Introduction to the Illinois HEN March 2013

Overview – Illinois HEN Partnership – IHA & HRET/CMS  1600 hospitals in 34 states  Goal by December 2013 Reduce harm by 40% - (CLABSI, CAUTI, SSI, VTE, ADE, Falls, EED, PU, VAP) Reduce readmissions by 20% Equip hospitals with leadership, change management, facilitation, quality improvement & teamwork skills Focus on improving the safety culture 2

Overview – IHA P4P HEN 59 HEN Hospitals in Illinois

IHA Partnership for Patients HEN Hospitals Advocate South Suburban HospitalMcDonough District HospitalSaint Joseph Hospital Central DuPage HospitalMetroSouth Medical CenterSaints Mary & Elizabeth Medical Center Delnor HospitalMorris HospitalSalem Township Hospital Dr. John Warner HospitalNorwegian American HospitalShelby Memorial Hospital Edward HospitalOur Lady of the Resurrection Medical CenterShriners Hospital for Children - Chicago Fairfield Memorial HospitalPassavant Area HospitalSt. Anthony's Memorial Hospital FHN Memorial HospitalPekin HospitalSt. Elizabeth's Hospital Franciscan St. James Health/Chicago HeightsProvena Covenant Medical CenterSt. Francis Hospital Franciscan St. James Health/Olympia FieldsProvena Mercy Medical CenterSt. John's Hospital Gateway Regional Medical CenterProvena Saint Joseph HospitalSt. Joseph's Hospital Graham HospitalProvena Saint Joseph Medical CenterSt. Joseph's Hospital Hammond-Henry HospitalProvena St. Mary’s HospitalSt. Margaret's Hospital Hartgrove HospitalProvena United Samaritans Medical CenterSt Mary's Hospital Holy Family Medical CenterRed Bud Regional HospitalSt. Mary's Hospital Jersey Community HospitalResurrection Medical CenterThorek Memorial Hospital Kishwaukee Community HospitalRichland Memorial HospitalUnion County Hospital Linden Oaks at EdwardRiverside Medical CenterVista Medical Center East Loretto HospitalRockford Memorial HospitalWabash General Hospital Loyola Gottlieb HospitalRush-Copley Medical CenterWashington County Hospital MacNeal HospitalSaint Francis Hospital

Overview – Illinois HEN Partnership – IHA & HRET  Partnership for Patients funded resources Help to identify HAC’s in need of intensive & moderate support 3 levels of improvement activity at the HRET level – Stand-alone webinars – Coaching calls – Waves Fellowships (900 trained) Collaboratives 5

Overview – Illinois HEN Partnership – IHA & HRET  Partnership for Patients funded resources Topic specific toolkits, guidelines & checklists Ongoing access to subject matter experts in all 10 areas Intensive support for hospitals or regions with significant challenges Targeted interventions for specific hospital types (children’s, LTACH, psychiatric) 6

Affinity Groups Update 7 Topic:Date: CAH/RuralTuesday, May 14, 11:00-11:45 AM, CDT Children’sTuesday, May 14, 12:00-12:45 PM, CDT LTAC/RehabThursday, May 16, 11:00-11:45 PM, CDT PsychiatricThursday, May 16, 12:00-12:45 PM, CDT The next series of affinity group coaching calls will take place this month. Information on how to register can be found on the HRET HEN Events page. Please see the schedule below for September’s webinars.HRET HEN Events page

HRET/HEN Website Resources and tools for the ten focus areas (webinars, podcasts, toolkits, and links to other helpful information)

Overview – Illinois HEN Partnership – IHA & HRET  Partnership for Patients funded resources LISTSERVs® and monthly Progress Reports Dedicated program website where all calls and webinars will be archived along with written material and important links 9

Listserv Adverse Drug Events Adverse OB Events Readmissions Surgical Site CLABSI/CAUTI & VAP Falls & Pressure Ulcers VTE

Overview – Illinois HEN Partnership – IHA & HRET  Partnership for Patients funded resources Data collection and Progress monitoring & support – Selection of measures that minimize data collection burden – Comprehensive Data System (CDS) secure, web-based data collection system. Users must have a connection to the Internet and a browser which supports SSL (secure socket layer) encryption. 3,597 registered users with 62 percent of hospitals submitting data on at least one measure 11

Overview – Illinois HEN Partnership – IHA & HRET  Partnership for Patients funded resources – Comprehensive Data System (CDS) Data administrator - Data administrators should be persons with experience in data collection and measurement. An administrator will be permitted to add and delete users, edit data, and view reports (when available). Data entry user - Data entry users should have experience with entering data, and shall only be permitted to enter and edit data. – Encyclopedia of Metrics – Support of multiple data entry modalities – Illinois Data Plan 12

Overview – Illinois HEN IHA  Illinois HEN Data Plan ADE - IHA COMPdata, hospital CAUTI - IHA COMPdata, NHSN CLABSI - IHA COMPdata, NHSN Falls - IHA COMPdata, NDNQI OB - IHA COMPdata, hospital PU - IHA COMPdata, NDNQI Readmission – IHA Database SSI - IHA COMPdata, NHSN VAP - IHA COMPdata, NHSN VTE - IHA COMPdata, NHSN 13

Overview – Illinois HEN IHA IHA HEN Coach – Each hospital will have a primary HEN staff member (Marie, Sara, Adam) assigned to them who will act as your “point person” – You may direct any questions, concerns or any HEN related activity through your point person – They will be acting as your mentoring coach and will work with you as you plan your implementation, monitor your progress and move forward throughout the initiative 14

Overview – Illinois HEN IHA IHA P4P HEN Weekly Update – sent out each Friday Upcoming Events (webinars, workshops, etc.) Hospital Highlights Reminders Other resources to help you 15

Weekly Update

Overview – Illinois HEN IHA – Quality Leader Boot Camp – CPHQ, ABQAURP – National Patient Safety Foundation – Community – American Society of Professionals in Patient Safety – Education – NPSF Online Patient Safety Curriculum – Certification-Professional Advancement Practice Test Certified Professional In Patient Safety Certification Examination – Board Level Engagement 17

Statewide Workshops 3 Statewide Workshops - July – Springfield, Naperville, Salem Goal : to leave the meeting with a set plan of action and necessary tools to achieve the 40%/20% targets Will be held in between “Waves” going forward

Data Hospital specific HEN Network Reports will be provided by IHA Use this data to help identify& prioritize your focus areas & track progress

Data Control charts for the ten HACs will be provided by IHA

Questions? For additional information & questions contact Marie Cleary-Fishman at or Adam Kohlrus at