Introduction to the Hospital Engagement Network (HEN)

Introduction to the Hospital Engagement Network (HEN)
IHA 4/21/2017 Introduction to the Hospital Engagement Network (HEN) February 21, 2014 Sara Bader and Adam Kohlrus

WELCOME NEW HENs!!! We’re Glad You Decided to Join!
Objectives for the hour Review Origins of the Hospital Engagement Network and Illinois program and progress AHA/HRET HEN overall goals AHA/HRET IHA Program support Comprehensive Data System (CDS) Website and Listserv IHA HEN Coaches Improvement Leader Fellowship Education and certification State of the AHA/HRET Illinois HEN Measure alignment Eliminating Harm Across the Board

Partnership for Patients

Overview – HEN Partnership – IHA & HRET/CMS
1600 hospitals in 31 states Original 2 year program, ending December 31, 2013 Optional 3rd year goals, continue work of the first 2 years Reduce harm by 40% - (CLABSI, CAUTI, SSI, VTE, ADE, Falls, OB Harm, EED, PU, VAP) Reduce readmissions by 20% Equip hospitals with leadership, change management, facilitation, quality improvement & teamwork skills Focus on improving the safety culture Provide option to report/track on 7 new areas of harm

Illinois HEN 2014 70 hospitals +
Option year new members – 16 and counting… Enhanced focus on: Improvement Data Submission Measure Alignment Pay for performance

Overview – HEN Partnership – IHA & HRET
Partnership for Patients funded resources Help to identify HAC’s in need of intensive & moderate support 3 levels of improvement activity at the HRET level Stand-alone webinars – Boot Camps (Intensives) Coaching calls Improvement Leader Fellowships 3 levels: Junior, Senior, and Champion An improvement leader at every hospital

Overview – HEN Partnership for Patients funded resources
Partnership – IHA & HRET Partnership for Patients funded resources Topic specific toolkits, guidelines & checklists, including new optional areas (upcoming in 2014) Ongoing access to subject matter experts in all 10 areas Intensive support for hospitals or regions with significant challenges Targeted interventions for specific hospital types (children’s, LTACH, psychiatric)

HRET/HEN Website http://www.hret-hen.org/
Resources and tools for the ten focus areas (webinars, podcasts, toolkits, and links to other helpful information) Registration required for membership access

Overview – HEN Partnership for Patients funded resources
Dedicated program website where all calls and webinars will be archived along with written material and important links LISTSERVs® and monthly Harm Across the Board Reports – New 2014

Join the AHA/HRET HEN LISTSERV® Please and request to be added to the LISTSERV® . Put the name of the HAC you would like to be added to in the Subject line. Please allow 3-5 business days for your request to be processed. Please note this is a closed LISTSERV® and your hospital needs to be signed up with the AHA/HRET HEN to participate.

HEN Performance Target for 2014: 40% Reduction in Harm-20% Readmissions
40 percent reduction in 10 harm topics with over 80 percent of hospitals reporting data In order to achieve these goals we will utilize data from COMPdata but we also need your commitment to confer rights from NHSN and submit data on ADE, EED and Falls

2014 Level of Individual Hospital Progress on Meeting HEN Goals

4/21/2017 Overview – HEN Partnership – IHA & HRET Partnership for Patients funded resources Data collection and progress monitoring & support Encyclopedia of Measures (EOM) Selection of measures that minimize data collection burden Comprehensive Data System (CDS) secure, web-based data collection system. Users must have a connection to the Internet and a browser which supports SSL (secure socket layer) encryption. 1000’s of registered users with majority of hospitals submitting data on at least one measure

Encyclopedia of Metrics-EOM

Data Review-Hospital Responsibilities

Overview – HEN IHA Illinois HEN Data Plan & Data Alignment
ADE - hospital CAUTI - IHA COMPdata, NHSN CLABSI - IHA COMPdata, NHSN Falls - IHA COMPdata, hospital OB/EED - IHA COMPdata, hospital (EED data) PU - IHA COMPdata Readmission – IHA Database SSI - IHA COMPdata, NHSN VAP - IHA COMPdata, NHSN VTE - IHA COMPdata, NHSN

1) Adverse drug events (Hospital) 2) Elimination of Early Elective Deliveries (Hospital) 3) Falls with injury (Hospital) 4) CLABSI (NHSN) 5) CAUTI (NHSN) 6) SSI (NHSN) 7) VAP (NHSN)

Comprehensive Data System-CDS

HEN Dashboard

Data Submission and Alignment
Renewed emphasis and incentives on data submission and measurement alignment HRET has emphasized the alignment of specific measures Submission of outcome metrics on the following HACs are imperative in 2014: -ADE -EED -Falls Conferring rights to NHSN-host of new metrics HRET is seeking Work as a team to share data mining techniques

2014 Additional Topics Education on other topics: - Sepsis - MRSA
These topics will not have a data reporting component, but there will be educational events offered on the following topics: - Sepsis MRSA - C-diff Acute renal failure - Procedural harm Expanded focus on Healthcare Disparities : HRET will be hosting webinars focusing on diversity, cultural competency and data collection and use

2014 HEN Commitments Data Participation Submission of ADE Measures
Anticoagulation Hypoglycemia Opioids Submission of EED data Submission of Falls data Conferring Rights in NHSN as applicable (CAUTI, CLABSI, VAP/VAE, SSI) PEFL Survey Completion of Harm Across the Board Template(s) Attendance at Statewide Workshops Completion of at least 2 Site Visits Participation in Improvement Leader Fellowship Webinar attendance

Grace and Poise Under Pressure
IHA HEN Team Coaches: Marie Cleary-Fishman Adam Kohlrus Sara Bader Teresa Baumgartner Mary Stankos AKA: Disney Princess Grace and Poise Under Pressure AKA: Superman All Things Data AKA: The Brain Smart and Fast AKA: Pollyanna Quick with Answers AKA: The Newbie Determined To Help

HEN Coaches IHA IHA HEN Coach
4/21/2017 HEN Coaches IHA IHA HEN Coach Each hospital will have a primary HEN staff member assigned to them who will act as your “point person” You may direct any questions, concerns or any HEN related activity through your point person They will be acting as your mentoring coach and will work with you as you plan your implementation, monitor your progress and move forward throughout the initiative Two coaching site visits are planned for 2014, one visit prior to June 30 and the second prior to November 30 Quality team and leaders are expected to participate

Weekly Update IHA Sent out each Friday IHA P4P HEN Weekly Update
Upcoming Events (webinars, workshops, etc.) Hospital Highlights Reminders Other resources to help you

Statewide Workshops Goal : to leave the meeting with a set plan of action and necessary tools to achieve the 40%/20% targets 4 Upcoming workshops in Springfield and Naperville -February 19th and 21th -May 22th and 23rd -September 18th and 19th -November 20th and 21st -HRET Improvement Leader Fellowship

Eliminating Harm Across the Board
Must complete Eliminating Harm Across the Board (HAB) template Utilization of the Improvement Calculator Story Board of who you are, where you are, what action you have taken, what you’ve learned, and what opportunities do you see Monthly, single HAC focused HAB update submitted via the listserv Expectations for transparency

Harm Across the Board (HAB): Monthly Update
Hospital: ________________ State: ______ Month: _________

Opportunities in the HEN 2014
CPHQ Certification CPPS Certification Quality Boot Camp ABQUARP Certification for physicians IHI NPSF Conference Regional SWW

Opportunities Under Consideration in 2014
CIC Certification Advanced Quality Boot Camp TEAMSTEPPS Planetree-Making Patient-Centered Care a Reality-Online Nursing Course High Reliability Organizations

Hospital Engagement Network: Questions?

HEN: 2014 Priorities, Expectations and Opportunities
IHA 4/21/2017 HEN: 2014 Priorities, Expectations and Opportunities Marie Cleary-Fishman, Sara Bader, Adam Kohlrus February 19, 2013

Agenda HEN Overview 2014 Data and Performance 2014 Commitments
2014 Illinois HEN Scoring Leadership for a New Era: Adding Harm Across the Board to your Toolkit 2014 Harm Across The Board 2014 Improvement Leader Fellowship

HEN Performance 2013: /6/60

2014 Hospital Level Progress Report

5 Things you need to know in 2014
1. The 40/20 goal is here… 2. Renewed emphasis and incentives on data submission and measurement alignment 3. Your participation and engagement will drive funding-Pay for Performance 4. Monetary incentives exist if data commitments are met 5. IHA is instituting a value-based scoring system which will determine your invitation to IHI and overall performance in 2014

2014 Calendar 2014 SWW #1-February 19th (Springfield) and 21st (Naperville) 2014 SWW #2-May 15th (Naperville) 2014 SWW #3-September 18th (Springfield) and 19th (Naperville) 2014 SWW #4-November 20th (Springfield) and 21st (Naperville) HRET In Person Fellowship Meeting (Naperville)-TBA

2014 Opportunities QHR 3rd Annual New Quality Director Boot Camp-May 19-23rd Advanced Quality Director Boot Camp to be offered as well TeamSTEPPS-TBD CPHQ Certification-TBA CPPS Certification-TBA CIC Certification-TBD

HEN: 2014 Data and Performance
IHA 4/21/2017 HEN: 2014 Data and Performance Marie Cleary-Fishman, Sara Bader, Adam Kohlrus February 19, 2013

HEN Performance 2014: ACT Data Scoring Criteria
CMS has implemented a scoring criteria to determine the success of each state from a data reporting and improvement perspective. This criteria is comprised of 3 elements. Element 1: Measure Alignment with PfP 40/20 Goals -(Points awarded for meeting measure alignment for at least 30 percent of hospitals) Element 2: Completeness of Data -(Points awarded for level of reporting: 70 percent, 80 percent) Element 3: Measure Trends and Meeting Benchmark -(Points awarded based on improvement) ACT SCORE ELEMENTS (A = alignment with 40/20 goals, C = completeness of data, T = trend or benchmark)

AHA State ACT: Illinois, December 2013
AHA State ACT and PEPL Report: Illinois, December 2013 ACT SCORE ELEMENTS (A = alignment with 40/20 goals, C = completeness of data, T = trend or benchmark) Score Component ADE CAUTI CLABSI Falls OB-EED OB-Oth PrU SSI VAP VTE Readm Points Earned Maximum Possible Points Element 1: Measure Alignment with PfP 40/20 Goals (Points awarded for meeting measure alignment for at least 30 percent of hospitals) 1 2 7 22 Element 2: Completeness of Data (Points awarded for level of reporting in the AEA: 70 percent, 80 percent, or 80 percent and measure alignment (at least 1 point) in the AEA) 0.5 1.5 15 Percent reporting outcome data across AEA 9% 68% 98% 99% 78% Element 3: Measure Trends and Meeting Benchmark (Points awarded based on measure with highest improvement in the AEA and at least 60 percent reporting, as well as considering improvement occurring during PfP period of work) 3 4 16 44 Bonus: At least one measure meets all trend criteria (overall improvement, recent improvement, measure quality) AND currently meets benchmark Yes 2 11

Illinois Compared to HRET HEN and PfP Average
Score Type PfP HRET HEN Illinois ACT Points (rescaled to 100) 41 43 ACT Bonus (max=11) 1 2 ACT Score 52 45

COMPdata Metrics Uploaded to CDS
IHA/HRET Hospital Engagement Network Outcome Measures Supplied by IHA to HRET/CDS Num Category New 2014 TITLE EOM/CDS Reference Number NUMERATOR DENOMINATOR SOURCE 1 ADE Adverse Drug Event - Manifestations of Poor Glycemic Control EOM-ADE-110 ICD-9 Diagnosis code: , , 251.0, , All Patients CMS HAC 2 CAUTI Catheter-Associated Urinary Tract Infection IL-CAUTI-2-1 ICD-9 Diagnosis code: 3 CLABSI Central Line-Associated Bloodstream Infection IL-CLABSI-3-1 ICD-9 Diagnosis code: , CMS HAC (bloodstream infections only, does not include local infections [999.33]) 4 FALLS Falls & Trauma EOM-FALLS-39 ICD-9 Diagnosis code (must also be on CMS CC or MCC list): , , , , , 5 OB OB Trauma - Vaginal Delivery with Instrument (AHRQ PSI 18) EOM-OB-54 All vaginal delivery with instrument and 3rd and 4th degree OB trauma ICD-9-CM Obstetric trauma diagnosis codes: DEL W 3 DEG LACERAT-UNSP; DEL W 3 DEG LACERAT-DEL; DEL W 3 DEG LAC-POSTPART; TRAUMA TO PERINEUM AND VULVA DURING DELIVERY, FOURTH-DEGREE PERINEAL LACERATION; TRAUMA TO PERINEUM AND VULVA DURING DELIVERY, FOURTH-DEGREE PERINEAL LACERATION; TRAUMA TO PERINEUM AND VULVA DURING DELIVERY, FOURTH-DEGREE PERINEAL LACERATION All vaginal delivery discharges with any procedure code for instrument-assisted delivery. (see source document for specific codes) AHRQ QI - PSI 18 Data will be uploaded to HRET/CDS no later than one week after the close of the calendar quarter

No hospital specific data will ever be sent to CMS
CMS Special: Illinois HEN State-Wide Burrito loaded with extra data and improvement ILLINOIS

ADE: Data Reporting Currently at zero in elements 1/2/3
AHA State ACT and PEPL Report: Illinois, December 2013 ACT SCORE ELEMENTS (A = alignment with 40/20 goals, C = completeness of data, T = trend or benchmark) Score Component ADE CAUTI CLABSI Falls OB-EED OB-Oth PrU SSI VAP VTE Readm Points Earned Maximum Possible Points Element 1: Measure Alignment with PfP 40/20 Goals (Points awarded for meeting measure alignment for at least 30 percent of hospitals) 1 2 7 22 Element 2: Completeness of Data (Points awarded for level of reporting in the AEA: 70 percent, 80 percent, or 80 percent and measure alignment (at least 1 point) in the AEA) 0.5 1.5 15 Percent reporting outcome data across AEA 9% 68% 98% 99% 78% Element 3: Measure Trends and Meeting Benchmark (Points awarded based on measure with highest improvement in the AEA and at least 60 percent reporting, as well as considering improvement occurring during PfP period of work) 3 4 16 44 Currently at zero in elements 1/2/3 Only 9% of hospitals reporting ADE metrics Hypoglycemia/Anticoagulation/Opioid

Aligned Measures-ADE Manifestations of Poor Glycemic Control (ADE HAC) will still not be accepted by CMS. ADE continues to have the lowest data submission. ADE is a key target area for IHA, AHA/HRET, CMS. Hospitals will need to collect and report all three measures into the AHA/HRET CDS.

Aligned Measures-ADE Current Top Two Most Popular Measures New Measure
Focus and report on all three measures

Results: ADE Improvement: -7.25% n=5 (7.35%)

EED: Data Reporting AHA State ACT and PEPL Report: Illinois, December 2013 ACT SCORE ELEMENTS (A = alignment with 40/20 goals, C = completeness of data, T = trend or benchmark) Score Component ADE CAUTI CLABSI Falls OB-EED OB-Oth PrU SSI VAP VTE Readm Points Earned Maximum Possible Points Element 1: Measure Alignment with PfP 40/20 Goals (Points awarded for meeting measure alignment for at least 30 percent of hospitals) 1 2 7 22 Element 2: Completeness of Data (Points awarded for level of reporting in the AEA: 70 percent, 80 percent, or 80 percent and measure alignment (at least 1 point) in the AEA) 0.5 1.5 15 Percent reporting outcome data across AEA 9% 68% 98% 99% 78% Element 3: Measure Trends and Meeting Benchmark (Points awarded based on measure with highest improvement in the AEA and at least 60 percent reporting, as well as considering improvement occurring during PfP period of work) 3 4 16 44 Currently at 2 points (element 1), 1 point (element 2) and 3 points (element 3) Only 78% of hospitals reporting EED metric Continuous reporting is essential

Aligned Measures-EED Current Most Popular Measure
Hospitals will need to enter data into AHA/HRET CDS for EED or provide data to IHA for upload.

Results: EED Improvement: 74.46% n=38 (77.5%)

Falls: Data Reporting AHA State ACT and PEPL Report: Illinois, December 2013 ACT SCORE ELEMENTS (A = alignment with 40/20 goals, C = completeness of data, T = trend or benchmark) Score Component ADE CAUTI CLABSI Falls OB-EED OB-Oth PrU SSI VAP VTE Readm Points Earned Maximum Possible Points Element 1: Measure Alignment with PfP 40/20 Goals (Points awarded for meeting measure alignment for at least 30 percent of hospitals) 1 2 7 22 Element 2: Completeness of Data (Points awarded for level of reporting in the AEA: 70 percent, 80 percent, or 80 percent and measure alignment (at least 1 point) in the AEA) 0.5 1.5 15 Percent reporting outcome data across AEA 9% 68% 98% 99% 78% Element 3: Measure Trends and Meeting Benchmark (Points awarded based on measure with highest improvement in the AEA and at least 60 percent reporting, as well as considering improvement occurring during PfP period of work) 3 4 16 44 Currently at 0 points (element 1), 1.5 point (element 2) and 0 points (element 3) Have over 80% reporting EOM 37 or 38 to ramp up element 2 and 3

Aligned Measures-Falls
Current Top Two Most Popular Measures EOM 37 & EOM 38 Hospitals will need to collect and report at least one measure into the AHA/HRET CDS. IHA considers EOM-Fall-38 Falls with Injury the priority measure. The CMS falls HAC measure will not be accepted by CMS.

Aligned Measures-Falls
Definition Numerator Denominator Source Falls With or Without Injury (NSC 4) All documented falls, with or without injury, experienced by patients Number of patient falls, with or without injury to the patient. A patient fall is an unplanned descent to the floor (or extension of the floor, e.g., trash can or other equipment) with or without injury to the patient, and occurs on an eligible reporting nurse unit. All types of falls are to be included whether they result from psychological reasons (fainting) or environmental reasons (slippery floor). Include assisted falls-when a staff member attempts to minimize the impact of the fall Patient days included populations: Inpatients, short stay patients, observation patients and same day surgery patients who receive care on eligible inpatient units for all or part of a day. Adult critical care, step-down, medical, surgical, medical-surgical combined units. Any age patient on an eligible reporting unit is included in the patient day count. NQF NSC 4 Falls With Injury (Minor or Greater) (NSC 5) All documented patient falls with an injury level of minor or greater Total number of patient falls of injury level minor or greater (whether or not assisted by a staff member) during the calendar month Adult critical care, step-down, medical, surgical, medical-surgical combined, critical access and adult rehabilitation inpatient units.

Results: Falls Improvement: % n=68 (98.5%)

HEN Performance 2014: Data Reporting
AHA State ACT and PEPL Report: Illinois, December 2013 ACT SCORE ELEMENTS (A = alignment with 40/20 goals, C = completeness of data, T = trend or benchmark) Score Component ADE CAUTI CLABSI Falls OB-EED OB-Oth PrU SSI VAP VTE Readm Points Earned Maximum Possible Points Element 1: Measure Alignment with PfP 40/20 Goals (Points awarded for meeting measure alignment for at least 30 percent of hospitals) 1 2 7 22 Element 2: Completeness of Data (Points awarded for level of reporting in the AEA: 70 percent, 80 percent, or 80 percent and measure alignment (at least 1 point) in the AEA) 0.5 1.5 15 Percent reporting outcome data across AEA 9% 68% 98% 99% 78% Element 3: Measure Trends and Meeting Benchmark (Points awarded based on measure with highest improvement in the AEA and at least 60 percent reporting, as well as considering improvement occurring during PfP period of work) 3 4 16 44 NHSN (CAUTI-CLABSI-SSI-VAE) We are asking that you confer “all data” If you have already conferred rights we ask that you go back and make sure that you have conferred all data

Aligned Measures-CAUTI
Current Top Two Most Popular Measures New Measures Focus and report on EOM-18, EOM-19 and utilization ratio Strongly encourage a focus to reduce catheter insertion in the ED

Results: CAUTI Improvement: 1.51% n=68 (98%)

Aligned Measures-CLABSI
Current Top Two Most Popular Measures New Measure Hospitals will continue to confer rights to NHSN and expand data entry beyond the ICU. For larger hospitals, a utilization ratio (EOM-122) is encouraged.

Results: CLABSI Improvement: 54.18% n=64 (100%)

Aligned Measures-SSI Current Top Two Most Popular Measures
Expanding to more Surgical Classes through COMPdata Hospitals need to continue to confer rights in NHSN for two measures listed above.

Results: SSI Improvement: % n=67 (100%)

Aligned Measures-VAP 6 Measures within NHSN-All Units/ICU Measure
Definition Numerator Denominator Source VAC Rate-All Units (CDC NHSN) EOM-96a Ventilator-Associated Condition (VAC); including those that meet the criteria for IVAC and Possible/ Probable VAP rate Number of events that meet the criteria of VAC; including those that meet the criteria for IVAC and Possible/Probable VAP Number of ventilator days CDC NHSN IVAC EOM-96b Infection-Related Ventilator-Associated Condition (IVAC); including those that meet the criteria for Possible/Probable VAP rate Number of events that meet the criteria of IVAC; including those that meet the criteria for Possible/ Probable VAP VAP EOM-96c Pneumonias that are ventilator-associated Ventilator-associated pneumonia rate (Incidence of VAP) Number of ventilator days (collected daily)

Aligned Measures-VAP ICU Measures Measure Definition Numerator
Denominator Source VAC Rate-All ICU Units (CDC NHSN) Ventilator-Associated Condition (VAC) in ICU Units; including those that meet the criteria for IVAC and Possible/ Probable VAP rate Number of events that meet the criteria of VAC in ICU Units; including those that meet the criteria for IVAC and Possible/Probable VAP Number of ventilator days in the ICU CDC NHSN VAE IVAC Rate-All ICU Units (CDC NHSN) Infection-Related Ventilator-Associated Condition (IVAC) in ICU Units; including those that meet the criteria for Possible/Probable VAP rate Number of events that meet the criteria of IVAC in ICU Units; including those that meet the criteria for Possible/ Probable VAP Possible/Probable VAP Rate-All ICU Units (CDC NHSN) Possible/Probable VAP in ICU Units rate Number of events that meet the criteria of Possible/Probable VAP in ICU Units

Results: VAP Improvement: 48.91% n=63 (100%)

1) Adverse drug events (Hospital) 2) Elimination of Early Elective Deliveries (Hospital) 3) Falls with injury (Hospital) 4) CLABSI (NHSN) 5) CAUTI (NHSN) 6) SSI (NHSN) 7) VAP (NHSN)

Results: OB Adverse Events
Improvement: 18.62% n=49 (100%)

Results: Pressure Ulcers
Improvement: 28.68% n=68 (98.5%)

Results: VTE Improvement: 16.34% n=68 (98.5%)

Results: Readmissions
Improvement: 4.03% n=68 (98.5%)

HEN Performance

2014 Additional Topics Education on other topics: - Sepsis - MRSA
These topics will not have a data reporting component, but there will be educational events offered on the following topics: - Sepsis MRSA - C-diff Acute renal failure - Procedural harm Expanded focus on Healthcare Disparities : HRET will be hosting webinars focusing on diversity, cultural competency and data collection and use

CDS Upgrades Upgraded CDS technology so users can access CDS with Internet Explorer 10 (and 11!), as well as Google Chrome and Mozilla Firefox Updated the Individual Measure and Measure Comparison reports so that drop-downs only include those hospitals, topics, and measures for which data have been submitted! Updated the Resource section to eliminate download issues

CDS Enhancements In Progress
NEW report – Individual Measure with Trendline NEW report – Measure Comparison report with State & Project Median (EOM and State defined measures only) New Measures for core sub-topics and expanded topics Days Between Data Entry and Reports Data Submission Status Reports

Measure Comparison report

Individual Measure with Trendline

IHA 4/21/2017

HEN: 2014 Commitments Marie Cleary-Fishman, Sara Bader, Adam Kohlrus
IHA 4/21/2017 HEN: 2014 Commitments Marie Cleary-Fishman, Sara Bader, Adam Kohlrus February 19, 2013

2014 HEN Commitments Data Participation Submission of ADE Measures
Anticoagulation Hypoglycemia Opiods Submission of EED data Submission of Falls data Conferring Rights in NHSN (CAUTI, CLABSI, VAP/VAE, SSI) PFE/Leadership Survey Attendance at Statewide Workshops Completion of Harm Across the Board Template(s) Completion of at least 2 Site Visits Participation in Improvement Leader Fellowship Webinar attendance

Data Commitments COMMITMENT: ADE data submission
On a monthly/quarterly basis submission of: Excessive Anticoagulation with Warfarin – inpatients (EOM-12); and Hypoglycemia in inpatients receiving insulin (EOM-13); and ADEs due to opioids (EOM-111)

Data Commitments COMMITMENT: EED Data Submission
On a monthly/quarterly basis submission of: Elective Deliveries at >=37 Weeks and <39 Weeks (JC PC 1) (EOM-40)

Data Commitments COMMITMENT: Falls data submission
On a monthly/quarterly basis submission of: Falls With or Without Injury (NSC 4) (EOM-37); or Falls With Injury (Minor or Greater) (NSC 5) (EOM-38)

Data Commitments COMMITMENT: Confer Rights in NHSN
Confer rights to AHA/HRET HEN for CAUTI, CLABSI, VAE/VAP and SSI by March 31, 2014.

Data Commitments COMMITMENT: Completion of PFE/Leadership Survey
Complete the Patient and Family Engagement and Leadership Survey Questionnaire at least quarterly or as change to your systems are made.

Participation Commitments
COMMITMENT: Statewide Workshop Attendance Attendance by at least 1 staff member at 3 out of 4 Illinois Statewide Workshops.

COMMITMENT: Submission of HAB Template Submission of at least one HAB Template by May 1, Regular submission thereafter of updated template as reduction of harm across the board occurs. IHA will help with the data components of the HAB templates

COMMITMENT: Participation in at least 2 site visits with HEN Coach and hospital teams. Target: 1st visit March – June; 2nd visit August -November. Invite senior leadership, topic leads, front line staff, etc.

COMMITMENT: Improvement Leader Fellowship Active participation by at least one fellow from each hospital (webinar participation, pre-work, sharing, etc.) Attendance by fellows at in-person fellowship

COMMITMENT: Webinar Participation Regular participation in topic specific webinars, virtual boot camps, etc. Opportunities to present and share your story

Scoring System We will be offering a limited number of places to the IHI Summit in Orlando. To determine who will go, we are developing a scoring system based on the 2014 goals. We want your input!

2014 HEN Commitments: SCORING
Data Participation Submission of ADE Measures Anticoagulation Hypoglycemia Opioids Submission of EED data Submission of Falls data Conferring Rights in NHSN (CAUTI, CLABSI, VAP/VAE, SSI) PFE/Leadership Survey TOTAL POINTS AVAILABLE: 59 Attendance at Statewide Workshops Completion of Harm Across the Board Template(s) Completion of at least 2 Site Visits Participation in Improvement Leader Fellowship Webinar attendance TOTAL POINTS AVAILABLE: 59

TOTAL POINTS AVAILABLE: 30
Data Commitments COMMITMENT: ADE data submission On a monthly/quarterly basis submission of: Excessive Anticoagulation with Warfarin – inpatients (EOM-12); and 1 Point x 10 Months = 10 Points Hypoglycemia in inpatients receiving insulin (EOM-13); and 1 Point x 10 Months = 10 Points ADEs due to opioids (EOM-111) 1 Point x 10 Months = 10 Points TOTAL POINTS AVAILABLE: 30

Data Commitments COMMITMENT: EED Data Submission On a monthly/quarterly basis submission of: Elective Deliveries at >=37 Weeks and <39 Weeks (JC PC 1) (EOM-40) 1 Point x 10 Months = 10 Points TOTAL POINTS AVAILABLE: 10

Data Commitments COMMITMENT: Falls data submission On a monthly/quarterly basis submission of: Falls With or Without Injury (NSC 4) (EOM-37); or Falls With Injury (Minor or Greater) (NSC 5) (EOM-38) 1 Point x 10 Months = 10 Points TOTAL POINTS AVAILABLE: 10

Data Commitments COMMITMENT: Confer Rights in NHSN Confer rights to AHA/HRET HEN for CAUTI, CLABSI, VAE/VAP and SSI by March 31, 2014. TOTAL POINTS AVAILABLE: 5

Data Commitments COMMITMENT: Completion of PFE/Leadership Survey Complete the Patient and Family Engagement and Leadership Survey Questionnaire at least quarterly or as change to your systems are made. 1 Point x 4 Quarters = 4 Points TOTAL POINTS AVAILABLE: 4

COMMITMENT: Statewide Workshop Attendance Attendance by at least 1 staff member at 3 out of 4 Illinois Statewide Workshops. 3 Points per Workshop TOTAL POINTS AVAILABLE: 12

COMMITMENT: Submission of HAB Template Submission of at least one HAB Template by May 1, Regular submission thereafter of updated template as reduction of harm across the board occurs. 5 Points for first HAB + 2 Points if submitted by May Point for each additional HAB submitted monthly thereafter IHA will help with the data components of the HAB templates TOTAL POINTS AVAILABLE: 16

COMMITMENT: Participation in at least 2 site visits with HEN Coach and hospital teams. Target: 1st visit March – June; 2nd visit August -November. Invite senior leadership, topic leads, front line staff, etc. 5 Points per Visit TOTAL POINTS AVAILABLE: 10

COMMITMENT: Improvement Leader Fellowship Active participation by at least one fellow from each hospital (webinar participation, pre-work, sharing, etc.) 1 Point for each event x 8 events = 8 Points Attendance by fellows at in-person fellowship 3 Points TOTAL POINTS AVAILABLE: 11

COMMITMENT: Webinar Participation Regular participation in topic specific webinars, virtual boot camps, etc. 1 Point per month x 10 months = 10 Points Opportunities to present and share your story Bonus Points! TOTAL POINTS AVAILABLE: 10

Bonus Points There will be an opportunity to gain “bonus points” throughout the year Presenting on webinars/in person events Completion of a Case Study Others to be announced

Data Participation Submission of ADE Measures 30 Anticoagulation 10 Hypoglycemia 10 Opioids 10 Submission of EED data 10 Submission of Falls data 10 Conferring Rights in NHSN (CAUTI, CLABSI, VAP/VAE, SSI) 5 PFE/Leadership Survey 4 TOTAL POINTS AVAILABLE: 59 Attendance at Statewide Workshops 12 Completion of Harm Across the Board Template(s) 16 Completion of at least 2 Site Visits 10 Participation in Improvement Leader Fellowship 11 Webinar attendance 10 TOTAL POINTS AVAILABLE: 59

Thoughts, Suggestions, Comments, Questions?

Leadership for a New Era: Adding Harm Across the Board to your Toolkit
Presentation to Illinois Hospital Association Partnership for Patients February 19, 2014 Jackie Conrad RN, BSN, MBS Improvement Advisor Cynosure Health

Moving from Micro Many pieces Topic related strategies & teams
Competing priorities Silos

Many Pieces

To Macro Big Picture Cross Cutting Strategies Cultural Transformation
Unified Approach to Safety Population Health

One vision, one goal

How do we make the shift? Transformational Leadership
Transparency Innovation Empowerment Culture of Safety Blame free Systems Approach Reporting Learning Environment Story Telling Motivate Teach Change

Leadership Old, Traditional New, Transformational Top Down Linear
Command and control Do more with less Code of silence around errors Data not shared Risk averse, conservative Focus on planning large scale projects Bottom up Dynamic Influence and inspire Do more with many Learn from errors Transparency Creative, Innovative Focus on small scale execution

Will → Ideas → Execution
So How Do We Do This? Will → Ideas → Execution

Execution

Group Exercise

Table Talk In your organization, where is your greatest strength
Transparency Innovation Empowerment How do you use this strength in your efforts to reduce or eliminate harm?

Culture is Key

Bricklayer #1: “Putting one brick on top of another.”

Bricklayer #2 “Building a wall for the west side of a church”

Bricklayer #3 “Creating a cathedral that will stand for centuries and inspire people to do great deeds”

How do you Grow a Culture?

Belonging Something BIG “I” make a difference Meaningful Journey

What is Culture? Shared values about what is important
Beliefs about how things operate within the organization How these beliefs interact with unit and organizational structures and systems All of which produce behavioral norms. Singer, HRET, 2008

What is Culture? These principles highlight the key interaction of
personal interpersonal work unit and organizational contributions in forming shared basic assumptions that individuals within organizations develop over time.

Let’s Simplify WHAT IS CULTURE?

What is Culture? “How we do things here.”

How can we change how we do things to make care safer?

What does the Literature Tell Us?
↑ safety culture ↓ safety events ↑ teamwork ↓ falls with injury ↑ work climate (ICU’s) ↓ occupational injury ↑ safety culture (ICU’s) ↓ length of stay ↓ readmissions (AMI,HF)

What are the Key Components?
A just culture A reporting culture A learning culture

Story Telling Using Harm Across the Board to tell your hospital story of Harm Reduction

ISMP Sept 2011 “Compelling stories draw attention to problems and encourage people to act” “exposing humanity in stories serves as a catalyst for change” “story telling is a way to inspire and sustain culture change” “no matter how powerful the data, there is nothing more powerful than a story to motivate, teach, change”

Story Telling to Build Culture
Data tells a story Patient experiences tell a story

What story do you want to tell?

A new way of looking at harm data
Or This? A new way of looking at harm data Harm Across the Board

Number of Patients Harmed per Quarter
1 CAUTI 1 Fall 1 SSI 3 EEDs 2 EEDs 3 EEDs

Targeting Zero Harm: From 2
Targeting Zero Harm: From 2.25 to 2 Harms per Month (CY2012 compared to CYTD 2013)

Why Change? The idea of “all harms” or “harm across the board” helps shift organizational culture What Else?

Harm Across the Board Looks at a composite of all harms
Total Harm – includes all HACs and Readmissions Harm Across the Board – includes all HACs, Readmissions excluded Harm per Discharge – uses discharges as the denominator for all HACs

Improving Harm Rates (per discharge)
HACs Baseline Rate CY 2011 Target Rate 40/20 Goal Current Rate 1-2Q 2013 Improvement Status (scale) ADE 0.005 0.003 IDEAL CAUTI AT TARGET CLABSI Falls with Injury 0.0118 0.0071 0.0032 OB AE Pr Ulcer SSI 0.0067 0.004 VTE EED 0.0303 0.0182 Total 0.0588 0.0353 0.0062 Readmit 0.0571 0.0457 0.0421 Where was the greatest opportunity during the baseline period?

What is this story?

Our Hospital Risk Score Card
Our Safety Mandate Annual Volume (Discharges) 526 Total risk: annual harm opportunities 2305 Risks per patients (Total Opportunities)/Discharges) 4.38 Number of Risk Areas Number of PfP Risk Areas Applicable (0 – 11) 9 Number of PfP Risk Areas Applicable & Adopted Our Progress Number of PfP Areas with Major Improvement Opportunity 1 Number of PfP Areas at Improvement Target 2 Number of PfP Areas at IDEAL 6 What is the story on this slide?

4-5 Risks for Harm per Discharge

Discussion STEP 1 - Get up and introduce yourself to someone you don’t know. STEP 2 – Interview each other to find out: How can you use harm across the board in your organization to tell your hospital’s story? Who would be motivated by the information? How can you personalize the message to promote contemplation and reflection? What message about your culture would HAB reporting send to your staff, leaders and physicians?

Wrap Up, Next Steps

Contact Information Jackie Conrad RN, BSN, MBA Improvement Advisor Cynosure Health

Harm Across the Board

What is the HAB Report? The Centers for Medicare and Medicaid Services (CMS) / the National Content Developer (NCD) introduced the Eliminating the HAB Report last year, as a Partnership for Patients (PfP) tool to understand overall harm at each hospital participating in the American Hospital Association (AHA)/Health Research & Educational Trust (HRET) Hospital Engagement Network (HEN). Last year, we piloted this tool in the second half of the year at the National Quality and Safety Roadmap Meeting (in San Diego), and received over one hundred Eliminating HAB Reports. This year, in the spirit of quality improvement and to further our journey to make patient care safer, we are replacing the submission of monthly progress reports with monthly Eliminating HAB reports. The previous version of the Eliminating HAB Reports were extremely lengthy (e.g. 15 slides); we have PDSA’ed this process to the “Top 7 Key Slides” needed to understand how you are eliminating harm.

HAB-WIFM? Harm Across the Board-What’s in It For Me?
We strongly believe that these reports will: – Help shift your organizational culture; – Put a face on harm; – Tell a compelling story to support change; – Promote transparency; – Help you track your overall harm per discharge, which in turn will help your team see where your greatest opportunity is in eliminating harm; and – Tie all aspects of your HEN work together

Slide 1 Improving Harm Across the Board Insert your Team Motto here
Insert a photo of your hospital and logo here. Insert a photo of your Safety Team, including your CEO, here. Insert a caption, including the name of your hospital and the city and state where you are located, here. Insert a caption, including names for the Safety Team and CEO, here.

Improvement Calculator

Insert a title for your “Total Harms” run chart here, e.g.
Slide 2 Insert a title for your “Total Harms” run chart here, e.g. “Cut Harm Across the Board in ½” Customize the Heading Insert your “Total Harm per Discharge” run chart here, and update this each month. See the example run chart below.

Slide 3 Insert a title for your “Topic-specific” run chart here, e. g
Slide 3 Insert a title for your “Topic-specific” run chart here, e.g. “2014 Breakthrough in Reducing CAUTI: Journey to Zero” Customize the Heading Insert a your “Topic-specific” run chart here, and update this each month. See the example run chart below.

Risk Profile: The Areas of Risk We Are Committed To Controlling Annual discharges: __________HAC risk opportunities/discharge: _______ HACs Estimated annual number of patients at risk in each area Number of Opportunities ADE # of discharges: CAUTI # pts in IP units with catheter in place: CLABSI # pts in IP units with central lines: Falls Ob AE # of women with deliveries: Pr Ulcer SSI # of inpatient surgeries: VAP # of patients on a ventilator: VTE EED # of women with elective deliveries TOTAL Risk opportunities for harm across the board Readmit # of inpatients at risk of readmit:

Slide 5 Improving Harm Rates (/ Discharge)
Insert a your harm rates per discharge here, using the following table. For non-applicable topics – please insert “Z”. HACs Baseline Rate [time period] Target Rate Current Rate [time period – last 3 months] Improvement Status (scale) ADE CAUTI CLABSI EED OB Falls PU SSI VAP VAE Total Readmissions

Our Hospital Risk Score Card
Slide 6 Our Hospital Risk Score Card Insert your hospital risk score card here, using the following table. Our Safety Mandate Annual Volume (Discharges) Total risk: annual harm opportunities Risks per patients (Total Opportunities)/Discharges) Number of Risk Areas Number of PfP Risk Areas Applicable (0 – 11) Number of PfP Risk Areas Applicable & Adopted Our Progress Number of PfP Areas with Major Improvement Opportunity Number of PfP Areas at Improvement Target Number of PfP Areas at IDEAL

Pearls Bullet your biggest insights about what worked, and what caused it to work here. Include what you “tested” and “learned” Include how you will advance this topic over the next month (and beyond). List the most important drivers of safety that produced these results, but make this list succinct, high-level and clear. Include patient and family engagement (PFE), if relevant.

IHA 4/21/2017

The Improvement Leader Fellowship

Fellows Across the Country
143 in IL!

Framing the Fellowship in 2014
ILF Overarching Aim: In support of the Partnership for Patients aim of making care safer for patients in US hospitals, the ILF will build skills in improvement in SHA and HEN hospital leaders through continuous learning and coaching on improvement methods and tools as applied to the Partnership for Patients content areas. Goals: 1,000: HAB templates completed 2,000 Actively Participating Fellows 1,200 Open school modules completed 60 Hospital Story Sharing

Delivering the Fellowship
In-Person Regional Meetings 22 meetings March through November On site meetings specifically designed to combine clinical knowledge with improvement techniques Monthly Live Streamed Meetings Fellowship Topics: 1:00 – 3:00 PM CST every third or fourth Wednesday of the month

In-Person Regional Meetings
Promote shared discussion and learning All Fellows in one room Didactic Hospital story sharing Coaching Half-day sessions: Topic Specific Mini Collaborative: led by Cynosure IA Fellowship Topic: led by IHI faculty

Monthly Live Streamed Meetings
Wednesday 1:00 – 3:00 pm CST every third or fourth week of the month Utilize the in-person audience and discussion First Meeting: March 19, 2014 Live Streamed from Colorado

Tracking & Evaluating Participation
Attendance 1 in-person meeting 8 out of 10 virtual meetings Commitment to the Program (endorsed by Sr. Leader at their organization) managed by the SHA HAB completion Pre-work assignments Specific requirements for each Fellowship Level Open School module completion

Who’s Who? Junior Fellows: Senior Fellows: Champion Fellows:
New hospital to HEN New to quality improvement No previous participation in ILF Senior Fellows: Previous participation in Track 1 or 2 Working on 1-2 improvement projects Strong understanding of science of improvement Champion Fellows: Previous participation in Track 2 Leading 1-2 improvement projects Deep understanding of science of improvement

Updated Resources HAB Templates White board videos IHI Open School
Topic LISTSERVs In-person and virtual meetings

Questions for Discussion
What Fellowship topics are the most valuable to your hospitals? Rate your Fellows – would you consider yourself a junior/senior/champion fellow?

Open Forum

Introduction to the Hospital Engagement Network (HEN)

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