2013 The Time is Now!

1. Georgia Hospital Engagement NetworkPatient and Family Centered Safe CarePutting Patients First40/20 by ‘13 2013 The Time is Now!

2. Partnership for Patients Campaign

3. Executive Engagement – Executive Quality Action Council Purpose: Provide guidance and support to the GHA Hospital Engagement Network on its goal of improving patient safety through implementation of the eliminating “all cause harm” approach and patient and family centered safe care.

4. Executive Action Quality CouncilMembers Co-Chairs Jim Davis, CEO, University Hospital and Sheila Bennett, Floyd Medical Center • David Andrews, Patient Advocate, Georgia Regents University • Susan Bowen, Shepherd Center • Melody Brown, Dodge County Hospital • Montez Carter, Good Samaritan Hospital • Nicole Franks, MD, Emory University Hospital Midtown • Freya Gilbert, Hughston Hospital • BabsHargett, Emory Healthcare • Michael Hester, Optim Medical Center-Jenkins • Angie King, St. Francis Hospital • Mindy McStott, Tift Regional Medical Center • Norma Jean Morgan, Effingham Health System • Heidi Nelson, University Hospital • Teri Newsome, Habersham Medical Center • Mary Pizzino, Effingham Health System • Tina Thomas, Ty Cobb Regional Medical Center • Brad Trower, Optim Medical Center-Jenkins • Jerry West, Houston Medical Center

5. Executive Quality Action Council Vision: All Georgia hospitals will be a patient and family centered safe care organization. Mission: Provide leadership to the Georgia Hospital Engagement Network to reduce all cause harm among Georgia hospitals. Goals: • Address Aims: Better Health; Better Outcomes; Lower Cost • Assisting hospitals to meet the CMS Partnership for Patients goal of reducing readmissions 20% and hospital acquired conditions 40% by the end of 2013.

6. Executive Quality Action Council Objectives: • Foster the support of the hospitals’ C Suite and Board to engage all staff, including but not limited to, senior leaders, frontline staff and physicians, as well as patient and family representatives in the implementation of the patient and family safe care framework. • Provide insight on realistic approaches to implement enlightened executive leadership guide • Provide executive guide for implementation of selected best practices

8. All Cause Harm Global ToolsTo Meet Goals Have to Focus on Patient Safety Culture • Leadership • Evidence – based Leadership • Rounding: Executive Leaders • Engagement and Process Design Tools: • Comprehensive Unit Safety Program (CUSP) • Rounding: Managers and Staff • Reliable System Process Design • Lean/Six Sigma • Communication and Team Work • TeamSTEPPS • Patient and Family Centered Care/Engagement • The Healthcare and Patient Partnership Institute (H2Pi): The Patients as Partners Training Guide http://h2pi.org/ • Partnership for Women and Families

9. Patient/Family Centered Safe Care • Advisory Action Group • Partnerships • National Partnership for Women and Family • Healthcare and Patients Partnership Institute Ask Listen Evaluate Respond Test

10. Cohorts/Hospital Visits/Calls • Every hospital has a GHA liaison • Face-to-face hospital visit by liaison • Why Create Cohorts • All Teach, All Learn concept • Coaching available • Achieve rapid change • Small groups • Promotes networking • More one-on-one assistance when needed • Mentoring encouraged

11. Cohorts/Hospital Visits/Calls • Monthly Cohort calls – attendance required for recognition points • Cohort 1: Joyce Reid (1a) , Kathy McGowan (1b), Lorna Martin (1c) - 1st Wednesday 11:30 a.m. – 12:15 p.m. • Cohort 2: Denise Flook (2) • 2nd Wednesday 11:30 a.m. – 12:15 p.m. • Cohort 3: Tracy Rutland (3) • 3rd Wednesday 11:30 a.m. – 12:15 p.m. • Cohort 4: Lynne Hall (4) • 4th Wednesday 11:30 a.m. – 12:15 p.m.

12. Cohorts/Hospital Visits/Calls • Format of monthly cohort calls • Discussion based on data • Offers & Requests • What do you need to be successful? • What do you bring to the table? • Requests from Partnership for Patients & CMS • Time for Implementation

13. Cohorts/Hospital Visits/Calls • Hospital visits – opportunity to share & showcase • Review data – Organizational Assessment Tool, HAC, Readmission, Core Measure, etc. • What keeps you up at night? • Resources

14. Specific Topic Affinity Webinars*: All Teach, All Learn • GHA will offer monthly Affinity Group calls on Wednesdays from 11:00 a.m. – 11:30 a.m. (See Calendar) • First Wednesday: Reducing Readmissions* • Second Wednesday: Hospital Acquired Infections (HAI) • Third Wednesday: Hospital Acquired Conditions/Events (HACs) • Fourth Wednesday: OB Adverse Events • CMS national calls – will be notified of date & time • *February 11 – Patient & Family Engagement 3:00 p.m. – 4:30 p.m. • *March 4 – Readmissions 3:00 p.m. – 4:30 p.m. (will replace March 6 Readmission call) • *April 1 – Adverse Drug Events 3:00 - 4:00 pm • Extra credit for recognition

15. Regional Meetings • Combine cohorts • All Teach, All Learn • Dates • May & August • November – Year End Celebration • Geographic locations • Albany • Athens • Dalton • Macon • Marietta • Waycross

16. Small/Rural CAH Approach • Umbrella of Quality Improvement • Taking down the silos – building new relationships • Expanding our horizons • Promoting our culture of safety • Learning from each other • Rural Affinity Change Package • Fine-tuning our strategies • Hard stop for discharge program • Celebrating as we go!

17. Calendar of Events • You Asked For It!

18. Organizational Assessment Tool • Assessment: • Some questions confusing • Terminology needs clarification on some questions • Tool more sensible when read currently compared to a year ago when the HEN was just beginning to launch and some of the content was new • Data reports and analysis seem premature since this is baseline data • National Content Developer (NCD) listened to our feedback • Currently revising the OAT • New version available in the Spring

19. Organizational Assessment Tool • Recommendations: • Conduct a mandatory conference call for HEN leaders • Prior to conference call, send electronic .pdf version of the OAT survey to all members and set the expectation that they read for clarity • During the conference call, identify additional items that require clarification in addition to the questions listed above • Ask GHA staff to compile a data dictionary for these questions and terms based on our GHA HEN leaders and then circulate the document • Launch “wave two” of the survey in Spring 2013 with the intent to evaluate where we have progressed with the guidance of the HEN activities

20. Organizational Assessment Tool • Recommendations continued • Communicate effectively that the OAT survey should not be used with the intent to compete with one another but as a personal tool for each organization to identify if their actions are producing the gain that is expected. • Subsequent reports should feature “wave one” survey as the baseline and “wave two” as effect of change.

21. Upcoming Educational Opportunities 2013 Statewide In-Person Meetings (attendance required for Recognition Program) • February 12-13 GHA Annual Meeting • June 5-7 Nurse Leadership Institute • July 9-12 GHA Summer Meeting • August 7-9 Center for Rural Health Lean Six Sigma Green Belt Training • June 17-21, GHA Education Center

22. Partnership for Patients (PfP) National Calls • Strategies for Advancing Patient and Family Engagement as a Change Engine • Monday, February 11, 2013 3:00 p.m.- 4:30 p.m. • To register go to: http://www.visualwebcaster.com/event.asp?id=91854 • All Cause Harm Across the Board/Readmission • Monday, March 4, 2013 3:00 p.m.- 4:30 p.m. • Adverse Drug Events • Monday, April 1, 2013 3:00 p.m.- 4:00 p.m

23. Data Requirements • Outcomes • Most HACs and Readmission data from other sources so no further submission needed • HAIs (CLABSI, CAUTI, SSI (colon surgeries) and VAE) – must confer rights to NHSN data to GHA, monthly data • EED data submitted monthly • ADE data • Process Measure Data • Quarterly Best Practices Attestation online survey

24. 2013 Proposed Recognition Program The GA HEN Recognition scores are calculated based on the following dimensions: • Participation (15%) • In Person Meetings • Cohort Meetings • Regional Meetings • Completion of Evaluations for any HEN Meeting (10%) • Submissions (25%) • Completion of the Organizational Assessment Tool in Spring 2013 • Quarterly Best Practices Attestation Survey • Submission of outcomes data as required (EED, NHSN, ADE, Core Measures) • Achieving the HEN Targets (50%)

25. Recognition Program Participation scores are calculated as a percentage of attendance in required HEN Meetings. • In Person Meetings: • Patient Safety Summit (January 9 - 10, 2013) • Trustee Meeting (January 11 - 13, 2013) • February Kick Off (February 7, 2013) • GHA Annual Meeting (February 12 - 13, 2013) • Nurse Leadership Institute (June 5 - 7, 2013) • GHA Summer Meeting (July 9-12, 2013) OR Center for Rural Health Meeting (August 7-9, 2013) • Regional Cohort Meetings held in various Georgia regions in May, August, and November

26. Recognition Program • Cohort Meeting Dates:

27. Recognition Program The following data sources are used: • Georgia Discharge Database: used in the calculation of Hospital Acquired Conditions and Patient Safety Indicators • Readmissions Data: We have partnered with the Georgia Medical Care Foundation to obtain overall 30-day Readmissions data. • Early Elective Deliveries: This data is directly reported to us by the hospitals. • National Healthcare Safety Network (NHSN): Used for CAUTI, CLABSI, SSI and VAE

28. Recognition Program

29. Recognition Program • Extra Credit points are awarded for: • Participation in Affinity Group educational calls • Achieving 4’s and 5’s by CMS rating scale • Meeting the CMS Patient and Family Engagement Requirements; defined on the Attestation document • Presentations in GHA and CMS meetings • Participation in the SUSP Program • Maximum extra credit points = 10

30. Recognition Program Three categories of Exemplar hospitals are identified based on overall Recognition Scores: • Elite Circle: Hospitals who achieve 90th percentile rank • Chairman’s Circle: Hospitals who achieve 80th percentile rank • Presidential Circle: Hospitals who achieve 70th percentile rank Ideal Hospital: Achieving CMS ranking of 4 or 5 in six or more HACs

31. We Look Forward to Working With You in 2013!

32. Contact Information • Phone: 770-249-4500 • Vi Naylor: vnaylor@gha.org • Kathy McGowan: kmcgowan@gha.org • Joyce Reid: jreid@gha.org • Denise Flook: dflook@gha.org • Faizah Muheb: fmuheb@gha.org • Martha Harrell: mharrell@gha.org • Lynne Hall: lhall@gha.org • Lorna Martin: lmartin@gha.org • Tracy Rutland: trutland@gha.org • Michelle Sprouse: msprouse@gha.org • Shearl Lesser: slesser@gha.org