1. Intermountain-led CMS Hospital Engagement Network Preventing Pressure Ulcers March 25, 2014 Affinity Call Marlyn Conti –Patient Safety Coordinator, Intermountain Monica Spencer—NP/ Manager Wound Care, Baylor Scott & White Health Gina Honermann-Garinger—Baylor Scott & White Health Center for Clinical Innovation

2. Outline for Discussion Review of 2013 data through Q4 ‘High performers’ – what are they doing? PfP recommended metrics “Just-one-thing” – updated document 2014 plans for improvement: – Reach out to low performers to provide assistance. – Baylor has called a task force together to review the HAPU policy/procedure and document performance – Intermountain PrU Bundle

3. Overall Progress Through 2013

4. Intermountain HEN 2012-13 submitting Hospitals AHRQ PSI 3 Pressure Ulcers National high performing benchmark (0.25)

5. Intermountain HEN 2012-13 submitting Hospitals AHRQ PSI 3 Pressure Ulcers

6. Intermountain HEN 2012-13 submitting Hospitals HAPU (Prevalence)

8. HEN Pressure Ulcer Measures Metric specification resource manual http://www.henlearner.org/wp- content/uploads/2012/03/HEN_measure_Feb5.pdf http://www.henlearner.org/wp- content/uploads/2012/03/HEN_measure_Feb5.pdf Submission schedule: – May 20, 2014: for data through March 2014

9. HEN Pressure Ulcer Measures PSI 3 SOURCE/DEFINITIONNUMERATORDENOMINATOR Outcome Decubitus ulcer - Adult AHRQ PSI #3 Patients with Stage III, Stage IV or unstageable pressure ulcers Inpatient discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM code of pressure ulcer in any secondary diagnosis field and ICD- 9-CM code of pressure ulcer stage III or IV (or unstageable) in any secondary diagnosis field. ICD-9-CM Pressure ulcer diagnosis codes: 7070 – PRESSURE ULCER 70700 - PRESSURE ULCER, SITE NOS 70701 - PRESSURE ULCER, ELBOW 70702 - PRESSURE ULCER, UPR BACK 70703 - PRESSURE ULCER, LOW BACK 70704 - PRESSURE ULCER, HIP 70705 - PRESSURE ULCER, BUTTOCK 70706 - PRESSURE ULCER, ANKLE 70707 - PRESSURE ULCER, HEEL 70709 - PRESSURE ULCER, SITE NEC ICD-9-CM Pressure ulcer stage diagnosis codes: 70723 - PRESSURE ULCER, STAGE III 70724 - PRESSURE ULCER, STAGE IV 70725 – PRESSURE ULCER, UNTAGEBL All inpatient medical and surgical discharges age 18 years and older defined by specific DRGs or MS-DRGs. EXCLUDE CASES: with length of stay of less than 5 days with principal diagnosis of pressure ulcer or a secondary diagnosis of pressure ulcer present on admission* and a secondary diagnosis of pressure ulcer stage III or IV present on admission MDC 9 (Skin, Subcutaneous Tissue, and Breast) MDC 14 (pregnancy, childbirth, and puerperium) with any diagnosis of hemiplegia, paraplegia, or quadriplegia with any diagnosis of spina bifida or anoxic brain damage with a procedure code for debridement or pedicle graft before or on the same day as the major operating room procedure (surgical cases only) transfer from a hospital (different facility) transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) transfer from another health care facility with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing) * Only for cases that otherwise qualify for the numerator

10. HEN Pressure Ulcer Measures HAPU Prevalence SOURCE/DEFINITION NUMERATORDENOMINATOR Outcome HAPU Prevalence NDNQINDNQI Prevalence Patients with hospital acquired pressure ulcers The total number of patients with a hospital-acquired pressure ulcer. INCLUDE: Stage 1,2,3,4, unstageable and deep tissue injuries. EXCLUDE: Pressure ulcers present on arrival. Number of patients surveyed during the prevalence survey day. INCLUDE: Inpatients, short stay patients, observation patients, and same day surgery patients who receive care on an inpatient unit for all or part of a day. Critical care, step-down, medical, surgical, medical- surgical combined, critical access and rehabilitation inpatient units. Patients of any age on an eligible reporting unit

11. HEN Pressure Ulcer Measures HAPU Prevalence— Stage III & greater SOURCE/DEFINITION NUMERATORDENOMINATOR Outcome HAPU ≥ St3 Prevalence NDNQINDNQI St3 Prevalence Patients with hospital acquired pressure ulcer stage 3 or greater Count of hospital acquired pressure ulcers stage 3 or greater. INCLUDE: Stage 3, 4 injuries. EXCLUDED: Pressure ulcers present on arrival. Number of patients surveyed during the prevalence survey day. INCLUDE: Inpatients, short stay patients, observation patients, and same day surgery patients who receive care on an inpatient unit for all or part of a day. Critical care, step-down, medical, surgical, medical- surgical combined, critical access and rehabilitation inpatient units. Patients of any age on an eligible reporting unit Should we change this to be in-line with the national metric and include stage II and greater?

12. High Performing Hospital Highlight… % Improvement Baylor University Medical Center - actions Hospital Name SUTTER COAST HOSPITAL BAYLOR MEDICAL CENTER AT WAXAHACHIE THE HEART HOSPITAL BAYLOR PLANO DENVER HEALTH MEDICAL CENTER BAYLOR MEDICAL CENTER AT CARROLLTON CALIFORNIA PACIFIC MEDICAL CTR BAYLOR ALL SAINTS MEDICAL CENTER AT FW BAYLOR MEDICAL CENTER AT IRVING BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE BAYLOR MEDICAL CENTER AT GARLAND BAYLOR UNIVERSITY MEDICAL CENTER SUTTER ROSEVILLE MEDICAL CENTER ALTA VIEW HOSPITAL AMERICAN FORK HOSPITAL

13. High Performing Hospital Highlight… Rates Hospital Acquired Pressure Ulcers (Prevalence) Top 10 HOSPITALS ALTA VIEW HOSPITAL OREM COMMUNITY HOSPITAL PARK CITY MEDICAL CENTER THE ORTHOPEDIC SPECIALTY HOSPITAL BEAR RIVER VALLEY HOSPITAL SANPETE VALLEY HOSPITAL - CAH BAYLOR MEDICAL CENTER AT WAXAHACHIE ST PATRICK HOSPITAL HILLCREST BAPTIST MEDICAL CENTER DELTA COMMUNITY MEDICAL CENTER

14. Just One Thing Matrix Recommendations Getting StartedWorking HarderAhead of the Curve Appoint a leadership supported team or work group to drive improvement & education SWAT (or champion) teams that includes unit nurse (moderate-high evidence) Adopt decision algorithms for nursing staff to select appropriate surfaces, physical therapy and dietary referrals (moderate-high evidence) Establish monthly prevalence studies or collect incidence data from electronic medical records, then feed that data back to the SWAT teams (moderate-high evidence)

15. Intermountain Pressure Ulcer Bundle

16. Getting Started Access Available Tool Kits Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care http://www.ahrq.gov/resear ch/ltc/pressureulcertoolkit/ http://www.ahrq.gov/resear ch/ltc/pressureulcertoolkit/ National Pressure Ulcer Advisory Panel http://www.npuap.org/ http://www.npuap.org/ http://www.Henlearner.org AHRQ PSNet http://www.psnet.ahrq.g ov/ http://www.psnet.ahrq.g ov/ AHRQ Web M&M http://www.webmm.ahrq.gov/ http://www.webmm.ahrq.gov/ AHRQ Health Care Innovations Exchange http://www.innovations.a hrq.gov/ http://www.innovations.a hrq.gov/ Getting Started

17. 2014 plans for improvement Reach out to low performers to provide assistance. Baylor has called a task force together to review the HAPU policy/procedure and document performance Intermountain PrU Bundle Collect and share best practices across our network hospitals & system in a single document