0. CONFIDENTIAL - Internal Use Only
HVHC Sepsis Safety Team
October 14, 2015
CONFIDENTIAL - Internal Use Only

1. CONFIDENTIAL - Internal Use Only
Agenda
Introductions
Transitioning from CMMI sepsis to Safety Program: Differences and Parallels
Dissemination/Implementation project overview
HVHC Fall Conference
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2. CONFIDENTIAL - Internal Use Only
Introductions
Andreas Taenzer, MD, MS
Physician SME for Sepsis Safety Team
Lucy Savitz, PhD, MBA
Chair of HVHC Safety Program
Jason Scott, MPH, MPP
Project Manager for HVHC Safety Program
Jillian Bath, BA
Project Coordinator for HVHC Safety Program
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3. Continuity of the CMMI sepsis work
Safety and Dissemination
CMMI enrollment ends
CMMI
starts
2015
2012
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4. HVHC 2.0 Governance Structure
Executive Committee
Chairs of Board subcommittees
Finance Committee
Discovery & Dissemination
Chair – L. Savitz
Population Health
Episode-Based Care
Safety
Programs
V. Chair –J. Tatman
Dissemination
Chair – S. Kraft
V. Chair – L. Savitz
Data Governance
Data Stewardship
Security & Privacy
Scientific Committee
Measures Stewardship
Scientific Review Board
Advocacy & Affinity Groups
Affinity Groups
Advocacy
Program Management Office (PMO)
Board Committees

5. Differences and parallels
Work over the last 3 years is continued under the Safety Program
Collecting the same data means continuity and creating a longitudinal data set that has no equal due to the linkage to CMS data (Current n = 6,452 patients)
We are building on the success of the work accomplished under the CMMI award period by disseminating to additional units and beyond

6. Three Hour Bundle Adherence by Quarter (enrolled patients meeting criteria)
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7. Standardized 90-day post sepsis episodes cost
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8. 90-day post discharge mortality (unadjusted)
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9. Dissemination & Implementation (D&I) Project Aims
Design a Collaborative D&I Conceptual Model
Design generic conceptual model for broad-scale dissemination across HVHC members
2. Apply this conceptual model to our Sepsis Care Model for D&I HVHC-wide and beyond
Apply the model to the Sepsis Care Model implementing evidence-based care across HVHC members and beyond
Note: Ongoing work on the Sepsis clinical model will fold into the HVHC Safety Program (formerly Intermountain HEN)
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10. CONFIDENTIAL - Internal Use Only
Framework
Framework to share and collaborate on tools and resources across HVHC
Ask for tools & resources to help populate
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11. Dissemination & Implementation (D&I) Project Aims
Design a Collaborative D&I Conceptual Model
Design generic conceptual model for broad-scale dissemination across HVHC members
2. Apply this conceptual model to our Sepsis Care Model for D&I HVHC-wide and beyond
Apply the model to the Sepsis Care Model implementing evidence-based care across HVHC members and beyond
Note: Ongoing work on the Sepsis clinical model will fold into the HVHC Safety Program (formerly Intermountain HEN)
Confidential - Internal Use Only

12. New Efforts and Level of Participation OverviewED
ICU
Inpatients
Current State/Level of Participation
Total %
Sustaining 34
(50%)
(64%) 12
(22%)
New Effort or in Progress 33 10
(32%)
(78%)
Full Data (time stamps) 25
(75%) 22
(91%) 18
(88%)
Simple Data (Y/N flags) 23 17
No Data 19
(25%) 4
(9%) N 77 44 45
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13. Members choose from 3 participation levels
Level of Participation
Input
Data Elements
Output
Dissemination Level
Simple Study Level
Full Study Level
Web-based training tools
Customizable materials
CMS regional comparators
CMS outcomes
Publications – dissemination/QI level
Site ID
% participating units
% employees trained per unit
Surveys only:
Leadership and unit sepsis leads
Surveys plus:
3-hour bundle process measures no timestamps
Above plus:
Patient ID
Process elements Y/N
Above plus:
Change over time internal performance
Comparison to other institutions
Cohort CMS outcome data
Publications - quantitative
Above plus:
Patient ID
Process elements Y/N
ED, ICU, inpatient unit start time
Process element and time
Above plus:
Continuation of CMMI level sepsis data
Longitudinal data, outcomes, publications
Deeper analytics of outcomes over time
Surveys plus:
3-hour bundle process measures with timestamps

14. Project Targets Q3’15 Q4’15 Q1’16 Q2’16 – Q1’17
80% of hospitals complete current state & readiness assessment
80% of participating units complete readiness steps (tailored to current state of sepsis bundle)
80% of participating units implement sepsis bundle
80% of participating units complete quarterly dissemination surveys
Targets based on current state of sepsis bundle:
Not started / planning:
10% increase in bundle adherence
10% relative reduction in mortality rate
5% decrease in cost of care
In progress:
5% increase in bundle adherence
5% relative reduction in mortality rate
2.5% decrease in cost of care
Sustaining:
Sustain bundle adherence
Sustain performance
Relative rate of improvement
Readiness Track defined as:
Not Started/Planning (or < 20% 3-hour-bundle compliance) - Planning but not piloted or tested any processes
In progress/Started (or 20-40% 3-hour-bundle compliance) - Have piloted sepsis care models
Sustaining (or >40% 3-hour-bundle compliance) - Have implemented a standard model of sepsis care and continued to monitor performance

15. Readiness Tasks for Implementation
Type
Reporting needs
Completed by
Identify the individual local leader for each participating unit
Name
October 26
Core improvement teams established to drive implementation of the Sepsis Care Model. Improvement team to include the following role functions (1) project management, one (1) physician champion, and one (1) quality improvement specialist.
Complete? Yes/No
December 15
Improvement targets have been established according to readiness track.
March 25
Current state and future care model roles and workflows have been defined.
Training and learning capacity has been established using options provided by program office. Options may include, but are not limited to, identification of local trainers, completion of the “train-the-trainer” program, and customization of training curricula.
Tools and templates have been configured using starter kits provided by the program office. Kits may include implementation guides, posters outlining Sepsis Care Model steps, and communication templates.
Anticipated implementation start date per unit
Date
Included as an FYI but will not be addressed in detail during presentation
CONFIDENTIAL - Internal Use Only

16. HVHC Sepsis Bundle Dissemination and Implementation Program: Identifying your team
Role
Representing
Responsibilities
PMO Point of Contact
System level
Distribute quarterly surveys to appropriate respondents
Serves as the primary contact for PMO reporting needs e.g., launch date, progress, changes in participation, escalate risks
Serves as the primary contact for project communications
Clinical champion
System level or hospital level*
Expert clinical knowledge on sepsis
Work with HVHC collaborative experts reviewing evidence and best practices for sepsis care model
Participate on HVHC calls/webinars and conferences
Willing to serve as a resource for other HVHC members seeking information
Project manager
Monitors and maintains project timelines and deliverables
Participates on relevant HVHC sepsis D&I collaborative calls
Data coordinator
Maintains measurement plan
Data collection
Included as an FYI but will not be addressed in detail during presentation
*Due to variations in organizational structures, there may be more than one person in this role at your system.

17. HVHC Sepsis 3-Hour Bundle Dissemination and Implementation Program: Identifying your team
Role
Representing
Responsibilities
Quality improvement or implementation coach
System or hospital*
Provides support for implementation activities using standard methodology at that system/hospital
Adapt implementation plans as needed based on local context
IT Analyst
Adapt EHR clinical decision support tools for sepsis detection and treatment
Training and education
Deploy EHR tools
Site leaders for implementation
Each participating unit
(ED or ICU)
Lead local implementation of sepsis care model
Complete HVHC survey regarding sepsis implementation efforts (anticipated time to complete survey is <10 mins)
Coordinates HVHC-related communications with local team
Included as an FYI but will not be addressed in detail during presentation
*Due to variations in organizational structures, there may be more than one person filling in this role at the system

18. Current State & Readiness Assessments
Distributed in August for a mid-September return
Purpose of these assessments:
Inform the development of a framework and model for rapid wide scale dissemination and implementation
Better understand system/hospital/unit level readiness for implementation of the 3-hour bundle for sepsis
Thank you!!
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19. Quarterly “pulse check” of unit reps
Purpose
Understand adherence at the dissemination level as a proxy for patient level data submission
Obtain more information about what you perceive to be barriers and facilitators to implementation to inform quarterly webinars with the Sepsis Safety Team
Frequency
Quarterly
6 simple questions
Survey respondent
Local unit leader responsible for 3-hour bundle implementation
First survey will come from PMO to Program Leads November 2 for a return by November 16
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20. CONFIDENTIAL - Internal Use Only
Framework request
Please send tools and resources for
sepsis 3-hour bundle implementation to
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21. CONFIDENTIAL - Internal Use Only
HVHC Fall Conference
When: Tuesday, October 27 at 9:30 to 11:30am MST
Agenda:
Sepsis Dissemination/Implementation
Implementation timeline (November 2015 through March of 2017)
Member expectations and readiness tasks
Participating units by member
Website
Quarterly collaborative calls through the Safety Program
Evaluation Plan
Data collection
Site visits
Safety Program Topics (30 minutes)
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22. Upcoming Sepsis Safety Webinars
Quarterly webinars scheduled for:
January 13, 3pm Eastern
April 13, 3pm Eastern
July 13, 3pm Eastern
To join the meeting, go to: To join the AUDIO portion of the meeting, dial: Enter the Meeting ID: followed by the (#) pound sign
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23. CONFIDENTIAL - Internal Use Only