Transcript Slide 1

PfP 2014:
Priorities and Expectations
Agenda
• Welcome new Oregon hospitals
• Provide overview of 2014 PfP activities and
programs
– AHA/HRET Improvement Leader Fellowship
– Patient/Family Engagement
• Data expectations and measures
• Oregon Lean
• Other resources
– Listserv update
– Optional topics
• Travel funds
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New hospitals: Welcome!
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Ashland Community
Kaiser Westside
Pioneer Heppner
St Anthony
West Valley
Vibra
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2014 Oregon PfP Map +
Improvement Advisors
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PfP Overview
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Partnership for Patients
• Goal: 40% Reduction in Preventable Hospital
Acquired Conditions
• Goal: 20% Reduction in Hospital Readmissions
• Ultimately to provide safer care and decrease cost
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Oregon PfP working together to
achieve a bold aim
• On our way to the 40/20 goal by Dec 2014
• 2014 year focus:
– Reporting and analyzing data for all applicable
areas
– Patient and family engagement (PFE)
– Leadership support
– Healthcare disparities
– Teamwork and communication
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National HEN Targeted Harms
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Adverse drug events
OB Adverse Events
Elimination of Early Elective Deliveries
Central line-associated blood stream infections
Catheter-acquired urinary tract infections
Falls with injury
Surgical infections and complications
Venous thromboembolism
Pressure ulcers
Readmissions
Ventilator-associated events
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PfP Option Year: 2014
ADE
+ (at minimum) opioid safety, anticoagulation safety, and glycemic
management
CAUTI
+ all hospital settings, including avoiding placement of catheters in
the ER
CLABSI
+ all hospital settings (not just ICU)
OB Adverse Events
+ Management of postpartum hemorrhage and
pre-eclampsia (probably obstetric hypertension)
VTE
+ all surgical settings
VAP/VAE
+ Infection-related Ventilator-Associated Complications (IVAC) and
Ventilator-Associated Pneumonia (VAP)
SSI
+ multiple classes of surgeries
Falls, HAPU,
Readmissions
Same focus
Overview of PfP activities and
programs
• National:
– Boot camps
– Webinars
• State:
– CAUTI program Feb. 27,2014 @ the Grand Hotel
Bridgeport
– State meetings:
• Friday April 4th, Portland
• Fall 2014, Medford
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Resources
• Updated change packages and checklists for all CORE
topics will be reflected in the AHA/HRET HEN website
(www.hret-hen.org) by early February.
• The website will also include new sections for information
and resources regarding all OPTIONAL topics.
• Make sure to review the topics Resource sections to find
tools, checklists and other resources shared on topicspecific LISTSERVs
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AHA/HRET
Improvement Leader Fellowship
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Fellows Across the Country
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Delivering the Fellowship
• In-Person Regional Meetings
• 22 different state meetings March through November
• On site meetings specifically designed to combine clinical
knowledge with improvement techniques
• Monthly Live Streamed Meetings
• Fellowship Topics: 1:00 – 3:00 PM CST every third or
fourth Wednesday of the month
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In-Person Regional Meetings
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Promote shared discussion and learning
All Fellows in one room
Didactic
Hospital story sharing
Coaching
Topic Specific Mini Collaborative: led by Cynosure IA
Fellowship Topic: led by IHI faculty
Oregon PfP: our state meeting is being scheduled for this
spring
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Tracking & Evaluating Participation
• Attendance
– 1 in-person meeting
– 8 out of 10 virtual meetings
• Commitment to the Program (endorsed by Sr. Leader at
their organization)
• Harm Across the Board (HAB)completion
• Pre-work assignments
• Specific requirements for each Fellowship Level: Junior,
Senior, and Champion
• Open School module completion
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No More Progress Reports!
• HAB will replace the monthly progress
reports.
• HAB is being revised to include 6 slides
– Webinar in Feb. 2014, date TBA
• Complete a Harm Across the Board (HAB)
report by March 31, 2014
• HAB report due quarterly to your IA
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Patient & Family Engagement
(PFE)
• The AHA/HRET HEN team will collaborate with Institute
for Patient- and Family-Centered Care (IPFCC) to provide:
• Six educational webinars will take place in: February,
March, April, June, August and October
• Each webinar will be approximately one hour, and will
incorporate two hospitals (focused on their PFE actions)
• 30-minute Office Hours
• In-state PFE Roadshows
• Monthly content for the Weekly SHA Newsletter
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Data and Measurement
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Measures
• We are ahead of many states since we
already had aligned measures
• Some changes plus additions necessary due
to push to reach PfP goals
• Baseline data needed for all new measures
– Preferably 2013 data; could use Jan 2014 if
necessary
– Indicate baseline time frame. Notify your IA.
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Adverse Drug Events
 2014 Oregon PfP focus
Category
Measure Name
Definition
Numerator
Hypoglycemia in
inpatients receiving
insulin
Hypoglycemia in inpatients
receiving insulin or other
hypoglycemic agents
Hypoglycemia in inpatients
receiving insulin or other
hypoglycemic agents (e.g.
hypoglycemia defined as plasma
glucose concentration of 50 mg
per dl or less)
Inpatients receiving insulin or
other hypoglycemic agents
ASHP Safe
Use of
Insulin
Excessive
Anticoagulation
with Warfarin
All inpatients who had
excessive anticoagulation
with warfarin
Inpatients experiencing
excessive anticoagulation with
warfarin (e.g. INR > 6)
Inpatients receiving warfarin
anticoagulation therapy
ISMP
ADEs due to opiods
Naloxone reverses opioid
intoxication. For this reason,
naloxone administration can be
used to identify patients who
may have experienced an
adverse drug event due to an
opioid.
Number of patients treated
with opioids who received
naloxone during the review
period.
Number of patients who received
an opioid agent during review
period.
ISMP and
PA-HEN
ADE
ADE
ADE
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Denominator
Source
Catheter Associated Urinary Tract
Infection (CAUTI)
 2014 Oregon PfP focus
Category
Measure Name
Definition
Catheter-Associated
Urinary Tract
Infections Rate - All
Tracked Units (CDC
NHSN)
Rate of patients with a
catheter-associated
urinary tract infections
per 1000 urinary
catheter days- all tracked
units
Catheter-associated urinary
tract infections based on CDC
NHSN definition (all tracked
units)
Total number of urinary catheter
days for all patients that have an
indwelling urinary catheter in all
tracked units
CDC NHSN
CAUTI
Emergency
Department CAUTI
Measure/s- TBD
TBD
TBD
TBD
CUSP:
CAUTI
CAUTI
Numerator
*OPTIONAL*
CAUTI-ED
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Denominator
Source
Central Line Associated Blood
Stream Infection (CLABSI)
 2014 Oregon PfP focus
Category
Measure Name
CLABSI Rate - All
Tracked Units
(Device Days)
CLABSI
Definition
Numerator
CLABSI rate (healthcareassociated primary
bloodstream infection (BSI)) in
a patient that had a central
line within the 48-hour period
before the development of the
BSI and that is not related to
an infection at another site
The Primary Bloodstream
Infection (BSI) form (CDC 57.108)
is used to collect and report each
CLABSI that is identified during
the month selected for
surveillance
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Denominator
Number of all units device
days (Central line days)
Source
CDC NHSN
Falls
 2014 Oregon PfP focus
Category
Measure Name
Falls With Injury
(minor or greater)
(NSC-5)
Falls
Definition
All documented patient
falls with an injury level of
minor or greater
Numerator
Total number of patient falls of
injury level minor or greater
(whether or not assisted by a
staff member) during the
calendar month.
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Denominator
Patient days
Source
NQF
OB Adverse Events
 2014 Oregon PfP focus
Category
OB
OB
OBHemorrhage
OBpreeclampsia
Measure Name
Definition
Numerator
Elective
Deliveries at >=
37 Weeks and <
39 Weeks (JC PC1)
Patients with elective vaginal
deliveries or elective
cesarean sections at ≥ 37 and
< 39 weeks of gestation
completed
Patients with elective
deliveries
Patients delivering newborns with
≥ 37 and < 39 weeks of gestation
completed
Joint
Commission
C-Section
Delivery Rate (JC
PC-2)
Nulliparous women with a
term, singleton baby in a
vertex position delivered by
cesarean section
Patients with cesarean
sections
Nulliparous patients delivered of a
live term singleton newborn in
vertex presentation
Joint
Commission
Total OB blood
transfusions
Total number of blood
products used per 100
women giving birth
Total number of units of
blood products (RBCs, FFP,
Platelet packs, Cryo)
All women giving birth ≥20 weeks
(birth hospitalization)
ACOG and
CMQCC
Timely treatment
for severe
hypertension
Treatment within 60 minutes
per 100 mothers with
preeclampsia and severe
hypertension (either Systolic
>=160 OR Diastolic >=110)
Women who are treated
within 60 minutes with firstline medications (IV
labetalol or IV hydralazine
or PO nifedipine if IV access
has not been established)
All women giving birth ≥20 weeks
(birth hospitalization) with a diagnosis
of Severe Preeclampsia (Eclampsia
(642.6x), Severe Preeclampsia
(642.5x), or Preeclampsia
superimposed on pre-existing HTN
(642.7x)) AND who had severe
hypertension (either Systolic ≥160 OR
Diastolic ≥110)
Exclusions:
women with gestational hypertension
or chronic hypertension without
superimposed preeclampsia (642.0x,
642.1x, 642.2x, or 642.3x)
CMQCC
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Denominator
Source
Hospital Acquired Pressure
Ulcers
 2014 Oregon PfP focus
Category
Measure
Name
Pressure Ulcer
(MCR FFS) (CMS
HAC)
PU
Definition
Number of occurrences
with a Hospital Acquired
Pressure Ulcer at Stage
III or IV
Numerator
Number of occurrences
with Pressure ulcer stages
III and IV (707.23
(MCC)707.24 (MCC)) as a
secondary diagnosis
(diagnoses 2-9 on a claim)
with a POA code of ‘N’ or
‘U’
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Denominator
Number of acute inpatient
discharges
Source
CMS HAC
Surgical Site Infections (SSI)
• Need to expand to include more classes of
surgeries
• Adding procedures:
– CABG
– Colon
– Hysterectomy
• We will be asking you to continue to confer
rights in NHSN.
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Surgical Site Infections (SSI)
 2014 Oregon PfP focus
Category
SSI
SSI
Measure Name
Definition
Numerator
Denominator
Source
Total Hip
Procedures - SSI
(in-hospital) (CDC
NHSN subset)
Surgical site infection rate
among total hip
replacement procedures
Total number of total hip
surgical site infections based
on CDC NHSN definition
All patients having total hip
replacement operative
procedures
CDC NHSN SSI
Total Knee
Procedures - SSI
(in-hospital) (CDC
NHSN subset)
Surgical site infection rate
among total knee
replacement procedures
Total number of total knee
surgical site infections based
on CDC NHSN definition
All patients having total knee
replacement operative
procedures
CDC NHSN SSI
Colon SSI
CDC NHSN SSI
Hysterectomy SSI
CDC NHSN SSI
Cardiac/CABG SSI
CDC NHSN SSI
SSI
SSI
SSI
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Venous Thromboembolism
(VTE)
 2014 Oregon PfP focus
Category
Measure
Name
Potentially
Preventable VTE
(VTE-6)
VTE
Definition
The number of patients
diagnosed with
confirmed VTE during
hospitalization (not
present at admission)
who did not receive VTE
prophylaxis between
hospital admission and
the day before VTE
diagnostic ordering date
Numerator
Patients who received no
VTE prophylaxis prior to the
VTE diagnostic test order
date
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Denominator
Patients who developed
confirmed VTE during
hospitalization
Source
Joint Commission
Specifications
Manual for
National Hospital
Inpatient Quality
Measures
Ventilator Associated Pneumonia/
Ventilator Associated Events (VAP/VAE)
 2014 Oregon PfP focus
Category
Measure Name
Definition
Numerator
Denominator
Source
Ventilator-Associated
Pneumonia Rate - All
Units (CDC NHSN)
Pneumonias that are ventilatorassociated (i.e. patient was intubated
and ventilated at the time of, or
within 48 hours before, the onset of
the event)
Ventilator-associated pneumonia rate
(incidence of VAP)
Number of ventilator days
(collected daily)
CDC NHSN VAP
VAC Rate- All Units (CDC
NHSN)
Ventilator-Associated Condition
(VAC); including those that meet the
criteria for IVAC and
Possible/Probable VAP rate
Number of events that meet the criteria of
Ventilator-Associated Condition (VAC);
including those that meet the criteria for IVAC
and Possible/Probable VAP rate
Number of ventilator days
CDC NHSN VAE
VAC Rate- All ICU Units
(CDC NHSN)
Ventilator-Associated Condition (VAC)
in ICU units; including those that
meet the criteria for IVAC and
Possible/Probable VAP rate
Number of events that meet the criteria of
Ventilator-Associated Condition (VAC) in ICU
units; including those that meet the criteria for
IVAC and Possible/Probable VAP rate
Number of ventilator days in
the ICU
CDC NHSN VAE
Possible/Probable VAP
Rate- All Units (CDC
NHSN)
Possible/Probable VAP rate
Number of events that meet the criteria of
Possible/Probable VAP
Number of ventilator days
CDC NHSN VAE
VAE
Possible/Probable VAP
Rate- All ICU Units (CDC
NHSN)
Possible/Probable VAP in ICU units
rate
Number of events that meet the criteria of
Possible/Probable VAP in ICU units
Number of ventilator days in
the ICU
CDC NHSN VAE
VAE
IVAC Rate- All Units (CDC
NHSN)
Infection-Related VentilatorAssociated Condition (IVAC); including
those that meet the criteria for
Possible/Probable VAP rate
Number of events that meet the criteria of
Infection-Related Ventilator-Associated
Condition (IVAC); including those that meet the
criteria for Possible/Probable VAP
Number of ventilator days
CDC NHSN VAE
IVAC Rate- All ICU Units
(CDC NHSN)
Infection-Related VentilatorAssociated Condition (IVAC) in ICU
Units; including those that meet the
criteria for Possible/Probable VAP
rate
Number of events that meet the criteria of
Infection-Related Ventilator-Associated
Condition (IVAC) in ICU Units; including those
that meet the criteria for Possible/Probable VAP
Number of ventilator days in
the ICU
CDC NHSN VAE
VAP
VAE
VAE
VAE
VAE
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Readmissions
 2014 Oregon PfP focus
Category
Measure Name
Definition
Numerator
Denominator
Source
Potentially
Preventable
Readmissions
(PPR)
As calculated by Apprise
Health Insights, using
3M algorithm
Number of readmission
chains
Number of at-risk
readmissions
State-defined
measure (Apprise
Health Insights)
Readmission
within 30 days
(All Cause)
Inpatients who were
readmitted within 30
days for any reason
Inpatients returning as an
acute care inpatient within
30 days of date of discharge
Total inpatient discharges
(excludes expired patients)
Based on CMS
Hospital
Compare
measure
READ
READ
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Possible Advanced Options
Things to think about…..
Severe Sepsis/Septic Shock
C-Diff including antibiotic stewardship
Hospital Acquired Acute Renal Failure
Airway Safety
Iatrogenic Delirium
Procedural harm (pneumothorax, blood)
Undue Exposure to radiation
Failure to Rescue
Culture of Safety (patient/ worker)
Expanding outreach to community for all topics
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Optional Sustainability Measures
• New sustainability measures are available
• These optional measures may be valuable
for:
– CAHs
– Rural Hospitals
– Hospitals that have sustained 0’s for extended
periods of time
– Any organization interested in tracking their
progress
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Oregon Lean
We are offering Lean in 2014 through
Purdue Healthcare Advisors
• Additional green belt training (2 days)
• New! Black Belt training (1 day)
Monthly Lean webinars
Monthly office hours with Purdue trainers
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Other Resources
• Resources coming later to address
– Disparities
– Optional topics
– Listserv updates
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Resources
• HRET
– HEN website: www.hret-hen.org including private side
– Top Ten Process Checklists/posters
– HRET PfP Change packages
– HRET webinars/boot camps
• OAHHS
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OAHHS improvement advisor
PfP advisory committee
PfP newsletter
PfP website: www.oahhs.org/quality/initiatives/partnership-for-patients
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Travel Funds
• We will provide assistance for travel to instate PfP & Improvement Leader Fellowship
meetings
• Details pending
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Next Steps
• Submit your 2014 commitment form ASAP
• Submit baseline data for new measures
• Continue to submit data on all harms
monthly
• Continue improvement work in all areas to
strive for the 40/20 goal
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OREGON PFP LEADERSHIP TEAM:
• Diane Waldo, director of quality and clinical
services
[email protected]
503.479.6016
• Jodie Elsberg, associate director of quality
[email protected]
503.479.6028
• Lyndsey Shaver, quality coordinator
[email protected]
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503.479.6022