1. Title Block 2014 K-HEN Commitments Elizabeth Cobb Donna Meador Dolores Hagan

2. Welcome! Thank you so much for your support throughout this project so far, and for helping us gain approval for continuing in 2014!

3. Agenda 1.Discussion of Commitments for 2014: a. Data Submission Requirements in the 10/11 clinical focus areas b. Continued work on Patient & Family Engagement, Leadership, Teamwork, and Communication, and Measurement c. Add/begin component of Health Care Disparities 2.Incentives to continue: a. Data Submission Incentive (quarterly) b. Improvement Incentive (mid-year and at end of project)

4. Agenda, continued c. Harm Across the Board Incentive -(replacing monthly progress report) 3. Education and Activities Planned for 2014 4.Improvement Leader Fellowship changes for 2014 5.Q & A, Feedback

5. 1. Commitments for 2014 Data Submission Requirements: - all applicable topic areas - standardized (aligned) measures for each topic – we will prescribe a minimum submission requirement & a higher level for increased incentive - data submission schedule - data submission tool will be coming out- All 2014 data will be submitted directly to K- HEN via the tool instead of the CDS

6. Measures by Area Adverse Event Area (AEA) Measures Adverse Drug Events (ADE) Excessive anticoagulation (EOM-12) Glucose control (EOM-13) Opioid safety (EOM-111) An overall measure of ADEs* FallsFalls with or without Injury (EOM-37) Falls with injury (minor or greater) (EOM-38) Pressure UlcerStage II or Greater hospital acquired (EOM-58) Stage III or IV greater subset (AHRQ PSI 3) (EOM-61) VTEPost-op PE or DVT (AHRQ PSI 12) (EOM-105) Potentially preventable VTE (EOM-104) EEDEarly Elective Delivery (JC PC-01) (EOM-40)

7. AEA Measures Other OBBirth Trauma Rate – Injury to Neonate (AHRQ PSI 17) (EOM- 48) OB Trauma rate-vaginal delivery with instrument (AHRQ 18) (EOM-54) Birth Trauma Rate-vaginal delivery without instrument (AHRQ 19) (EOM-55) OB Hemorrhage* Preeclampsia treatment and management to prevent morbidity and mortality* Readmissions Diagnosis specific 30-Day readmission rate AMI (EOM-76); Heart Failure (EOM-77); Pneumonia (EOM-78) 30-Day All Cause readmission rate (EOM-75)

8. AEAMeasures CAUTI CAUTI Rate (NHSN/NDNQI) – ICU only (EOM-19) CAUTI Rate (NHSN/NDNQI) – All Units (EOM-18) Catheter utilization ratio (catheter days/patient days) (EOM-21d) ED Catheterization rate* CLABSICLABSI rate (NHSN/NDNQI) ICU only (EOM-25) CLABSI rate (NHSN/NDNQI) All Units (EOM-24) Days Since Last CLABSI* SSISurgical site infection rate (NHSN) for colon and abdominal hysterectomy procedures within 30 days of procedure(EOM-89) Surgical site infection rate (NHSN) for four or more procedures within 30 days of procedure** VAE/VAPVAC (NHSN) (EOM-96a or EOM-96d) IVAC (NHSN) (EOM-96b or EOM-96e) Possible/Probable VAP (NHSN) (EOM-96c or EOM-96f)

9. Incentive Requirements Both minimum and full participation require timely data submission –Data is due at the end of the month for the previous month (exceptions: Readmissions and SSI) –Full participation requires either submission or attestation that at least one corresponding process is being collected

10. Commitments cont’d. Continued work on Patient and Family Engagement and Leadership– we will continue to submit data to HRET on 5 elements of PFE and 4 elements of Leadership; we will continue to offer education and resources related to patient safety, teamwork, and communication; we will continue to work with hospitals on data/measurement/reporting Add/begin HealthCare Disparities Component - for now this will consist of 2 surveys throughout the year from HRET for each hospital

11. 2014 Incentive Structure 2014 Funding for all of the HENs based on data submission and improvement structure – We will be implementing a 2-tiered quarterly bonus/incentive strategy based on completing minimum and maximum requirements Mid-year and end-of-project bonus/incentive based on improvement levels

12. Incentive Structure cont’d. Monthly progress reports will now be submitted as “Harm Across the Board” reports – moving from focus on single harm to harm across the board – we will incentivize hospitals who submit at least one HAB report each qtr. (we will provide more info on the HAB report later)

13. 2014 Education and Activities K-HEN: 1.Coaching Calls monthly and bi-monthly depending on topic 2.Site Visits to all hospitals 3.Annual KHA/K-HEN Quality Conference 3/18-19 4.TeamSTEPPS webinars and workshops 5.Patient Safety Hero Awards 6.OB Advisory Committee Meetings 7.Periodic focused meetings, such as K-HEN or HRET staff meeting with local community coalitions

14. 2014 Educ. & Activities cont’d 8. Sponsorships to national meetings – AHA Rural Conference, NAHQ, IHI, NPSF Congress, AHA Quality and Safety Roadmap, etc. 9. Regional Meetings 10. Other Suggestions/Needs? 11. Improvement Leader Fellowship education and activities (next slide)

15. 2014 Educ. & Activities cont’d HRET: 1.Updated Change Packages - each topic 2.2-3 day Boot Camps dedicated to data, OB, Readmissions, ADE, C-Diff, and Sepsis; each will be repeated during the same week 3.ILF program with in-person meetings & monthly live-streamed meetings 4.Other events in process

16. 2014 Improvement Leader Fellowship Great program in 2012 and 2013 – changes to design make more beneficial to hospitals Currently 1200+ fellows (8 in KY) 27 ILF meetings held, 533 registered for IHI Open School Feedback from fellows has been very positive 2014 – Junior, Senior, and Champion levels Goal – build skills in improvement in SHA and HEN hospital quality leaders through continuous learning & coaching on improvement methods & tools as applied to the Partnership for Patients content areas.

17. 2014 Improvement Leader Fellowship 2014 Plans: 1.In-Person Regional Meetings – 22 meetings March-November - on-site meetings specifically designed to combine clinical knowledge with improvement techniques, ½ day in length, for networking & shared learning, at State Hosp. Assoc. offices (KHA?) 2. Monthly live-streamed meetings, 1-3 CT every third or fourth Wednesday of the month

18. 2014 Improvement Leader Fellowship Fellowship education led by IHI Faculty Attendance requirements – 1 in-person meeting, 8 of 10 virtual meetings HAB completion Pre-work assignments Specific assignments for each level * Secondary goals for KY – build improvement capacity for ongoing quality work, foster systems thinking knowledge, keep the enthusiasm going!

19. Questions? Feedback? Thank you!