KHEN Progress Overview Next Steps for QI and

K-HEN Progress Overview & Next Steps for QI and Opportunities Our Progress Toward the 40/20 Goal Donna R. Meador, K-HEN Project Director

K-HEN Framework CMS Partnership for Patients Hospital Engagement Network Program (HEN) HRET (AHA) 32 Other State Hospital Associations 25 other HENS K-HEN 91 hospitals 2

K-HEN Framework STAY FIT CLABSI CAUTI SSI VAP GO RED Readmissions ADE Patient Safety Culture PIVOT VTE Pressure Ulcers Falls OB HARM *Early Elective Deliveries 3

K-HEN Services Benchmarking Coaching Calls Best Practices Education and Resources Technical Assistance Patient Safety Culture Education and Resources • Reports, including CEO Dashboard • • • 4

K-HEN Results 5

ADE (Adverse Drug Events) 6

ADE (Adverse Drug Events) 54% Improvement 7

CAUTI 8

CAUTI 15% Improvement 9

CLABSI 4% Improvement 10

CLABSI 11

Early Elective Deliveries 59% Improvement Early Elective Deliveries (EOM-OB-40) 25, 0% 20, 0% EED Rate 15, 0% 10, 0% 5, 0% 0, 0% дек-13 22% 10% 13 к- 13 я- де 3 но т-1 13 ок н- г-1 3 авг-13 сен-13 окт-13 ноя-13 22% 22% 7% 8% 8% 13% 13% се 13 ав л- 13 ию н- 13 й- ию 13 р- ма 3 13 ап р- -1 ма 3 -1 фе в ян в 12 дек-12 янв-13 фев-13 мар-13 апр-13 май-13 июн-13 июл-13 22% 22% 9% 13% 11% 10% 13% 6% 13% 13% к- 12 я- де 2 но т-1 12 ок н- 2 се г-1 12 ав л- 12 ию н- 12 й- ию 12 ма р- 2 12 ап р- -1 ма фе в ян в -1 2 янв-12 фев-12 мар-12 апр-12 май-12 июн-12 июл-12 авг-12 сен-12 окт-12 ноя-12 Baseline 22% 22% 22% Hospital 14% 18% 17% 16% 14% 11% Goal 13% 13% 13% 12

OB Harm 3% Improvement 13

Falls 61% Improvement 14

Falls 15

Pressure Ulcers 56% Improvement 16

Pressure Ulcer 17

Preventable Readmissions 18

Preventable Readmissions 15% Improvement 19

Surgical Site Infection 15% Improvement 20

Safe Surgery 21

VAP 62% Improvement 22

VAP 23

VTE (Venous Thromboembolism) 29. 8% Improvement 24

Potentially Preventable VTE 25

Improvement/Harm Calculators Dolores Hagan, RN BSN K-HEN Education/Data Manager

Calculator Overview • Created by Cynosure Health in partnership with HRET • Formulas perform calculations/graphs in the background • Excel spreadsheet – Contains a separate sheet for each HEN topic – Two sheets for Falls and HAPU – Total Harm sheet – Harm Across the Board sheet • Reference for cost estimates are included 27

About Your Calculator • Prepared for each hospital • Only included data on state-wide top two measures • Patient days and Discharges obtained from IPOP Claims database • Fully editable by you • Electronic copy on your USB drive 28

Calculator Basics • Sheets and workbook are protected to allow easy data entry • Enter Hospital Name on the Total Harm tab first and it will flow over to all other tabs • Required information for each tab – Number of months for baseline period – Frequency of reporting (monthly or quarterly) 29

Calculator Snapshot 30

Protection • • Select the ‘Review’ toolbar Select ‘Unprotect Sheet’ (toggle) Make changes, then select ‘Protect Sheet’ Save changes 31

What’s Included in the Calculations 1 -3 4 5 6 1. Current rate – calculated by summing the most recent 3 months numerators/denominators 2. % change from baseline (Current rate – Baseline)/Baseline 3. Most recent Month-Year for data 4. Number prevented To-Date—takes all months of data into account & based on baseline rate 5. Cost savings To-Date = # prevented to date X Avg. cost 6. Estimated # to prevent to be at Goal by next month— 32

Total Harm • Numerator – Total Harm – Readmissions + ADEs + Falls with Injury + HAPUs Stage III/IV + CAUTIs + CLABSIs + VAPs + SSIs + EEDs + OB Harms • Denominator – Total Harm – Patient Days – must be manually entered – Required for numerator to populate • MUST specify the number of months the baseline represents 33

Harm Across the Board (HAB) • Numerator – Total Harm – ADEs + Falls with Injury + HAPUs Stage III/IV + CAUTIs + CLABSIs + VAPs + SSIs + EEDs + OB Harms (excludes Readmissions) • Denominator – Total Harm – Discharges– must be manually entered – Required for numerator to populate • MUST specify the number of months the baseline represents 34

Contact Information Help is only a phone call or email away! Dolores Hagan (502) 992 -4389 dhagan@kyha. com 35

Current Focus “Small Ball” Strategy to capture data in all applicable topics for 100% of K-HEN hospitals • Sustaining and spreading improvements already made • Enhanced improvement work targeted to Adverse Drug Events, CAUTI, CLABSI, OB Adverse Events, Pressure Ulcer, and Readmissions 36

K-HEN Seed Grant Opportunity • Purpose • Timeline – Submissions Due November 22 – Awardees will be notified by November 27 and it will be posted to the K-HEN Website – Begin December 2, 2013 and end May 31, 2014 • Awards – 4 -6 Grants up to $10, 000 • Contact: Sharon Perkins sperkins@kyha. com 37

Next Steps for QI and Opportunities Our Progress Toward the 40/20 Goal

2014 – “Option Year” • CMS notified HRET on October 8 they intend to fund “Option Year” • January – December 2014 • Extend and Expand scope of improvement work • All 26 national HEN’s invited to apply – Applications due November – State SHA’s submitting work plan to HRET – Contract awards made by CMS by December 8, 2013 39

Hospital Commitment – Option Year • Hospital Administrators to Sign Commitment Form – System Commitment Letters not allowed • Data: Hospitals to submit outcome and process data on ALL applicable areas • Data: CMS requiring use of approved measures • 11 Improvement areas and expansion within areas 40

Option Year continued • Work plan tailored as much as possible to the feedback provided by hospitals through day-to-day discussions, meetings, site visit, and surveys • Strategies: • changing frequency of coaching calls – some monthly, some quarterly; • 2014 KHA Quality Conference may be in a “Quality and Patient Safety Boot Camp” format • Utilize what we have learned through LEAN, Grants, etc to spread improvement • Planning to continue hospital site visits, Team. STEPPS workshops, regional meetings; • HRET will continue to provide resources and support on a national level 41

Option Year Improvement Areas • Falls – No substantial change • Pressure Ulcer – No substantial change • ADE – anticoagulation management, – opioid safety, and – glycemic management 42

Option Year • CAUTI Topic – All tracked units (not just ICU) – CAUTI in the ER – Urinary catheter utilization • CLABSI – All tracked units (not just ICU) 43

Option Year • VTE – All surgical areas • Obstetrical Adverse Event – EED – OB Hemorrhage – Treatment of Pre-Eclampsia to reduce morbidity and mortality 44

Option Year • SSI Topic – Expand to include all surgeries • VAE – VAC – IVAC – Probable/Possible VAP • Use of Surveillance data– CMS is steering hospitals away from use of administrative data and want more hands-on analysis 45

Feedback from K-HEN evaluation and Participation Survey • • 17 Hospitals participate in the survey 41% Report participating frequently in Coaching Calls 70 % Report scheduling conflicts with calls 60% would like the Coaching Calls to be every other month 65% Report no site visit from K-HEN staff (91 participating hospitals with 71 site visits made) 77% want more training in New Evidence-based practices followed by 65% want prioritization in next steps Everyone who participated in the survey requested assistance in a collaborative area. 46

Other Strategies for continued quality work at KHA -

Other Strategies for continued quality work at KHA • Patient Safety Work ranked 5 th priority by KHA Strategic Planning Committee • Seeking funding opportunities to continue QI work – Wellpoint grant – Kellogg grant – Researching other grant opportunities • Create small rural benchmarking program through Flex Grant 48

Questions? 49