Patient Safety Learning Collaborative Recognition Program Georgia Hospital Engagement Network Kathy McGowan, VP, Quality & Safety, PHA Lynn Hall, Patient Safety Specialist, PHA

What is the GA HEN Recognition Program? The GA HEN Recognition Program is a unique approach to measure the performance of GA HEN Hospitals in meeting the goal of reducing Hospital Acquired Conditions by 40% and reducing Readmissions by 20% by 2013, and to recognize top performing hospitals.

Who is eligible for the GA HEN Recognition Program? GA HEN hospitals are required to select two Learning Collaboratives, from the following based on individual hospital improvement needs: O Hospital Acquired Infections (HAI), O Hospital Acquired Conditions (HAC), O Reducing Readmissions (RR), O OB Adverse Events (EED),

What are the different criteria used in the HEN Recognition Program? O The GA HEN Recognition scores are calculated based on the following dimensions: O Participation in HEN In-Person and Webinar meetings (25%) O Completion of HEN Assignments, the assignments included in this first round are: O Completion of the OAT (5%) O Completion of Evaluations for each of the Required HEN Meetings (15%) O Submission of Process Data for each of the Required Learning Collaborative (20%) O Achieving the HEN Targets (35%)

How are the Participation Scores calculated? O Participation scores are calculated as a percentage of attendance in required HEN Meetings. O Each GA HEN Hospital is required to participate in the following In-Person meetings:

How are the Participation Scores calculated? O Patient Safety Summit (January 4 - 5, 2012) O Trustee Meeting (January 6 – 8, 2012) O HEN Kick Off Meeting (February 8, 2012) O GHA Annual Meeting (February 21 – 22, 2012) O OB EED Kick- Off Meeting (May 2, 2012) (Required only for Birthing Hospitals)

How are the Participation Scores calculated? O Nurse Institute (June 6-8, 2012) O GHA Summer Meeting (July 10 – 12, 2012) O Center for Rural Health Meeting (August 8 – 10, 2012) (Required only for Center Members) O Additionally, each GA HEN hospital is required to participate in all the monthly Webinars for their respective Learning Collaboratives.

How are the Targets for GA HEN established? O GA HEN targets were established by reducing the 2010 Baseline data by 40% for Hospital Acquired Conditions, and 20% for Readmissions. O Studies have shown that only 44% of the HACs are preventable. O Therefore the overall PFP goal is a 17.6% reduction in total measured HACs (40% of the 44% (preventable fraction) = 17.6%).

What are the different data sources for this program? The following data sources are used: O Georgia Discharge Database: used in the calculation of Hospital Acquired Conditions and Patient Safety Indicators O Readmissions Data: We have partnered with the Georgia Medical Care Foundation to obtain overall 30-day Readmissions data. O Early Elective Deliveries: This data is directly reported to us by the hospitals.

What are the different outcome measures used for Achieving HEN Target scores and what are their specifications?

How are my scores for Achieving HEN Targets calculated? O Hospitals who are at or below the HEN target receive the full points for Achieving HEN Target. O Hospitals who are above the HEN Target receive an increment of points based on their performance. O Achieving HEN Target scores are calculated only for your selected First Focus topic of your respective Learning Collaborative (i.e. CLABSI in HAI)

What is the Time Period for this report? O Participation: Attendance to GA HEN Meetings (January – September 2012) O Achieving HEN Target: GDDS (January – June 2012), Readmissions (January – March 2012)

How is the Extra Credit Points awarded and calculated? O Extra Credit points are awarded based on participation, data submission, and achieving targets in non-required Learning Collaboratives. O Additionally extra credit points are awarded for hospitals who present at the GA HEN meetings. O A Maximum of 10 Extra Credit points are possible.

For questions and information: O Faizah Muheb – O Kathy McGowan –

Questions?