Transcript HEN Readmission Affinity Call

Intermountain-led
CMS Hospital Engagement Network
Adverse Drug Event Prevention
June 24, 2014
Affinity Call
Outline for Discussion
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Review of the HEN ADE work
“Just-one-thing” Recommendations
High performers
National ADE action plan
Overall Progress Through Q1 2014
Intermountain HEN 2012-Q1 2014
ADE w/ Harm
Intermountain HEN 2012-Q1 2014
ADE w/ Harm
Intermountain HEN 2012-Q1 2014
ADE per 1000 Patient-Days
Intermountain HEN 2012-Q1 2014
ADE per 1000 Patient-Days
Intermountain HEN 2012-Q1 2014
PSI 12 Post Operative PE or DVT
Intermountain HEN 2012-Q1 2014
PSI 12 Post Operative PE or DVT
Intermountain HEN 2012-Q1 2014
• ADE Due to Opioids
• Controlled Postoperative Serum Glucose
• Excessive Anticoagulation with Warfarin
– Low Reporting
Just One Thing Matrix
Recommendations
Getting Started
Working Harder
Ahead of the Curve
Identify accountable
teams to review all
ADEs and work on
performance
improvement.
(moderate level of
evidence)
Build in automated
medication
administration alerts
and processes, i.e.,
bar coding.
(low level of
evidence)
Automate ADE
triggers and
implement into
pharmacy work flow
with patient specific
alerts.
High Performing Hospital Highlight…
ADE w/ Harm
Most Improvement
Lowest Rates
SANPETE VALLEY HOSPITAL - CAH
SUTTER MATERNITY & SURGERY CENTER OF
SANTA CRUZ
MILLS PENINSULA HEALTH SERVICES
SUTTER MATERNITY & SURGERY CENTER OF SANTA
CRUZ
DENVER HEALTH MEDICAL CENTER
LOS BANOS MEMORIAL HOSPITAL
SOCORRO GENERAL HOSPITAL
PARK CITY MEDICAL CENTER
BEAR RIVER VALLEY HOSPITAL
MENLO PARK SURGICAL HOSPITAL
EDEN MEDICAL CENTER
LINCOLN COUNTY MEDICAL CENTER
RIVERTON HOSPITAL
SEVIER VALLEY MEDICAL CENTER
DIXIE REGIONAL MEDICAL CENTER
HEBER VALLEY MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
GARFIELD MEMORIAL HOSPITAL
SUTTER ROSEVILLE MEDICAL CENTER
UPPER CONNECTICUT VALLEY HOSPITAL
High Performing Hospital Highlight…
ADE per 1000 Patient-Days
Most Improvement
Lowest Rates
SANPETE VALLEY HOSPITAL - CAH
MENLO PARK SURGICAL HOSPITAL
MENLO PARK SURGICAL HOSPITAL
GARFIELD MEMORIAL HOSPITAL
DENVER HEALTH MEDICAL CENTER
SANPETE VALLEY HOSPITAL - CAH
SEVIER VALLEY MEDICAL CENTER
SUTTER MATERNITY & SURGERY CENTER OF
SANTA CRUZ
DENVER HEALTH MEDICAL CENTER
SUTTER SOLANO MEDICAL CENTER
BEAR RIVER VALLEY HOSPITAL
MILLS PENINSULA HEALTH SERVICES
ALTA BATES SUMMIT MEDICAL CENTER
SEVIER VALLEY MEDICAL CENTER
NOVATO COMMUNITY HOSPITAL
LOS BANOS MEMORIAL HOSPITAL
SUTTER MATERNITY & SURGERY CENTER OF SANTA
CRUZ
ALTA BATES SUMMIT MEDICAL CENTER
UTAH VALLEY REGIONAL MEDICAL CENTER
SUTTER COAST HOSPITAL
High Performing Hospital Highlight…
PSI 12 Post Operative PE or DVT
Most Improvement
Lowest Rates
SUTTER LAKESIDE HOSPITAL
LOGAN REGIONAL HOSPITAL
SUTTER SOLANO MEDICAL CENTER
SUTTER AUBURN FAITH HOSPITAL
SUTTER AUBURN FAITH HOSPITAL
SUTTER SOLANO MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
PARK CITY MEDICAL CENTER
LDS HOSPITAL
SUTTER DAVIS HOSPITAL
MCKAY DEE HOSPITAL CENTER
HILLCREST BAPTIST MEDICAL CENTER
PROVIDENCE ST VINCENT MEDICAL CENTER
RIVERTON HOSPITAL
UTAH VALLEY REGIONAL MEDICAL CENTER
VALLEY VIEW MEDICAL CENTER
SUTTER MEDICAL CENTER OF SACRAMENTO
ESPANOLA HOSPITAL
DENVER HEALTH MEDICAL CENTER
SUTTER TRACY COMMUNITY HOSPITAL
2014 plans for improvement
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hospitals & system in a single document