data office hours - k (hen...data: baseline thanks for submitting your data! k- hen goal = >70%...
TRANSCRIPT
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1
Title BlockWelcome to the K-HEN 2.0
Monthly Update Webinar!
Agenda• Welcome!
• Data Update: Baseline Data – thank you!
– Where are we as a state by topic? Data Analysis
• Monitoring Data Update: upcoming deadlines
– Operational Assessment questions – survey monkey
sent 2/18 – deadline 2/29
• Update on Incentive Payments
• Fellowship Activity
• Listserv Registration
• Upcoming Events – IP Boot Camp, Quality
Conference
• Q&A
Data: Baseline
Thanks for submitting your data!
K- HEN goal = >70% hospitals submitting
baseline data by the deadline
K-HEN results = 99%! Thanks for helping
us knock it out
of the park!
4
ADE Measures
51
38
44
0
10
20
30
40
50
60
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Excessive Anticoagulation with Warfarin - Inpatients
Hypoglycemia in Inpatients Receiving Insulin
Adverse Drug Events due to Opioids
HEN2-ADE-1a HEN2-ADE-1b HEN2-ADE-1c
All K-HEN Hosps Rate
All HRET Hosps Rate
# K-HEN Hosps Reporting
CAUTI SIR and Rate
42
43
44
45
46
47
48
49
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
CAUTI SIR - All Inpatient Units Excluding NICU (NHSN ONLY) CAUTI SIR - ICUs Excluding NICUs (NHSN ONLY)
HEN2-CAUTI-1a HEN2-CAUTI-1b
All K-HEN Hosps Rate All HRET Hosps Rate # K-HEN Hosps Reporting
0
10
20
30
40
50
60
70
80
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
CAUTI Rate - All Inpatient Units Excluding NICUs (ALL Facilities) CAUTI Rate - All ICUs Excluding NICUs (ALL Facilities)
HEN2-CAUTI-2a HEN2-CAUTI-2b
All K-HEN Hosps Rate All HRET Hosps Rate # K-HEN Hosps Reporting
CAUTI Utilization Ratio
0
5
10
15
20
25
30
Urinary Catheter Utilization Ratio - All Inpatient Units Excluding NICUs (ALL Facilities)
HEN2-CAUTI-3a
All HRET Hosps Rate All K-HEN Hosps Rate
CLABSI SIR and Rate
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
CLABSI Rate - All Inpatient Units (ALL Facilities) CLABSI Rate - All ICUs (ALL Facilities)
HEN2-CLABSI-2a HEN2-CLABSI-2b
All K-HEN Hosps Rate All HRET Hosps Rate
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
CLABSI SIR - All Inpatient Locations(NHSN Facilities)
CLABSI SIR - ICUs (NHSN Facilities)
HEN2-CLABSI-1a HEN2-CLABSI-1b
All K-HEN Hosps Rate All HRET Hosps Rate
CLABSI Utilization Ratio
0
5
10
15
20
25
Central line utilization ratio - All Inpatient Units (ALL Facilities)
HEN2-CLABSI-3a
All K-HEN Hosps Rate All HRET Hosps Rate
0
20
40
60
80
100
120
140
OB Trauma - Vaginal Delivery with Instrument (AHRQ PSI 18) OB Trauma - Vaginal Delivery without Instrument (AHRQ PSI 19)
HEN2-OB-1 HEN2-OB-2
All K-HEN Hosps Rate All HRET Hosps Rate
9.3
9.4
9.5
9.6
9.7
9.8
9.9
10
10.1
10.2
10.3
Early elective deliveries (PC-01, NQF 0469)
HEN2-EED-1
All K-HEN Hosps Rate All HRET Hosps Rate
Early Elective Delivery2013
Other OB Harm2011
Falls With Injury
0
0.5
1
1.5
2
2.5
Falls with Injury (NQF 0202)
HEN2-Falls-1
All K-HEN Hosps Rate All HRET Hosps Rate
Pressure Ulcer
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Pressure Ulcer Rate, Stages 3+ (AHRQ PSI 03) Pressure Ulcer Prevalence, Hospital-Acquired-Stage 2+ (NQF 0201)
HEN2-PrU-1 HEN2-PrU-2
All K-HEN Hosps Rate All HRET Hosps Rate
HW 30 Day All Cause Readmissions
7.2
7.4
7.6
7.8
8
8.2
8.4
8.6
8.8
Readmission within 30 Days (All Cause)
HEN2-READ-1
All K-HEN Hosps Rate All HRET Hosps Rate
SSI SIR – Colon/Abdominal Hysterectomy
0
0.2
0.4
0.6
0.8
1
1.2
SSI SIR - Colon Surgeries (NHSN ONLY) SSI SIR - Abdominal Hysterectomies (NHSN ONLY)
HEN2-SSI-1a HEN2-SSI-1b
All K-HEN Hosps Rate All HRET Hosps Rate
SSI Rates
0
1
2
3
4
5
6
SSI Rate - Colon surgeries (ALL Facilities) SSI Rate - Abdominal hysterectomies (ALL Facilities)
SSI Rate - Total knee replacements (ALL Facilities)
SSI Rate - Total hip replacements (ALL Facilities)
HEN2-SSI-2a HEN2-SSI-2b HEN2-SSI-2c HEN2-SSI-2d
All K-HEN Hosps Rate All HRET Hosps Rate
VAE – VAC/IVAC
0
0.5
1
1.5
2
2.5
Ventilator Associated Condition (VAC) - ALL Facilities Infection-Related Ventilator-Associated Complication (IVAC) - ALL Facilities
HEN2-VAE-1 HEN2-VAE-2
All K-HEN Hosps Rate All HRET Hosps Rate
VTE
3.55
3.6
3.65
3.7
3.75
3.8
3.85
3.9
3.95
Post-Operative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) Rate (AHRQ PSI 12)
HEN2-VTE-1
All K-HEN Hosps Rate All HRET Hosps Rate
C. Difficile SIR and Rate
0
1
2
3
4
5
6
7
8
9
Standardized Infection Ratio (SIR) for patients with C. difficile (NHSN-submitting facilities only)
Facility-wide C. difficile Rate
HEN2-CDI-1a HEN2-CDI-1b
All K-HEN Hosps Rate All HRET Hosps Rate
Post Operative Sepsis
0
2
4
6
8
10
12
14
16
Postoperative Sepsis Rate
HEN2-SEPSIS-1a
All K-HEN Hosps Rate All HRET Hosps Rate
Data: Monitoring
Monitoring data – Ky. Quality Counts (KQC) site
ready for outcomes measures monitoring data
Process measures are in progress-We will be
Survey-Monkeying you AGAIN about process
measure choices
Contact Melanie or Dolores with questions
Remember, all monitoring data goes into KQC
www.hret-hen.org for Encyclopedia of Measures
– EOM is updated periodically
Goal: Monitoring data through February in KQC
counts by 3/15 for incentive and by 3/31 to stay
on track 20
Operational Assessment ?
Follow up to the Needs Assessment
Data will be queried quarterly
Current query via Survey Monkey is
due 2/29
Contact Donna Meador or Melanie
Moch for questions
Data – Incentive Updates
• Milestone 1 - 74 hospitals received
$500 for participation (to offset
additional data work), totaling
$37,000 to Kentucky Hospitals
• Milestone 2 – 51 hospitals to receive
$500 for submitting baseline data by
deadline, totaling $25,500 to
Kentucky hospitals
Action Leader Fellowship
23
• AHA/HRET in Partnership with IHI
• Content related to the science of improvement to
support your quality improvement (QI) teams to
drive change, basic and experienced levels
• Need to participate in live webinar in at least 8 of 10
webinars – we are on webinar #5
• Special consideration for Ky Fellows who are
attending the Quality Conference on 3/9 and will
miss the live webinar
We have 24 Fellows in progress in Kentucky!
Thank you for helping us build Quality Improvement
Capacity in Kentucky!
Listserv Information• Register for the listservs on HRET
website –http://www.hret-hen.org/inc/dhtml/listserv.dhtml
Adverse Drug Event (ADE)
Data Analytics
Infections – includes CAUTI, CDI, CLABSI,
SSI, and VAE
Early Elective Delivery & OB Adverse Event
Other Harm – includes VTE, Airway Safety, Failure to Rescue,
Iatrogenic Delirium and Radiation Exposure
Patient & Family Engagement/Health Care Disparities
Pressure Ulcers & Falls
Readmissions
Rural/Critical Access Hospitals
Sepsis
Listservs – you might be missing out….
Falls: Hello Falls Champions,
A big thank you to Eve Brown from Henry May Newhall Hospital in Valencia, CA for
sharing her organization’s “Call Don’t Fall” video and handout used for partnering
with patients to prevent falls.
Attached you will find the handout and here is a link to the
video: https://www.youtube.com/watch?v=o7jVmrxjv2A
Thanks again for sharing! Jackie
Jackie Conrad RN, BS, MBA, RCC™| Improvement Advisor | Cynosure Health
Solutions
708-420-1130 (c) |[email protected]
All In Saves Lives. www.cynosurehealth.org
Listservs – you might be missing out….
Pressure ulcers: Greetings Pressure Ulcer Champions!
What’s your secret to success in implementing monthly Pressure Ulcer Prevalence
Studies?
· Do you use exempt staff (managers, educators, clinical specialists) or Front line staff
or Both?
· What creative approaches have you used to provide the manpower to conduct the
visual inspection of every patient on the day of the study? Do you use orientees? Light
duty staff? Creative scheduling?
A free resource to consider is tapping into student nurses! Have you considered involving
students? Baccalaureate Nursing Students are prime candidates for assisting with or
independently conducting your prevalence studies as part of their research or quality
improvement curriculum. Share this article with your nursing instructors as a way to
integrate the student’s learning into your unit’s quality improvement
plan. https://www.medlineuniversity.com/DesktopModules/Documents/ViewDocument.
aspx?AddToLog=1&DocumentID=1239
Jackie Conrad RN, BSN, MBA, RCC™ | Improvement Advisor | Cynosure Health
Solutions 708-420-1130 | [email protected] www.cynosurehealth.org
Wrap Up, Next Steps1. Complete monitoring data submission by
March 15
2. Go to Upcoming Events Tab on HRET
website for upcoming webinars• Next Fellowship is March 9 (same as Quality
Conference!)
• Next K-HEN Monthly Update webinar March 23
3. Kentucky Infection Prevention Boot Camp
March 8 & 9, Embassy Suites Hotel, Lexington
4. K-HEN Conference March 9 & 10, also Embassy Suites Hotel, Lexington
Do you have a Patient Safety Hero nominee?
Submit them to the K-HEN Website and be
recognized!
Q & A Session
Thank you for participating in the…
Race to Quality!
(Sprint /Marathon)