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 2 CMS Partnership for Patients Hospital Engagement Network Program (HEN) HRET (AHA) K-HEN 91 hospitals 32 Other State Hospital Associations 25 other HENS

K-HEN Framework 3 PatientSafetyCulture STAY FIT CLABSI CAUTI SSI VAP PIVOT VTE Pressure Ulcers Falls OB HARM *Early Elective Deliveries GO RED Readmissions ADE

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 5

ADE (Adverse Drug Events) 6

7 54% Improvement

CAUTI 8

9 15% Improvement

CLABSI 10 4% Improvement

CLABSI 11

Early Elective Deliveries 12 59% Improvement

OB Harm 13 3% Improvement

Falls 14 61% Improvement

Falls 15

Pressure Ulcers 16 56% Improvement

Pressure Ulcer 17

Preventable Readmissions 18

Preventable Readmissions 19 15% Improvement

Surgical Site Infection 20 15% Improvement

Safe Surgery 21

VAP 22 62% Improvement

VAP 23

VTE (Venous Thromboembolism) % Improvement

Potentially Preventable VTE 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 31 Select the ‘Review’ toolbar Select ‘Unprotect Sheet’ (toggle) Make changes, then select ‘Protect Sheet’ Save changes

What’s Included in the Calculations 32 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— based on current rate

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 away! Dolores Hagan (502)

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 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,

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 -

Patient Safety Work ranked 5 th 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