Georgia Hospital Engagement Network Patient and Family Centered Safe Care Putting Patients First 40/20 by ‘13 2013 The Time is Now!

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Presentation transcript:

Georgia Hospital Engagement Network Patient and Family Centered Safe Care Putting Patients First 40/20 by ‘ The Time is Now!

Learn. Act. Improve. Spread. Keep the Drum Beat Going. Partnership for Patients Campaign

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 Executive Engagement – Executive Quality Action Council Purpose: Provide guidance and support to the GHA Hospital Engagement Network on its goal of improving patient safety through implementation of the eliminating “all cause harm” approach and patient and family centered safe care. 3

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 Executive Action Quality Council Members Co-Chairs Jim Davis, CEO, University Hospital and Sheila Bennett, Floyd Medical Center 4 David Andrews, Patient Advocate, Georgia Regents University Susan Bowen, Shepherd Center Melody Brown, Dodge County Hospital Montez Carter, Good Samaritan Hospital Nicole Franks, MD, Emory University Hospital Midtown Freya Gilbert, Hughston Hospital Babs Hargett, Emory Healthcare Michael Hester, Optim Medical Center- Jenkins Angie King, St. Francis Hospital Mindy McStott, Tift Regional Medical Center Norma Jean Morgan, Effingham Health System Heidi Nelson, University Hospital Teri Newsome, Habersham Medical Center Mary Pizzino, Effingham Health System Tina Thomas, Ty Cobb Regional Medical Center Brad Trower, Optim Medical Center- Jenkins Jerry West, Houston Medical Center

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 Executive Quality Action Council Vision : All Georgia hospitals will be a patient and family centered safe care organization. Mission : Provide leadership to the Georgia Hospital Engagement Network to reduce all cause harm among Georgia hospitals. Goals : Address Aims: Better Health; Better Outcomes; Lower Cost Assisting hospitals to meet the CMS Partnership for Patients goal of reducing readmissions 20% and hospital acquired conditions 40% by the end of

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 Executive Quality Action Council Objectives: Foster the support of the hospitals’ C Suite and Board to engage all staff, including but not limited to, senior leaders, frontline staff and physicians, as well as patient and family representatives in the implementation of the patient and family safe care framework. Provide insight on realistic approaches to implement enlightened executive leadership guide Provide executive guide for implementation of selected best practices 6

7

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 All Cause Harm Global Tools To Meet Goals Have to Focus on Patient Safety Culture Leadership – Evidence – based Leadership – Rounding: Executive Leaders Engagement and Process Design Tools: – Comprehensive Unit Safety Program (CUSP) – Rounding: Managers and Staff – Reliable System Process Design – Lean/Six Sigma Communication and Team Work – TeamSTEPPS Patient and Family Centered Care/Engagement – The Healthcare and Patient Partnership Institute (H2Pi): The Patients as Partners Training Guide – Partnership for Women and Families 8

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 Patient/Family Centered Safe Care Advisory Action Group Partnerships – National Partnership for Women and Family – Healthcare and Patients Partnership Institute 9 Ask Listen Evaluate Respond Test Ask Listen Evaluate Respond Test

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 Cohorts/Hospital Visits/Calls Every hospital has a GHA liaison Face-to-face hospital visit by liaison Why Create Cohorts – All Teach, All Learn concept – Coaching available – Achieve rapid change – Small groups – Promotes networking – More one-on-one assistance when needed – Mentoring encouraged 10

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 Cohorts/Hospital Visits/Calls Monthly Cohort calls – attendance required for recognition points Cohort 1: Joyce Reid (1a), Kathy McGowan (1b), Lorna Martin (1c) - 1 st Wednesday 11:30 a.m. – 12:15 p.m. Cohort 2: Denise Flook (2) – 2 nd Wednesday 11:30 a.m. – 12:15 p.m. Cohort 3: Tracy Rutland (3) – 3 rd Wednesday 11:30 a.m. – 12:15 p.m. Cohort 4: Lynne Hall (4) – 4 th Wednesday 11:30 a.m. – 12:15 p.m. 11

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 Cohorts/Hospital Visits/Calls Format of monthly cohort calls – Discussion based on data – Offers & Requests What do you need to be successful? What do you bring to the table? – Requests from Partnership for Patients & CMS Time for Implementation 12

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13 Cohorts/Hospital Visits/Calls Hospital visits – opportunity to share & showcase Review data – Organizational Assessment Tool, HAC, Readmission, Core Measure, etc. What keeps you up at night? Resources 13

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 14 Specific Topic Affinity Webinars*: All Teach, All Learn GHA will offer monthly Affinity Group calls on Wednesdays from 11:00 a.m. – 11:30 a.m. (See Calendar) – First Wednesday: Reducing Readmissions* – Second Wednesday: Hospital Acquired Infections (HAI) – Third Wednesday:Hospital Acquired Conditions/Events (HACs) – Fourth Wednesday:OB Adverse Events CMS national calls – will be notified of date & time – *February 11 – Patient & Family Engagement 3:00 p.m. – 4:30 p.m. – *March 4 – Readmissions 3:00 p.m. – 4:30 p.m. (will replace March 6 Readmission call) – *April 1 – Adverse Drug Events 3:00 - 4:00 pm Extra credit for recognition 14

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 15 Regional Meetings Combine cohorts All Teach, All Learn Dates – May & August – November – Year End Celebration Geographic locations – Albany – Athens – Dalton – Macon – Marietta – Waycross 15

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 16 Small/Rural CAH Approach Umbrella of Quality Improvement Taking down the silos – building new relationships Expanding our horizons Promoting our culture of safety Learning from each other Rural Affinity Change Package Fine-tuning our strategies Hard stop for discharge program Celebrating as we go! 16

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 17 Calendar of Events You Asked For It! 17

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 18 Organizational Assessment Tool Assessment: – Some questions confusing – Terminology needs clarification on some questions – Tool more sensible when read currently compared to a year ago when the HEN was just beginning to launch and some of the content was new – Data reports and analysis seem premature since this is baseline data – National Content Developer (NCD) listened to our feedback Currently revising the OAT New version available in the Spring 18

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 19 Organizational Assessment Tool Recommendations: – Conduct a mandatory conference call for HEN leaders – Prior to conference call, send electronic.pdf version of the OAT survey to all members and set the expectation that they read for clarity – During the conference call, identify additional items that require clarification in addition to the questions listed above – Ask GHA staff to compile a data dictionary for these questions and terms based on our GHA HEN leaders and then circulate the document – Launch “wave two” of the survey in Spring 2013 with the intent to evaluate where we have progressed with the guidance of the HEN activities 19

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 20 Organizational Assessment Tool Recommendations continued – Communicate effectively that the OAT survey should not be used with the intent to compete with one another but as a personal tool for each organization to identify if their actions are producing the gain that is expected. – Subsequent reports should feature “wave one” survey as the baseline and “wave two” as effect of change. 20

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 21 Upcoming Educational Opportunities 2013 Statewide In-Person Meetings (attendance required for Recognition Program) February 12-13GHA Annual Meeting June 5-7Nurse Leadership Institute July 9-12GHA Summer Meeting August 7-9Center for Rural Health Lean Six Sigma Green Belt Training June 17-21, GHA Education Center 21

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 22 Partnership for Patients (PfP) National Calls Strategies for Advancing Patient and Family Engagement as a Change Engine – Monday, February 11, :00 p.m.- 4:30 p.m. – To register go to: All Cause Harm Across the Board/Readmission – Monday, March 4, :00 p.m.- 4:30 p.m. Adverse Drug Events – Monday, April 1, :00 p.m.- 4:00 p.m 22

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 23 Data Requirements Outcomes – Most HACs and Readmission data from other sources so no further submission needed – HAIs (CLABSI, CAUTI, SSI (colon surgeries) and VAE) – must confer rights to NHSN data to GHA, monthly data – EED data submitted monthly – ADE data Process Measure Data – Quarterly Best Practices Attestation online survey 23

Learn. Act. Improve. Spread. Keep the Drum Beat Going Proposed Recognition Program The GA HEN Recognition scores are calculated based on the following dimensions: Participation (15%) – In Person Meetings – Cohort Meetings – Regional Meetings Completion of Evaluations for any HEN Meeting (10%) Submissions (25%) – Completion of the Organizational Assessment Tool in Spring 2013 – Quarterly Best Practices Attestation Survey – Submission of outcomes data as required (EED, NHSN, ADE, Core Measures) Achieving the HEN Targets (50%) 24

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 25 Participation scores are calculated as a percentage of attendance in required HEN Meetings. In Person Meetings: – Patient Safety Summit (January , 2013) – Trustee Meeting (January , 2013) – February Kick Off (February 7, 2013) – GHA Annual Meeting (February , 2013) – Nurse Leadership Institute (June 5 - 7, 2013) – GHA Summer Meeting (July 9-12, 2013) OR Center for Rural Health Meeting (August 7-9, 2013) – Regional Cohort Meetings held in various Georgia regions in May, August, and November 25 Recognition Program

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 26 Cohort Meeting Dates: 26 Recognition Program Cohort 1Cohort 2Cohort 3Cohort 4 3/6/20133/13/20133/20/20133/27/2013 4/3/20134/10/20134/17/20134/24/2013 6/5/20136/12/20136/19/20136/26/2013 7/3/20137/10/20137/17/20137/24/2013 9/4/20139/11/20139/18/20139/25/ /2/201310/9/201310/16/201310/23/2013

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 27 The following data sources are used: – Georgia Discharge Database: used in the calculation of Hospital Acquired Conditions and Patient Safety Indicators – Readmissions Data: We have partnered with the Georgia Medical Care Foundation to obtain overall 30-day Readmissions data. – Early Elective Deliveries: This data is directly reported to us by the hospitals. – National Healthcare Safety Network (NHSN): Used for CAUTI, CLABSI, SSI and VAE 27 Recognition Program

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 28 Measure Data SourceTargetWeight CAUTI Rate per 1000 Catheter Days NHSN1.35 CLABSI Rate per 1000 Device Days NHSN SSI, Colon Surgery Rate per 100 Procedures NHSN1.75 ADE- INR>5 Hospital Reported 5% of Patients5 Falls and Trauma Rate per 1000 discharges CMS HAC0.295 Pressure Ulcer Rate per 1000 discharges AHRQ0.475 Postoperative PE or DVT Rate per 1000 discharges AHRQ4.055 EED-PC 01 (Rate) TJC5%5 Reducing Readmissions (Rate) Medicare PPS15.24%10 28 Recognition Program

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 29 Extra Credit points are awarded for: – Participation in Affinity Group educational calls – Achieving 4’s and 5’s by CMS rating scale – Meeting the CMS Patient and Family Engagement Requirements; defined on the Attestation document – Presentations in GHA and CMS meetings – Participation in the SUSP Program Maximum extra credit points = Recognition Program

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 30 Three categories of Exemplar hospitals are identified based on overall Recognition Scores: – Elite Circle: Hospitals who achieve 90 th percentile rank – Chairman’s Circle: Hospitals who achieve 80 th percentile rank – Presidential Circle: Hospitals who achieve 70 th percentile rank Ideal Hospital: Achieving CMS ranking of 4 or 5 in six or more HACs 30 Recognition Program

We Look Forward to Working With You in 2013! 31

Learn. Act. Improve. Spread. Keep the Drum Beat Going. 32 Contact Information Phone: Vi Naylor: Kathy McGowan: Joyce Reid: Denise Flook: Faizah Muheb: Martha Harrell: Lynne Hall: Lorna Martin: Tracy Rutland: Michelle Sprouse: Shearl Lesser: