Title Block Data Office Hours April 2013 Dolores Hagan, RN, BSN K-HEN Education/Data Manager

Agenda Hospital Engagement Network Dashboard State Summary Report from HRET Question and Answer

Page One Hospital Name/City/State - derived from the Comprehensive Data System (CDS) Data Submission Status Table – Outlines process and outcome data for each of the ten Topic Areas Column 1- Topic Columns 2 and 3 - Hospitals are noted as either submitting data (Y), not submitting data (N) or not eligible for the topic based upon services provided at the facility (Z) –Topics not applicable to a hospital are updated monthly in the CMS Level of Participation (LOP) report and only CLABSI, OB Adverse Events, SSI and VAP are eligible for a “Z” demarcation. In instances where a hospital is noted as a “Z” within the LOP report for a topic but submits data for the corresponding topic, the data take precedent over the LOP report. Columns 4 and 5 - The most recent data submitted is reflected in columns four and five respectively –When a hospital is not eligible for a topic (noted as a “Z” in columns two and three), the most recent data columns will reflect “N/A” (not applicable) –A dash (-) indicates that no data have been submitted

Page Two Outcome Measure Results Table Reflects outcome measures results for each of the ten Topics Data reflects Baseline through the most recent month end When more than one outcome measure is reported for a Topic, the measure reported most recently is used; if more than one measure was reported most recently, then the most common measure reported that month within the HEN is selected The measure used to populate the table is noted in the table footnote(s) When a hospital reports zero events due to zero risk (a zero denominator), “0/0” is reflected in the table rather than “0.00” When no data are submitted, a dash (-) serves as a placeholder

Page Three Readmission Race Inclusion in Readmission Race requires hospitals to: –report either the Encyclopedia of Measures (EOM) 30-Day All Cause readmission measure or an HRET Readmission Race specific measure (HRET-READ-RACE-1 or HRET-READ-RACE- 2) and –provide baseline data for one of these measures for comparison. For the purposes of this table (and only this table), “baseline” refers to either 2011 or, if none of the three measures was reported during 2011, the first six months of Thus the “Readmission Race” follow-up begins in July 2012 for all hospitals.

Readmission Race Cont’d Calculation - “Number of readmits prevented to date,” (from the Improvement Calculator) –The monthly average baseline readmission rate is compared to the current readmission rate –Using the current month total discharges (denominator), an estimate of the number of expected readmissions is calculated based upon the baseline rate –The actual number of readmissions during the month is then subtracted from this expected value to produce an estimate of number of readmissions prevented –If the actual number is greater than the expected number, this is reported as a negative value

Readmission Race Cont’d Cumulative estimate of excess costs averted or incurred –Excess costs averted are displayed in black font –Excess costs incurred are displayed in red and are preceded by a negative sign (-) –Cost per readmission is estimated at $9,600 –Cost/Readmission based on Medicare average reimbursement rate

Early Elective Delivery (EED) section – Applicable to hospitals providing labor and delivery services Hard Stop Policy: Indicates whether HRET has a record of an existing Hard Stop Policy based on information submitted monthly by K-HEN to HRET EED current rate and corresponding month (the Joint Commission measure PC-01) –Using all available data, an estimate of the number of EEDs prevented is calculated –The estimate of EEDs prevented is used to calculate excess costs averted at an assumed cost of $41,000 Source: GilbertWM, Nesbitt TS, Danielsen B. “The Cost of Prematurity: Quantification by Gestational Age and BirthWeight.” Obstet Gynecol Sep; 102(3):

Graphs All EOM process and outcome measures with post-baseline data with non-zero denominator(s) are displayed as run charts starting on page four Run charts include hospital values (red display color), state average (blue display color) and overall HEN average (black display color). Displayed measures with fewer than five hospitals reporting (at either the state or national level) are indicated with a footnote Also note that: –The baseline value is represented as a single value on the left of the chart –Sometimes the hospital, state, and/or HEN baseline or monthly rate will coincide which may one or two of the three values may not be visible –If there are no data for one or more consecutive months, the values for non-missing months prior to and following these months will be connected; however, such trends should be interpreted with caution, as they are based on limited data

State Summary Report State snapshot by topic area (HRET) Meeting CMS Directives –Previously focused on level of engagement –Now looking at level of improvement –Ultimate goal is 40% (20% for Readmissions) –New milestone: 30% improvement (15% Readmissions) by June 30 in at least six topic areas (Each State)

LOP/Improvement *Current- Last Three Months Rate (with at least One Month in Oct-12 to Jan-13) No reduction to date % reduction % reduction % reduction % reduction 0.04 No reduction to date 0.79 No reduction to date 3.78 No reduction to date % reduction 8.55% 60.24% reduction 0.07 No reduction to date 0.52% No reduction to date 10.0% 3.63% reduction 19.01% 13.96% reduction 2.69 No reduction to date % reduction 0.15 No reduction to date % reduction 2.70 No reduction to date No reduction to date Level of Participation (Engagement Level of Improvement

Open Discussion