Transcript Presentation Title - MHA An Association of Montana Health

Montana Regional Meeting
Glendive Medical Center
AHA/HRET Hospital Engagement Network
Charisse Coulombe, MS, MBA, CPHQ; Senior Director, HEN
Hospital Engagement Network
Health Research & Educational Trust
American Hospital Association
Hospital Engagement Network
• ACA considerable focus on quality
• Created the CMS Innovation Center
Hospital Leadership
• Public-private partnership
• Set 40/20 goal
• Tool: Hospital
Engagement Networks
• 26 contracts awarded
• Contracted with 31 state and
regional hospital associations
• 1,600 + hospitals
Clinicians & Front Line Staff (Teams)
THE PATIENT
Partnership for Patients
The 40/20 Goal
• Keep patients from getting injured or sicker
Reduce preventable hospital-acquired conditions by 40 percent
1.8 million fewer injuries to patients, with more than
60,000 lives saved over the next three years
• Help patients heal without complication
Reduce all hospital readmissions by 20 percent
1.6 million patients will recover from illness without
suffering a preventable complication requiring
re-hospitalization within 30 days of discharge
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Progress to Date
EEDs/OB Adverse Events
• 36%: Average percent reduction in EED > =37 weeks and <39 weeks for 612
hospitals (68%)
• 2,673 EEDs prevented (all hospitals)
• $1.9 m Estimated cost savings for avoided EED NICU admissions (all hospitals)
• Also tracking hard stop policies implemented across all birthing hospitals
CAUTIs
• 9%: Average CAUTI percent reduction in all tracked units for 985 hospitals
• 359 CAUTIs prevented (all hospitals)
• $269,000 Estimated cost savings for avoided CAUTIs
CLABSIs
• 11%: Average CLABSI percent reduction in all tracked units for 823 hospitals
• 308 CLABSIs prevented (all hospitals)
• $5.8M Estimated cost savings for avoided CLABSIs
Progress to Date
ADEs and Falls
•
•
Focus area for all HENs and all of the states within our HEN
Participate in the Boot Camps!
PRESSURE ULCERS
• 2.52 Percent reduction in patients with at least one Stage II or greater
pressure ulcer for 399 hospitals
• 8.18 Percent reduction in CMS HAC Pressure Ulcers for 367 hospitals
• Need more data submission from our hospitals!
• 34 Stage III/IV Pressure Ulcers prevented (all hospitals)
• $1.4M Estimated cost savings for avoided Stage III/IV Pressure Ulcers
SSIs
• <0.81%
• <1.26%
Average surgical site infection rate (in hospital) for 808 hospitals
Average SSI rate (within 30 days of procedure) for 752 hospitals
Progress to Date
VTEs
• 0.57 Average percent reduction in Post-op PE/ DVT (AHRQ PSI 12) rate
for 360 hospitals
• 12.7 Average percent reduction in Potentially Preventable VTE for 330
hospitals
VAPs
• 21 Average percent reduction in ventilator-associated pneumonia rate
in ICU for 486 hospitals
• 152 ICU VAPs prevented (all hospitals)
• $6.5m Estimated projected cost savings for avoided ICU VAPs (all
hospitals)
READMISSIONS
• 1.8 Average percent reduction for 30 day all cause readmission rate for
829 hospitals
• 2.7 Average percent reduction for Heart Failure 30 day all cause
readmission rate for 258 hospitals
Montana Summary Table
Topic
Most Popular
Outcome
Measure
Avg #
Hospitals
Reporting
Total
Eligible
Hospitals
Percent
Baseline
Reporting
Last 3
monitoring
months
Percent
Reduction
ADE
Med Errors Req
Pharma
Intervention
8
26
31%
1.82
0.78
57%
CAUTI
Pts Treated with 7
Abx for UTIs
26
27%
0
0
None
CLABSI
CLABSI
Infection Rate
7
13
54%
0
0
None
EED
TJC EED
4
13
31%
8.42
3.57
57%
OB
C-section
Delivery Rate
7
13
45%
31.87
35.19
N/A
Falls
Falls after
admission
9
26
35%
1.97
1.39
29%
Pressure
Ulcer
Decubitus Ulcer
9
26
35%
0
0
None
Montana Summary Table
Topic
Measure
Readmission
Avg #
Hospitals
Reporting
Total
Eligible
Hospitals
Percent
Reporting
Baseline
Q4 2012 or
last 3
monitoring
months
Percent
Reduction
Readmission 21
with same
dx
26
81%
3.73
3.96
N/A
SSI
SSI Rate (in
hospital)
8
13
62%
1.23
0.67
45%
VAP
*
VTE
Post Op
PE/DVT
8
26
31%
1.53
3.55
N/A
* Not enough monitoring data submitted to evaluate
What Data is Needed and
How Much?
• CMS’ focus is on outcome measures to track
progress of the HENs
• In order to be included in the HEN/state level
analysis, need to submit at least 4 data points
• Baseline and Monitoring periods are
compared
• Baseline is defined as pre-2012; if you started
collecting data after January 2012, we need
that data!
• We will review your first month submitted
and use as baseline reference to track your
progress
Data Tools for Hospitals to
Review Progress
• Hospital Dashboard
– Data Submission Status
– Individual Measure Data
– Run Charts
• Hospital CEO Dashboard
– Summary of the Hospital Dashboard
• Both located under Reports in the
Comprehensive Data System (CDS)
Intervention Tools Available
•
•
•
•
•
•
www.hret-hen.org has many resources
Topic specific change packages
Topic specific checklists
Reference articles
Previous recordings of webinars and meetings
Leadership, physician, patient/family
engagement resources
Next Steps
• Continue to work towards 40 percent harm
reduction and 20 percent readmission reduction
• Continue to submit data on your measures
• Continue to track your progress on all topics
through the progress reports
• Continue to share your ideas and tools with
others on the LISTSERVs
• Continue to share your success stories with us,
your states and your fellow hospitals
Thank You!
• AHA/HRET HEN is proud of the accomplishments
that have occurred to date and continue to look
forward to accelerating the improvement across all
topics!
• We are here to support you in any way possible
– General Email: [email protected]
– Data Specific Questions: [email protected]
– Check in with Casey Brewington!
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