Transcript CMS Partnership for Patients Overview of HRET/FHA Hospital

ELIMINATING EARLY ELECTIVE DELIVERIES
HRET-FHA HOSPITAL
ENGAGEMENT NETWORK
(HEN)
DATA OVERVIEW
September 24, 2012
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HOSPITAL ENGAGEMENT NETWORK
• Data Requirements
• HRET’s Comprehensive Data System (CDS)
• Overall hospital data
• Enter numerator & denominator
• No patient level data
• Requirement- per focus area
• One process measure
• One outcome measure
• Minimize data entry time burden
• Entering only 4 numbers in CDS!
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HOSPITAL ENGAGEMENT NETWORK
• Data Requirements
• HRET’s Comprehensive Data System (CDS)
• CDS Encyclopedia of Measures
• OB Measures: #40-55
• May define your own measure & submit it
• Submit baseline data
• Preferably prior to 2012
• Flexible- baseline can be 1, 3, 6 or 12 months
• Submit monitoring data monthly (CDS)
• Submit monthly Progress Report (FHA)
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HOSPITAL ENGAGEMENT NETWORK
• OB Process Measures- Examples
• Elective deliveries at >=37 weeks and <39 weeks (EED)
• Antenatal Steroids
• DVT Prophylaxis- C-Section
• OB Outcome Measures- Examples
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C- Section delivery rate
Elective Births <39 week births admitted to the NICU
5 Minute Apgar <7 all deliveries >39 weeks
Neonatal Mortality rate
HOSPITAL ENGAGEMENT NETWORK
• CMS Required Reporting- EED
• All hospitals must report EED rates
• Final Rule posted August 1, 2012
• Data collection begins January 1, 2013
• Payment Determination FY 2015
• Hospital must report zero if no OB
• Using the Joint Commission measure PC-01 (EED)
• Same measure the HEN is using in the CDS
• Measure # 40 in the CDS Encyclopedia of Measures
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Comprehensive Data System
• HRET’s project data collection system
– Web-based
– Secure
– Flexible
https://www.hretcds.org/
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CDS ENCYCLOPEDIA OF MEASURES
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OB
Elective Deliveries at >=37 Weeks and
<=39 Weeks (JC PC 1)
Patients with elective vaginal deliveries or elective
cesarean sections at >= 37 and < 39 weeks of gestation
completed
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OB
Antenatal Steroids (JC PC 3)
Patients at risk of preterm delivery at 24-32 weeks
gestation receiving antenatal steroids prior to delivering
preterm newborns
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OB
DVT Prophylaxis - C-Section (OB)
Measures adherence to current ACOG, SMFM
recommendations for use of DVT prophylaxis in women
undergoing cesarean delivery
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OB
C-Section Delivery Rate (JC PC 2)
Nulliparous women with a term, singleton baby in a vertex
position delivered by cesarean section
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OB
Elective <39 Week Births Admitted to
NICU (March of Dimes)
Number of infants admitted to the NICU or transferred to
another hospital for care after a scheduled elective
induction/ cesarean section between 37 0/7 and 38 6/7
weeks.
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Project Title _______________
( Name of Project Champion and Senior Leader Sponsor)
Date:________
Aim Statement
Aim: (Including your How Good
and By When statement)
Why is this project important?:
Changes being Tested,
Implemented or Spread
• For each listed change,
indicate whether it is being
tested (T), Implemented
(I) or Spread (S)
Self Assessment Score (1-5) = _____
Lessons Learned
Run Charts
Make fonts large, title, labels, dates
and notes very simple on graphs prior
to shrinking graphs. Should be able to
fit 6-8 readable graphs here.
If no data are available for a particular
measures either create “empty” run list
the name of the measure(s) to be
collected.
(Enter summary here)
Recommendations
and Next Steps
• Enter summary here
(what do you need from
Executive Project
Champion, sponsor at this
time to move project?)
• Recommendations
• Next Steps for testing
Team Members
(Names & Roles)
© 2012 Institute for Healthcare Improvement
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HOSPITAL ENGAGEMENT NETWORK
Progress Report
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SUMMARY
• Implement improvement teams
– Rapid Cycle: Small test of change
• Submit data monthly to CDS
– One process measure (EED) and one outcome
measure
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Participate in webinars, calls, meetings, etc.
Submit progress reports
Collaborate with other facilities
Celebrate success!!
HOSPITAL ENGAGEMENT NETWORK
Contacts
Sally Forsberg RN, Director of Quality & Patient Safety
(407) 841-6230, [email protected]
Kim Streit, VP/Healthcare Research & Information Services
(407) 841-6230, [email protected]
Martha DeCastro, VP/Nursing
(850) 222-9800, [email protected]
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