K-HEN Progress Overview & Next Steps for QI and Opportunities Our Progress Toward the 40/20 Goal

1. K-HENProgress Overview &Next Steps for QI and OpportunitiesOur Progress Toward the 40/20 Goal Donna R. Meador, K-HEN Project Director

2. K-HEN Framework

3. K-HEN Framework

4. K-HEN Services • Benchmarking • Coaching Calls • Best Practices Education and Resources • Technical Assistance • Patient Safety Culture Education and Resources • Reports, including CEO Dashboard

5. K-HEN Results

6. ADE (Adverse Drug Events)

7. ADE (Adverse Drug Events) 54% Improvement

8. CAUTI

9. CAUTI 15% Improvement

10. CLABSI 4% Improvement

11. CLABSI

12. Early Elective Deliveries 59% Improvement

13. OB Harm 3% Improvement

14. Falls 61% Improvement

15. Falls

16. Pressure Ulcers 56% Improvement

17. Pressure Ulcer

18. Preventable Readmissions

19. Preventable Readmissions 15% Improvement

20. Surgical Site Infection 15% Improvement

21. Safe Surgery

22. VAP 62% Improvement

23. VAP

24. VTE (Venous Thromboembolism) 29.8% Improvement

25. Potentially Preventable VTE

26. Improvement/Harm Calculators Dolores Hagan, RN BSNK-HEN Education/Data Manager

27. Calculator Overview • Created by Cynosure Health in partnership with HRET • Formulas perform calculations/graphs in the background • Excel spreadsheet • Contains a separate sheet for each HEN topic • Two sheets for Falls and HAPU • Total Harm sheet • Harm Across the Board sheet • Reference for cost estimates are included

28. About Your Calculator • Prepared for each hospital • Only included data on state-wide top two measures • Patient days and Discharges obtained from IPOP Claims database • Fully editable by you • Electronic copy on your USB drive

29. Calculator Basics • Sheets and workbook are protected to allow easy data entry • Enter Hospital Name on the Total Harm tab first and it will flow over to all other tabs • Required information for each tab • Number of months for baseline period • Frequency of reporting (monthly or quarterly)

30. Calculator Snapshot

31. Protection • Select the ‘Review’ toolbar • Select ‘Unprotect Sheet’ (toggle) • Make changes, then select ‘Protect Sheet’ • Save changes

32. What’s Included in the Calculations • Current rate – calculated by summing the most recent 3 months numerators/denominators • % change from baseline (Current rate – Baseline)/Baseline • Most recent Month-Year for data • Number prevented To-Date—takes all months of data into account & based on baseline rate • Cost savings To-Date = # prevented to date X Avg. cost • Estimated # to prevent to be at Goal by next month—based on current rate 1 - 3 4 5 6

33. Total Harm • Numerator – Total Harm • Readmissions + ADEs + Falls with Injury + HAPUs Stage III/IV + CAUTIs + CLABSIs + VAPs + SSIs + EEDs + OB Harms • Denominator – Total Harm • Patient Days – must be manually entered • Required for numerator to populate • MUST specify the number of months the baseline represents

34. Harm Across the Board (HAB) • Numerator – Total Harm • ADEs + Falls with Injury + HAPUs Stage III/IV + CAUTIs + CLABSIs + VAPs + SSIs + EEDs + OB Harms (excludes Readmissions) • Denominator – Total Harm • Discharges– must be manually entered • Required for numerator to populate • MUST specify the number of months the baseline represents

35. Contact Information Help is only a phone call or email away! Dolores Hagan (502) 992-4389 dhagan@kyha.com

36. Current Focus “Small Ball” Strategy to capture data in all applicable topics for 100% of K-HEN hospitals • Sustaining and spreading improvements already made • Enhanced improvement work targeted to Adverse Drug Events, CAUTI, CLABSI, OB Adverse Events, Pressure Ulcer, and Readmissions

37. K-HEN Seed Grant Opportunity • Purpose • Timeline • Submissions Due November 22 • Awardees will be notified by November 27 and it will be posted to the K-HEN Website • Begin December 2, 2013 and end May 31, 2014 • Awards • 4-6 Grants up to $10,000 • Contact: Sharon Perkins sperkins@kyha.com

38. Next Steps for QI and OpportunitiesOur Progress Toward the 40/20 Goal

39. 2014 – “Option Year” • CMS notified HRET on October 8 they intend to fund “Option Year” • January – December 2014 • Extend and Expand scope of improvement work • All 26 national HEN’s invited to apply • Applications due November • State SHA’s submitting work plan to HRET • Contract awards made by CMS by December 8, 2013

40. Hospital Commitment – Option Year • Hospital Administrators to Sign Commitment Form • System Commitment Letters not allowed • Data: Hospitals to submit outcome and process data on ALL applicable areas • Data: CMS requiring use of approved measures • 11 Improvement areas and expansion within areas

41. Option Year continued • Work plan tailored as much as possible to the feedback provided by hospitals through day-to-day discussions, meetings, site visit, and surveys • Strategies: • changing frequency of coaching calls – some monthly, some quarterly; • 2014 KHA Quality Conference may be in a “Quality and Patient Safety Boot Camp” format • Utilize what we have learned through LEAN, Grants, etc to spread improvement • Planning to continue hospital site visits, TeamSTEPPS workshops, regional meetings; • HRET will continue to provide resources and support on a national level

42. Option Year Improvement Areas • Falls • No substantial change • Pressure Ulcer • No substantial change • ADE • anticoagulation management, • opioid safety, and • glycemic management

43. Option Year • CAUTI Topic • All tracked units (not just ICU) • CAUTI in the ER • Urinary catheter utilization • CLABSI • All tracked units (not just ICU)

44. Option Year • VTE • All surgical areas • Obstetrical Adverse Event • EED • OB Hemorrhage • Treatment of Pre-Eclampsia to reduce morbidity and mortality

45. Option Year • SSI Topic • Expand to include all surgeries • VAE • VAC • IVAC • Probable/Possible VAP • Use of Surveillance data– CMS is steering hospitals away from use of administrative data and want more hands-on analysis

46. Feedback from K-HEN evaluation and Participation Survey • 17 Hospitals participate in the survey • 41% Report participating frequently in Coaching Calls • 70 % Report scheduling conflicts with calls • 60% would like the Coaching Calls to be every other month • 65% Report no site visit from K-HEN staff (91 participating hospitals with 71 site visits made) • 77% want more training in New Evidence-based practices followed by • 65% want prioritization in next steps • Everyone who participated in the survey requested assistance in a collaborative area.

47. Other Strategies for continued quality work at KHA -

48. Other Strategies for continued quality work at KHA - • Patient Safety Work ranked 5th priority by KHA Strategic Planning Committee • Seeking funding opportunities to continue QI work • Wellpoint grant • Kellogg grant • Researching other grant opportunities • Create small rural benchmarking program through Flex Grant

49. Questions?