Transcript Strategic Planning Committee

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
Patient
PIVOT
Readmissions
Safety
VTE
ADE
Culture
GO RED
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
ADE
7/1/13 “30/6/60” Goal – includes all
outcome measures submitted
Achieved
CAUTI
Achieved
CLABSI
Achieved
EED/OB
Harm
Falls
Near engagement goal – 41%
Pressure
Ulcers
Readmissions
Achieved
SSI
Achieved
VAP
Achieved
VTE
Well below engagement goal – 22%
HEN Topic
Near engagement goal – 52%
Well below engagement goal – 29%
New CMS Goal for 9/1/13 – includes state’s
top 2 most popular measures
At goal for improvement/near for
engagemt.
At goal for engagement/near for
improvemt.
At goal for engagement/near for
improvemt.
Achieved
At goal for engagement/near for
improvemt.
Neither goal reached yet
At goal for improvement/near for
engagemt.
At goal for engagement/near for
improvemt.
At goal for improvement/near for
engagemt.
Achieved
5
ADE (Adverse Drug Events)
Excessive Anticoagulation with WarfarinInpatients (EOM-ADE-12)
80.0
70.0
50.0
40.0
30.0
20.0
10.0
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
ADE Rate
60.0
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1 31.1
Hospital 19.1 72.5 59.7 45.5 32.3 72.7 0.0 75.8 70.2 35.6 46.3 36.5 59.0 45.0 56.9 39.8 51.1 52.3
Goal
18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7 18.7
6
ADE (Adverse Drug Events)
200.0
180.0
160.0
140.0
120.0
100.0
80.0
60.0
40.0
20.0
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
ADE Rate
Hypoglycemia in Inpatients Receiving
Insulin (EOM-ADE-13)
54%
Improvement
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.144.
Hospital 134.123.88.6 69.4 97.2 188.161.77.9 140.140.109.121.89.7 136.57.1 44.8 126.65.6 15.4 111.
Goal
86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5 86.5
7
CAUTI
2.5
2.0
1.5
1.0
0.5
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
CAUTI Rate/1,000 Catheter Days
Catheter-Associated UTI Rate in ICU
(EOM-CAUTI-19)
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2 1.2
Hospital 0.8 1.9 1.1 1.5 1.5 1.5 1.3 1.8 1.3 1.4 1.2 1.4 1.5 1.0 0.9 1.5 1.0 1.7
Goal
0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7
8
CAUTI
Catheter-Associated UTIs
All Tracked Units EOM-CAUTI-18
15%
Improvement
CAUTI Rate/1,000 Catheter Days
1.8
1.6
1.4
1.2
Baseline, 1.1
1.0
0.8
0.6
Goal, 0.7
0.4
0.2
0.0
9
CLABSI
CLABSI Rate-ICU (Device Days) (CDC 4%
Improvement
NHSN) (EOM-CLABSI-25)
2.0
1.5
1.0
0.5
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
CLBSI Rate/1,000 Line Days
2.5
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0
Hospital 1.7 1.3 1.9 1.5 1.4 0.8 1.4 1.4 1.4 1.0 1.6 1.3 1.0 0.9 0.5 1.0 1.3 0.6
Goal
0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6
10
CLBSI Rate/1,000 Patient Days
CLABSI
0.4
CLABSI Rate-All Units (Patient Days)
(EOM-CLABSI-27)
0.4
0.3
0.3
0.2
0.2
0.1
0.1
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
0.0
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1
Hospital 0.0 0.2 0.1 0.1 0.4 0.2 0.0 0.3 0.0 0.0 0.1 0.0 0.2 0.0 0.0 0.2 0.1 0.0
Goal
0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1
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%
Baseline
22%
22%
22%
22%
MayMayJun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13
Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13
12
13
22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22%
Hospital
14%
18%
17%
16%
16%
14%
14%
11%
9%
13%
11%
10%
13%
6%
7%
8%
8%
10%
Goal
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
13%
Jan-12 Feb-12 Mar-12 Apr-12
13%
13%
13%
13%
13%
12
13%
OB Harm
Cesarean Section Rate (AHRQ IQI-21)
3%
Improvement
40.0%
35.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
C-Section Rate
30.0%
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37% 37%
Hospital 35% 35% 33% 32% 34% 37% 33% 33% 34% 34% 35% 34% 36% 36% 34% 35% 36% 34%
Goal
22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22%
13
Falls
61%
Improvement
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Fall With Injury Rate/1,000 Patient Discharges
Injuries from Falls and Trauma
(EOM-FALLS-39)
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1 1.1
Hospital 1.0 1.3 1.0 0.9 0.9 0.6 0.7 0.9 1.4 1.2 0.7 0.3 0.4 0.7 0.6 0.5 0.4 0.4
Goal
0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 0.7 14
Falls
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Falls w/wo Injury Rate/1,000 Patient Days
Falls With or Without Injury (NSC4)
(EOM-FALLS-37)
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5 2.5
Hospital 3.2 3.5 2.7 3.1 3.1 3.7 3.3 4.0 4.2 3.8 3.6 3.8 3.4 3.8 3.9 3.4 2.8 3.2 3.1
Goal
1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.515
Pressure Ulcers
Pressure Ulcer (CMS HAC) (EOM-PrU-63)
56%
Improvement
0.25
0.20
0.15
0.10
0.05
0.00
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
HAPU Rate/1000 Discharges
0.30
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15 0.15
Hospital 0.08 0.12 0.00 0.17 0.20 0.00 0.00 0.12 0.04 0.04 0.04 0.13 0.15 0.25 0.00 0.08 0.08 0.04
Goal
0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 0.09 16
Pressure Ulcer
HAPU Stage II & Above (NSC2) (EOMPrU-58)
0.6%
0.4%
0.3%
0.2%
0.1%
0.0%
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
HAPU Rate
0.5%
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Hospital 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 1% 0% 0% 0% 0% 0%
Goal
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
17
Preventable Readmissions
Readmissions Within 30 Days (All Cause)
(EOM-READ-75)
14%
10%
8%
6%
4%
2%
0%
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Readmission Rate
12%
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12% 12%
Hospital 12% 12% 13% 13% 13% 13% 12% 12% 12% 12% 11% 12% 11% 12% 13% 11% 11% 12%
Goal
9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9%
18
Preventable Readmissions
Heart Failure Readmissions W/I 30 Days 15%
Improvement
EOM-READ-77
25%
20%
15%
10%
5%
0%
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
HF Readmission Rate
30%
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22% 22%
Hospital 27% 21% 24% 24% 21% 19% 18% 20% 21% 17% 18% 20% 21% 15% 20% 17% 19%
Goal
18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18% 18%
19
Surgical Site Infection
15%
Improvement
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
SSI Rate
SSI Rate (within 30 days after Procedure)
(CDC NHSN) (EOM-SSI-89)
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% 2%
Hospital 3% 3% 3% 2% 2% 1% 5% 2% 2% 2% 3% 2% 2% 1% 3% 2% 2% 2%
Goal
1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%
20
Safe Surgery
Post Operative Sepsis (AHRQ 12)
(KY-SSI-10-1)
2.0%
1.5%
1.0%
0.5%
0.0%
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Post-Op Sepsis Rate
2.5%
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%
Hospital 1% 2% 2% 1% 2% 2% 1% 1% 1% 1% 1% 1% 1% 1% 2% 1% 2% 1%
Goal
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 21
VAP
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
VAP Rate/1,000 Patient Days
0.0
Ventilator-Associated Pneumonia by 62%
Improvement
Patient Days (KY-VAP-7-1)
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec12 12 12 12 12 12 12 12 12 12 12 12 13 13 13 13 13 13 13 13 13 13 13 13
Baseline 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Hospital
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Goal
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
22
VAP
5.0
4.0
3.0
2.0
1.0
0.0
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
VAP Rate/1,000 Ventilator Days
6.0
Ventilator-Associated Pneumonia Rate
(CDC NHSN) (EOM-VAP-92)
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec12 12 12 12 12 12 12 12 12 12 12 12 13 13 13 13 13 13 13 13 13 13 13 13
Baseline 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5
Hospital
3.5 4.3 5.3 2.1 4.3 3.5 1.1 1.8 3.9 3.5 3.1 2.6
Goal
0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9
23
VTE (Venous Thromboembolism)
Post-Op PE orDVT (All Adults)
(AHRQ PSI12) (EOM-VTE-105)
29.8%
Improvement
0.7%
0.6%
0.4%
0.3%
0.2%
0.1%
0.0%
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
VTE Rate
0.5%
Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec Jan- Feb- Mar Apr- May Jun- Jul- Aug Sep- Oct- Nov Dec
12 12 -12 12 -12 12 12 -12 12 12 -12 -12 13 13 -13 13 -13 13 13 -13 13 13 -13 -13
Baseline 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%
Hospital 0% 0% 0% 1% 0% 1% 0% 1% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0%
Goal
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 24
Potentially Preventable VTE
Days Between Potentially Preventable VTE
250
213
Days Between Events
200
184
181
150
150
100
50
31
0
0
1/31/2011
6/30/2011
12/31/2011
Event Date
1/31/2012
8/31/2012
2/28/2013
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
[email protected]
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 [email protected]
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, TeamSTEPPS
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 5th 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