see if there is more we need to investigate. Fallout events on the follow-up report are cumulative. For example, certain bleeding events that occurred during the in-hospital stay will continue to show as a fallout for the 45-day, 6-month, 1-year, and 2-year follow-up periods. For this reason, numerators in the follow-up metrics section are color-coded with either a red dot to identify a new fallout event or a green dot to indicate no new fallout event in each of the time periods. This provides an extra visual when reviewing our outcomes to know when the fallout events are occurring and how they relate to the FDA medication protocol changes or the timing of events from implant date. As with our in-hospital dashboard metric review, at the quarterly meetings, we review the definitions of each of the follow-up metrics that we track. It also reinforces that the dashboard follow-up metrics will account for events from the procedure through the follow-up period and not just events that occurred from the prior follow-up. As our program started in 2019, we are just starting to see a full rolling year's worth of 2-year follow-up data for review. We will review at our quarterly meetings all of the data that we have available for the follow-up periods to see if we can identify any trends in our data. This continues to be beneficial with monitoring the FDA medication protocol adjustments and to assist us with monitoring our patient selection. Again, we look to identify patterns in our data and to make changes as needed to the different stages of the follow-up periods. The events are arranged in order by the number of days the event occurred from the date of the implant. Color coding of the different follow-up periods and fallout events are also used to help with visualizing when the events are occurring and different patterns. We have to look at a lot of material in a brief period of time, so any way to draw out patterns quickly is beneficial. We will also do the same in reviewing our bleeding events. First we review the definition. Then we look at the fallouts that have taken place. We begin reviewing the dashboard with all fallouts that were available. As we are starting to accumulate more data, this will now focus on the events of only the last four rolling quarters. Looking at all of the bleeding event data available, arranged by date of event from implant, helps us to identify patterns at the various stages. Again, we focus on looking at what events have occurred and the date of the event from implant. We look for events that will help us with patient selection or our follow-up care protocols. Color coding similar events assists with processing this data in a short period of time to allow for collaboration while the team is together reviewing the data. Since our program has now collected a full year's worth of two-year follow-up data, we have just begun to focus our efforts on reviewing the fallout events of only the last four rolling quarters. This is where we focus our attention to look for trends in our fallouts and identify where performance improvement is needed. It also helps us to see what we have improved upon when comparing to all historical data that we have collected. When reviewing our fallouts, we again focus on events in relation to the medication adjustment periods. In this example, when focusing on all follow-up bleeding events for the last four rolling quarters, it can be identified that the majority of bleeding events for all periods was GI-related events. I then look to see if there is something that requires additional review and drill down. All patients with bleeding events were reviewed to see if they had a history of bleeding events prior to the Watchman implant. Additional patient risk factors and review of what medications they were on at the time of the bleeding event are also reviewed to see if these factors may have contributed to the fallout. It will assist us with monitoring our patient selection process. We also look at the reason for starting and stopping medications that would differ from the FDA medication protocol and to see if this could also be a causative factor to the new bleeding event. Lastly, we compile all of the LAAO registry definitions for each of the dashboard metrics in a document that we call our strategic directives. This clearly shows the hospital leadership that takes ownership for the dashboard metrics. It again shows the definition of each metric and what goes into each numerator and denominator. My name is listed as the data owner and the benchmark sources with frequency of updates is clearly stated. The strategic directives are given to all of the people on the dashboard distribution list on an annual basis when the goals are updated with the most current registry benchmarks. This is also provided to new staff when they receive the first dashboard to assist with the understanding of the dashboard metrics that we track. Well, this is the end of my presentation. I would like to thank Julie Mobad, who is the project manager for the LAAO registry, for allowing me the opportunity of sharing our dashboard tracking metrics and processes. I am hoping that you have learned something from seeing how we are communicating and using our data from the LAAO registry dashboard for quality improvement at Waukesha Memorial Hospital. Also a special thank you to the LAAO registry support staff for assisting in the understanding and correct marking of our fallout events. Thank you for viewing.

LAAO registry dashboard

Watchman device

communication

patient outcomes

performance improvement

education