Reducing Readmissions K-HEN Data Collection & Submission Dolores Hagan, RN BSN K-HEN Education and Data Manager August 2012

Objectives Review reporting requirements Review K-HEN recommended measures Review the specifications for monitoring data (Inclusion and exclusion criteria) Discuss requirements for baseline data Define data entry and submission timeline Identify measures that may be pulled from other systems where data is currently being entered 2

Reporting Requirements For each topic area chosen, hospitals are required to submit data for at least – One process measure AND – One outcome measure Hospitals are strongly encouraged to report on the K-HEN recommended measures Additional outcome and/or process measures may be selected and reported as desired 3

K-HEN Recommended Measures Purpose—standardize reporting on the same measures across the state for robust benchmarking capability Measures selected based on polling data from the KHA Quality Conference in March 2012 Have continued to evolve with your feedback (Keep it coming! ) 4

HRET HEN Encyclopedia of Measures Lists all measures available in the CDS Defines the numerator and denominator for each measure Provides a link to the source of the measure hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_Measures_v3.pdf hen.com/Portals/16/Documents/HRET_HEN_ Encyclopedia_of_Measures_v3.pdf 5

Reducing Readmissions: Outcome Measure Survey recommended – HF 30-day risk standardized readmission rate Not feasible to collect real-time Preferred measure: #77 Heart Failure Patients - Readmission within 30 days (All Cause) Alternate measure: #75 Readmissions within 30 days (All Cause) 6

# 77 Heart Failure Readmission Criteria Numerator—Patients readmitted to the same facility, for any reason, within 30 days of date of discharge after hospitalization for HF (multiple readmissions for same patient within 30 days of the index admission should only be counted once) Denominator—All HF patients discharged alive with principal diagnosis code as listed in Encyclopedia of Measures Exclusions – Patients < 18 years of age – Observation patients – Discharged AMA or transferred to another acute care facility 7 Source: NQF 0330

# 75 Readmission Criteria Numerator—Non-elective inpatients returning as an acute care inpatient to the same facility within 30 days of the date of discharge Denominator—Total inpatient discharges Exclusions: – Observation patients – Expired patients – Discharged AMA or transferred to another acute care facility 8

Reducing Readmissions: Process Measure Preferred Measure: #69 Heart Failure Discharge Instructions Alternate Measure: #67 Patients receiving complete discharge education verified by Teach-back or other means 9

#69 HF Discharge Instructions Criteria CMS Core Measure – HF-1 Numerator—HF patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: Activity level Diet Discharge Medications Follow-up appointment Weight monitoring What to do if symptoms worsen 10 Denominator—HF Patients discharged home Source: Joint Commission Specifications Manual for National Hospital Inpatient Quality Measures

#67 Discharge Education Criteria Numerator Patients receiving complete discharge education verified by teach-back or other means Denominator All eligible patients 11

Baseline Data Only submitted one time For all topic areas except Readmissions: – Baseline data is from 2011 prior to January 1, 2012 – May be the entire calendar year of 2011 or any other period within the year (a month, a quarter, etc) – Enter your specific period beginning and ending dates Readmission Baseline Data – Preferably CY 2011 – May use Jan – Jun 2012 if 2011 data is not available If no baseline data is available, do not enter anything for baseline—begin with monitoring data 12

Date Entry and Submission Timeline CMS Reducing Readmissions focus – Requesting as much data as possible be entered from August through December 31 Data should be entered on a monthly basis as much as possible 13

Reducing Readmissions Complete baseline data entry by August 15! 14

Reducing Readmissions 2012 Monthly Data Entry Schedule Monitoring MonthData Entry AvailableData Entry Complete JanuaryImmediatelyAs soon as possible* FebruaryImmediatelyAs soon as possible* MarchImmediatelyAs soon as possible* AprilImmediatelyAs soon as possible* MayImmediatelyAs soon as possible* JuneAugust 1, 2012September 30, 2012 JulySeptember 1, 2012October 31, 2012 AugustOctober 1, 2012November 30, 2012 SeptemberNovember 1, 2012December 31, 2012 OctoberDecember 1, 2012January 31, 2013 NovemberJanuary 1, 2013February 28, 2013 DecemberFebruary 1, 2013March 31, *If data is available

Comprehensive Data System (CDS) Link to HRET training webinar for CDS located on K-HEN website under Data Page Data coordinator receives initial login and creates hospital’s users – At least two data administrators – As many data entry users as needed 16

Measure Selection Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures Determine which measures you will report Remember you MUST report on at least one process and one outcome measure per topic area selected 17

Measure Enrollment Enroll in the measures that you are reporting Select Admin  Measure Enrollment – Select the topic area – Select/deselect and save the measures that you will be reporting on – This will narrow your choices for data entry to only those selected – You may reselect those measures at a later time if desired 18

Data Collection & Entry Review the numerator and denominator criteria for the measures selected Collect and compile the data Sign on to the CDS – Select Data Entry tab – Select the topic from the drop  Select Next – Find the appropriate measure  Select Enter Data 19

Baseline Data Entry Defaults to the Baseline tab Enter the Measurement start and end dates  Select ‘Add’ Under ‘Data Entry’ column, Select ‘Go’ Was data collected for this measurement period?  Select Yes or No – If No, enter reason (e.g. data not available) – If Yes, enter the numerator and denominator – Select Save or Submit Save holds data in ‘temporary’ area and is not available for reporting within the CDS Data may be edited by the hospital until it is submitted 20

Monitoring Data Entry Select the Monitoring tab Under the Data Entry column, Select ‘Go’ for the appropriate month Was data collected for this measurement period?  Select Yes or No If No, enter reason (e.g. data not available) If Yes, enter the numerator and denominator Select Save or Submit – ‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS – Data may be edited by the hospital until it is submitted 21

Data Tidbits Each month should have data entered or a reason it was not collected Additional training will be provided after data has been entered and reporting is available 22

Monthly Progress Report Due to K-HEN by the 10 th of each month Use template provided One report per topic area Report template and sample complete report located on K-HEN website ( hen.com) under Tools and Resourceswww.k- hen.com 23

Aim?: (Including your How Good and By When statement) Why is this project important?: Aim Statement Changes being Tested, Implemented or Spread Recommendations and Next Steps Lessons Learned Run Charts (For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S)) (Enter summary here) Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?) Recommendations Next steps for testing Project Title: ______________________________ Date: _____________ Hospital Name: ____________________________ State: _____________ © 2012 Institute for Healthcare Improvement Team Members (Name of Project Champion, Senior Leader Sponsor & all other names & roles) (Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected.) Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) =

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Project Assessment Scale hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf hen.com/Portals/16/Documents/HRETHEN ProjectAssessmentScale.pdf 26

Homework Set up CDS users for your site Collect and enter baseline data by Aug 15 Enter monitoring data for Jan - May 2012 as available Enter monitoring data for Jun 2012 by Sep 1 Complete July progress report by Aug 10 and to 27

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