HEN 2.0 and The IHA Institute Road Ahead IMPROVING PATIENT SAFETY ACROSS ILLINOIS May 5, 2015

2 IHA Institute HEN Team Jay D. Bhatt, DO, MPH, MPA, FACP Chief Health Officer, Illinois Hospital Association Cathy N. Grossi, JD, BSN, CPHQ Vice President, Institute for Innovations in Care and Quality Helga Brake, PharmD, CPHQ, CPPS Senior Director, Institute for Innovations in Care and Quality Marchelle Djordjevic, MBA, CPHQ Director, Institute for Innovations in Care and Quality Adam Kohlrus, MS, CPHQ, CPPS Director, Institute for Innovations in Care and Quality

3 Marsha Curtis Manager, Institute for Innovations in Care and Quality Tammy De Leonardis Administrative Assistant, Institute for Innovations in Care and Quality IHA Institute HEN Team The HEN wouldn’t cluck without support from our amazing administrative staff!

As part of HEN 1.0, 100 IL IHA HEN hospitals prevented 15,887 instances of patient harm for a cost savings of $161.8 million between January 2012 and March 2014  14,294 readmissions prevented;  285 early-elective deliveries prevented;  234 post-operative pulmonary embolisms or incidents of deep vein thrombosis prevented;  192 central line-associated bloodstream infections prevented;  188 catheter-associated urinary tract infections prevented;  152 incidents of ventilator-associated pneumonia prevented;  131 surgical site infections prevented;  126 birth trauma or injuries to neonates prevented;  123 pressure ulcers prevented;  116 falls with injury prevented; and  46 manifestations of poor glycemic control prevented. 4

5 AHA/HRET: Achievement of Targets – November 2014 AREA At least 60% Reporting At least 70% Reporting At least 80% Reporting 17.6% Change from Baseline (15% Readm) AND At Least 60% Reporting 40% Change from Baseline (20% Readm) AND At Least 80% Reporting Met High Perf. Benchmk Achievement of Target ADE   CAUTI 100% reporting 33% reduction   CLABSI 100% reporting  61% reduction  Falls 60%-53% reporting 9% reduction/ 25% reduction    OB-EED 90% reporting 79% reduction  OB-Other 98% reporting  41% reduction    PrU 100% reporting 28% reduction  SSI 100% reporting  Readm 100% reporting  VAP/VAE 100% reporting  23% reduction     VTE 100% reporting  42% reduction   IL IHA HEN 1.0 Results

CMS Partnership for Patients Hospital Engagement Network “The Hospital Engagement Network (HEN) will engage the hospital, provider and broader caregiver communities to quickly implement well- tested, evidence-based harm and measured best practices… the end result of the overall initiative shall be reduction in hospital-based harm and preventable readmissions.” “Overall participation goal remains to recruit active participation of 100% of short-stay, acute care hospitals in the U.S.” HEN 2.0 Request for Proposal announced on February 11, 2015 Request for Proposal response submitted on March 30, 2015 Anticipate funding and contract awards in third quarter (July) month contract

IHA Institute’s Primary Goal To Provide the Highest Degree of Sustainable Value for Illinois Hospitals Prime Contractor selection criteria: 1.Dedicated to the implementation of evidence-based best practices 2.Utilizes proven methods to decrease hospital-acquired conditions and improve patient safety culture 3.Access to hospital, state and national patient safety experts 4.Strongly supports minimum data collection and reporting burden philosophy 7

Announcing! MHA-IHA HEN Partnership Should HEN 2.0 be funded and contracts awarded, IHA will be subcontracting with the Michigan Hospital Association’s (MHA) Keystone Center for the HEN 2.0 contract MHA’s Keystone Center successfully facilitated their own HEN from and was among the top HENs in the country from a performance perspective (ACT score) While we had an amazing experience with AHA, we know that subcontracting with MHA will put our IL hospitals in the most optimal and sustainable position during the HEN 2.0 year and moving forward beyond HEN 8

HEN 2.0 Focus Areas – Same as HEN 1.0 (40%/20% Reductions) 9 Catheter-associated urinary tract infections (CAUTI), in all hospital settings, including avoiding placement of catheters both in the ER and in the hospital Central line-associated blood stream infections (CLABSI), in all hospital settings, not only in ICUs Ventilator-Associated Events (VAE), to include Infection-related Ventilator- Associated Complication (iVAC) and Ventilator-Associated Conditions (VAC) Surgical site infections, to include measurement and improvement of SSI for multiple classes of surgeries Obstetrical adverse events, including early elective delivery, obstetrical hemorrhage, and preeclampsia treatment and management to prevent maternal morbidity and mortality Adverse drug events (ADE) Participating hospitals that have a primarily adult population must report measures related to opioid safety, anticoagulation safety and glycemic management, at a minimum

10 Readmissions Injuries from falls and immobility Pressure ulcers Venous thromboembolism (VTE), including, at a minimum, all surgical settings Additional topics for consideration Severe Sepsis and Septic Shock Hospital Culture of Safety (fully integrating patient safety with worker safety) Iatrogenic Delirium Clostridium Difficile (C.Dif.), including antibiotic stewardship Undue Exposure to Radiation Airway Safety Failure to Rescue HEN 2.0 Focus Areas – Same as HEN 1.0 (40%/20% Reductions)

Minimum Participation 4 Requirements 1.Signed Commitment Letter (HEN Lead, CEO, CMO, CNO) 2.Submission of monthly data set 30 measures in all, includes 6 Hospital directly reported Baseline year: Signed Data Use Agreement 4.Engagement in foundational education focused on Culture, High Reliability, and Patient and Family Engagement initiatives (Specifics TBD-meaningful, value added education) 11

MHA-IHA HEN Participation Benefits 12 1.Access to high-quality resources, tools, webinars, and other materials to support your improvement work on the HEN 2.Access to a data system to track progress on all applicable topics including reports 3.Access to national subject matter experts who can assist with improvement questions and recommendations 4.Opportunities to network, in-person and virtual, and access to shared forums to assist improvement teams with barriers and provide encouragement to continue the improvement journey

5. Opportunity to train staff in Quality Improvement principles through the QHR “Quality Boot Camp” at no cost 6. Opportunity to train and certify staff in patient safety, healthcare quality, and infection prevention (CPPS/CPHQ/CIC) at no cost 7.Opportunity to engage a physician from your organization in training and certification through the American Board of Quality Assurance and Utilization Review Physicians (ABQAURP) 8.Opportunity to compete for 1 of 20 slots in our “Go to the IHI on the IHA” friendly competition 9. The Quality Department of your organization will receive a direct financial incentive when you return the commitment letter and DUA to IHA with HEN Lead, CEO, CMO, & CNO signatures within 60 days of receiving it 13 MHA-IHA HEN Participation (even more) Benefits

MHA-IHA Approach to HEN

Deeper Dive into the MHA-IHA Collaboratives Structure – Kick-off in-person meeting, followed by monthly webinars and coaching calls with national experts. Each collaborative collects baseline and monthly data to ensure progress is made and sustained. Collaboratives utilize the Johns Hopkins University 4Es methodology: Engage: Share stories and baseline data that show how the project will improve culture and patient outcomes. Educate: Educate staff on evidence and interventions needed for change to occur. Execute: Standardize procedures, create independent checks, learn from mistakes and empower staff to pause a procedure if they see a potential error, safety or quality issue. Evaluate: View infections or harm as defects in care and provide feedback on performance. 15

Polling Question 16 If you were to join the MHA-IHA HEN, would you be interested in participating in the CAUTI Keystone collaborative during HEN 2.0? Interventions: assess current Foley catheter practices, implement CAUTI reduction practices, and educate staff and patients 1.Yes 2.Maybe 3.Doubt it 4.No

Polling Question 17 If you were to join the MHA-IHA HEN, would you be interested in participating in the PAIN MANAGEMENT Keystone collaborative during HEN 2.0? Objectives: to address appropriate pain management in the hospital setting and decrease the usage of opiates statewide 1.Yes 2.Maybe 3.Doubt it 4.No

Polling Question 18 If you were to join the MHA-IHA HEN, would you be interested in participating in the OBSTETRICS Keystone collaborative during HEN 2.0? Focuses on reducing risk of/and maternal and neonatal morbidity and mortality related to postpartum hemorrhage and preeclampsia 1.Yes 2.Maybe 3.Doubt it 4.No

Polling Question 19 If you were to join the MHA-IHA HEN, would you be interested in participating in the National CUSP 4 MVP-VAP Keystone collaborative during HEN 2.0? Objective: to reduce ventilator- associated events in hospitals using proven effective interventions 1.Yes 2.Maybe 3.Doubt it 4.No

Polling Question 20 If you were to join the MHA-IHA HEN, would you be interested in participating in the ICU SEPSIS Keystone collaborative during HEN 2.0? Objectives: prevent harm through implementation of bundles of interventions that ensure patients receive appropriate treatment for their condition and reduce the likelihood that a patient will die from severe sepsis or septic shock 1.Yes 2.Maybe 3.Doubt it 4.No

Polling Question 21 If you were to join the MHA-IHA HEN, would you be interested in participating in the ICU DELIRIUM AND EARLY MOBILITY Keystone collaborative during HEN 2.0? Interventions include: delirium assessment/management, and identification and management of progressive mobility 1.Yes 2.Maybe 3.Doubt it 4.No

6 Hospital Directly-Reported Measures: OB-EED (JC PC-01), Post-Partum Hemorrhage (JC/ACOG/CMQCC) ADE-Anticoagulant, Hypoglycemic, Opioid Falls-Falls with injury (NQF 0202) HEN 2.0 Data Reporting 30 required measures Measures reported for you by IHA’s CompData ADE-1OB-3 Pressure Ulcer-1 Readmits- 3 VTE-1Sepsis-1 14 Measures reported for you by conferring rights to MHA-IHA CAUTI- 3 CLABSI- 3 SSI-4VAE-2C.Dif-1 MRSA Hospital directly- reported measures ADE-3Falls-1 OB-EED & PPH

23 Data Platform Bye bye CDS! MHA has contracted with Battelle, a 501(c)(3) charitable trust to develop our data platform We are in the process of working with Battelle to develop reports and portal functionality Hospitals will still enter numerator/denominator data and be able to run reports Battelle is the world’s largest nonprofit research and development organization. Battelle was founded on industrialist Gordon Battelle’s vision that business and scientific interests can go hand-in-hand as forces for positive change.

HEN 2.0 Commitment Letter Eligibility and Recruitment: CMS is strongly urging 100 percent of short-stay, acute care U.S. hospitals to participate. As with HEN 1.0, hospitals are eligible to join any HEN but they may only join one HEN. A letter of engagement committing the organization to one HEN must be signed by the participating organization’s CEO and other C-suite executive sponsors within 60 days of project start. A commitment letter will be sent out once CMS funds the project and the primary contracts are awarded requiring signatures from the HEN Lead, CEO, CMO and CNO. 24

MHA-IHA HEN Our aim in HEN 2.0 is to provide you with an enhanced level of resources, networking and coaching to assist you in advancing your Quality Improvement and Patient Safety agendas IHA and MHA staff are hard at work planning an array of content webinars and educational opportunities that will cover all 11 focus areas in HEN 2.0 We are committed to providing you with a highly valued and successful initiative that will help IL hospitals meet and exceed national goals for the HEN year and beyond 25

Partnering Across the Continuum… 26

Next Steps… Signed Commitment Letter & Data Use Agreement You will receive the documents after the project is funded and the contracts are awarded (Quarter 3, 2015) Commitment letter & Data Use Agreement signatures must be obtained within 60 days to receive the financial incentive Look for the monthly Institute Insights newsletter to keep you informed. Contact to add HEN 2.0 Metrics Full list of 30 metrics available upon request 27

One Final Polling Question 28 Are you interested in joining the MHA-IHA HEN in ? 1.Yes 2.Maybe 3.Doubt it 4.No

29 Thank you Questions? Adam Kohlrus Director, Performance Improvement IHA,