hospital improvement innovation network · 2018-08-03 · 2018 hiin quality convening approximately...
TRANSCRIPT
Hospital Improvement Innovation Network
Toi Wilde, R.N., BSN, MBA, CPHQ
Program Manager
July 24, 2018
Agenda
High Reliability Organizing Framework & Practical Steps; Steven Tremain, M.D., FACPE
2018 HIIN Quality Convening Recap
HIIN Project Updates: Milestone 8
HRET/HIIN Virtual Events
Upcoming Events
Virtual
In-person
Resources
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Featured Speaker
Steven Tremain — Physician Advisor
Education: Doctor of Medicine (M.D.) — University of California, Los Angeles
Certifications
Board Certified Family Medicine
Certified Physician Executive
TeamSTEPPS Master Trainer
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High Reliability OrganizingFramework & Practical Steps
Missouri HIIN
July 24, 2018
High Reliable Organizing (HRO): So Long Autopilot
Steve Tremain, M.D.
Cynosure Health
What is HRO?High Reliability Organizing (HRO) is commonly discussed as a set of principles that help an organization perform safely and reliably in the face grave risk.
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“HRO’s have a deep appreciation for the liabilities of overconfidencedemonstrated by ongoing mindfulness embedded in practices that enact alertness, broaden attention, reduce distractions and forestall misleading simplifications”
Weick and Sutcliffe
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What HRO Isn’t
• It’s not really about “process reliability”– Reliability assumes we can get
near or at 100% efficiency
• You never quite become one– If you think you’ve arrived, by
definition you are not even close
• Numerators and denominators don’t work well
• It’s not about “standard work”
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50 65 80 95 01
Angled DecksAviation Safety Center
Naval Aviation Maintenance ProgramRAG (FRS) Concept Initiated
NATOPS ProgramSquadron Safety Program
System Safety Aircraft Design
CRM Aircrew reviews
ORM
Safety culture
776 aircraftdestroyed in
1954
Naval Aviation Class A Flight Mishap Rate
FY50-03
Fiscal Year
24 aircraftdestroyed in
FY03-all in flightmishaps
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HRO’s sustain a “mindful infrastructure”
Observes and tracks small failures and anomalies
Resists oversimplification
Remains sensitive to operations
Maintains capabilities for resilience
Looks to expertise not rank to inform decisions
Principles of
anticipation
Principles of
containment
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What is HRO?• Preoccupation with failure
– Attitude toward failure
– Be prepared to fail
• Refusal to simplify
– Hidden complexities
– Nonlinear interactions
• Sensitivity to operations
– Operations vs. plans
– Interactive real-time risk assessment and management
• Maintain resilience
– Persevere
– Work the problem
• Deference to expertise
– Local or specialized knowledge
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Non-HROs
• Focus on success (but you do need to celebrate occasionally)
• Underdeveloped cognitive infrastructure
• Focus on efficiency
• Inefficient learning (episodic)
• Lack of idea diversity (focused conformity)
• Information & communications filtering
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Characteristics of a Non-HRO
• Reject or excuse early warning signs of quality degradation
• Attend meetings and solve nothing
• Conduct briefings and persuade no one
• Find a single root cause to a problem
• Meet deadlines for projects on which the plugs have been (or should be) pulled
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Preoccupation with Failure
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Preoccupation with Failure
• Continually search for points of failure– Covert, compensated state vs. overt, decompensated state
• Maintain doubt in decision making– Success or failure occurs at the end
• Error– Errors can be self-correcting or create their own pattern
• Too many knitting errors in a sweater looks like a pattern
– Imperfect information
– Imperfect process
– Cascading failure
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Observe and track small failures and anomalies
- Worry chronically about errors
- Assume each day is a bad day
- Difficult to do
- “Collective bonds among suspicious people”
- Trust but verify
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So We Should Celebrate…
• Then be pre-occupied with failure.
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Reluctance to Simplify
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Reluctance to Simplify
• Nonlinear interactions create complexity– emergence of novel properties
• Logistic equation between two limits – chaos develops at high rate of change
• Shannon (Information) Entropy – the information state between order and randomness
• Availability Construct– first thought is most available to the brain, not the most
important• Use complexity to manage complexity
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Resisting Oversimplification
- All organizations must ignore many things
- Doing so may force them to ignore key sources of problems
- Restrain temptations to simplify
- Through checks and balances, adversarial reviews, and multiple perspectives
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Linear vs. Non-linear Approaches
HRO Leader
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Sensitivity to Operations
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Sensitivity to Operations
• Plans change due to environment and events
Δ Work = Work as Planned – Work as Performed
• Human performance fluctuates
• Team and system interactions are dynamic
• Co-workers help and interfere with each other
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Remain Sensitive to Operations
- Pay close attention to operations
- Everyone values organizing to maintain situational awareness
- Use resources so people can see and comprehend what is happening
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Maintain Resilience
• Engage (control distractions)
• Persevere (modulate emotion)
• Improvisation and anticipation
• Persevere, re-evaluate, change “sense-making”
• Work the problem
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Maintain Capabilities for Resilience
1. Anticipate trouble spots
2. Capability to improvise
3. Improve capacity to:
• Do quick studies
• Develop swift trust
• Engage in just‐in‐time learning
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Deference to Expertise
• Local knowledge– Dynamic– Ambiguous, vague, nuance– Lack of lexicon for description
• Information specific to the problem• Subject matter experts
– Unique knowledge of the subject, processes, or operations
• Self-organization– Order develops from local effects, short feedback
loops, internal influences, lack of external influences
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Look to expertise not rank to inform decisions
1. Let decisions “migrate” to those with expertise to make them
2. Avoid rigid hierarchies
3. Requires psychological safety
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What is Psychological Safety?
• The belief that you won’t be punished when you make a mistake1
• The ability to speak up about a concern without fear of being humiliated or receiving retribution
• It is both fragile and vital to success2
1 Delizonna, Laura, High-Performing Teams Need Psychological Safety. Here’s How to Create It, Harvard Business Review, Aug 24, 2017, https://hbr.org/2017/08/high-performing-teams-need-psychological-safety-heres-how-to-create-it2 Edmonson, Amy, Psychological Safety and Learning Behavior in Work Teams, Admin Science Quarterly, 1999, http://journals.sagepub.com/doi/abs/10.2307/2666999
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Fight, Flight, or Freeze?
• An ancient response rooted in the amygdala, the brain’s alarm bell
• Vital in uncertain, interdependent environments
• The brain processes a provocation (by a tiger, boss, competitive coworker, or dismissive subordinate) as a life-or-death threat.
• Higher brain centers are hijacked.
• Perspective and analytical reasoning is shut down.
• “Quite literally, just when we need it most, we lose our minds.” (Edmonson)
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Mindfulness
Mindfulness – a rich awareness of discriminatory detail and an enhanced ability to discover and correct errors that could escalate into a crisis.
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Mindfulness
To act mindfully, HROs:
• Organize in such a way that they are able to notice the unexpected in the making and halt its development or;
• if unable to halt the development of the unexpected, they focus on containing it;
• and, if the unexpected breaks through containment, they focus on resilience and swift restoration of system functioning
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Mindlessness
Mindlessness is characterized by a style of mental functioning in which people:
• follow recipes
• impose old categories to classify what they see
• act with excessive rigidity or structure
• operate on automatic pilot
• mislabel unfamiliar new contexts as familiar old ones
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“The ability to deal with a crisis situation is largely dependent on the structures that have been developed before chaos arrives”
Pat Lagadec
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The HRO Culture
• The culture that in real time creates knowledge through interactions with the environment
• It requires authority mitigation (gradient) and free information flow
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Just Culture
Reporting Culture
Informed Culture
HRO Culture
Safe Culture
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HRO: Where are MHA HIIN organizations on the 5
Principles?
The 5 Principles
• Preoccupation with failure
– Attitude toward failure
– Be prepared to fail
• Refusal to simplify
– Hidden complexities
– Nonlinear interactions
• Sensitivity to operations
– Operations vs. plans
– Interactive real-time risk assessment and management
• Maintain resilience
– Persevere
– Work the problem
• Deference to expertise
– Local or specialized knowledge
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2018 HIIN Quality Convening Recap
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2018 HIIN Quality Convening
Approximately 88 hospital representatives participated in MHA’s HIIN Quality Convening, held June 6 and 7 in Columbia, MO, to network with colleagues across the state and hear from national subject matter experts.
During the meeting, keynote speaker, Dr. Joel Dvoskin, gave an enlightening session on the safety of behavioral health and mental health patients, and HIIN Fellows were recognized at the fellowship graduation.
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Breakout Sessions
Those in attendance participated in three breakout sessions for hospital-specific examples and in-depth discussions on the UP Campaign, care transitions, and worker safety.
Case studies for the UP Campaign were presented by Hirshell Parker from Ste. Genevieve County Memorial Hospital, who spoke about their hospital’s successful implementation, and Jeanie Batson from Ranken Jordan Pediatric Bridge Hospital, who shared their Antibiotic Stewardship journey.
Presenting on their hospitals’ successes with care transitions and readmissions reduction were Meagan Gray, Julie Binder, and Becca Osburn from Mercy St. Louis and Susan Randolph from Perry County Memorial Hospital.
During the last session, Tabitha Stanfast from Salem Memorial District Hospital and Keri Barclay from Harrison County Community Hospital shared their processes for creating a safer work environment.
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Full Day Workshop
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Incorporating hands-on learning, participants took part in a full-day workshop in which they were tasked with creating a table wheel of strategies to overcome barriers for five topics: patient safety, high reliability, process improvement, physician inclusion, and patient and family engagement.
Most Zero Harm Measures Award MHA congratulates the following top 10 percent HIIN-
participating hospitals with the most zero harm measures reported. These organizations have achieved, and/or sustained, a zero rate of harm and are in the top 10 percent of HIIN-participating hospitals.
Carroll County Memorial Hospital
Cedar County Memorial Hospital
Harrison County Community Hospital
Iron County Medical Center
Mercy Hospital Carthage
Missouri Delta Medical Center
Pike County Memorial Hospital
Sullivan County Memorial Hospital
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Top 10 Greatest Percentage of Improvement Award MHA congratulates the following HIIN-participating hospitals that
achieved top 10 greatest percentage of improvement to date. These organizations met the criteria of maintaining a rate below four and had reductions of 20 percent or greater in the following cumulative topic areas: ADEs, Readmissions, C. diff, CAUTI, CLABSI, falls, MRSA, VTE, pressure ulcers, SSIs, and VAC.
Carroll County Memorial Hospital
Community Hospital-Fairfax
Freeman Hospital West
Harrison County Community Hospital
Iron County Medical Center
Mercy Hospital Carthage
Mercy Hospital Lincoln
Missouri Delta Medical Center
Research Medical Center
Ste. Genevieve County Memorial Hospital
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MHA Receives AHA’s Dick Davidson Award
The American Hospital Association announced that MHA will receive the 2018 Dick Davidson Quality Milestone Award for Allied Association Leadership. The award is presented annually to a state, regional, or metropolitan hospital association that demonstrates leadership and innovation in quality improvement and for contributions to national health care improvement efforts.
MHA was recognized for member-focused initiatives to achieve the Triple Aim of better health and better care at lower costs, programs to curb opioid abuse, and population health improvement investments. The Ohio Hospital Association received an honorable mention.
The award will be presented this month at the 2018 AHA Leadership Summit in San Diego.
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HIIN Project Updates
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Data Due Dates — HIIN Project Year 2
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Milestone 8 Stipend Criteria
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HIIN Improvement Goals
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HIIN Improvement Goals
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Milestone 8 Recap
Hard deadline for ALL data (October 2016 to May 2018) is Tuesday, August 21, by close of business.
For Acute/CAH/children’s hospitals, criteria includes:
Submission of 85 percent or greater of applicable required data AND must meet Year 2 goals in eight topic areas (eligible topic areas to be defined by HRET).
Hospitals that do not meet Milestone 6 AND 7 will NOT be eligible for Milestone 8.
All applicable measures must, at least, have data submitted through January 2018 to be eligible for Milestone 8. Milestone 8 stipend is $1,525.00, if earned by the facility.
For psych/LTACH/rehab hospitals, criteria includes:
Submission of 100 percent of identified measures from October 2016 – May 2018.
Milestone 8 stipend is $500.00, if earned by the facility.56
Milestone 7 Earners
Congratulations to all acute/CAH/children’s HIIN hospitals for earning Milestone 7! Dashboards, including a Milestone 7 memo, will be e-mailed to your CEO in early August.
Thank you for your continued dedication to data submission and progress toward the 20/12 goal.
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HIIN Data Reports Update
HIIN data reports (CEO Dashboards & Improvement Calculators) will be sent to HIIN leads by Tuesday, July 31. These reports will reflect any data submitted on, or prior to, June 11 — Milestone 7 data due date.
HIIN facilities can expect customized HIIN data reports in September and December.
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Opioid Knowledge Assessment
As a follow-up to the July 9 HRET HIIN Physician Virtual Event on "Opioid Safety and Introduction of Human Diagnosis Project,". AHA is partnering with the Human Diagnosis Project on a pilot opioid assessment tool that requires physicians to solve opioid cases.
The goal is to test and improve physicians’ knowledge of opioids and pain management while simultaneously validating this tool for medical education and training purposes. The pilot tool consists of 15 engaging and interactive cases that take 2-3 minutes each to solve.
To receive a score and earn two CME credit hours (if applicable), eight cases must be completed.
The goal is to have 1,000 physicians participate! Please reach out to your physicians and encourage them to participate in the pilot assessment by clicking here.
If your hospital would like to receive an aggregate report of their physician's participation and results, please sign up.
The pilot will be open from Monday, July 23 to Friday, Aug. 10. 59
HRET/HIIN Virtual Events
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IHI Webcast | Fresh Facts: Hospital Falls and Falls Prevention
Noon to 1 p.m. Thursday, July 26, 2018
Register (Use code COMP100 for free registration under HRET HIIN)
Sepsis Alliance | Sepsis: Across The Continuum of Care Webinar: Sepsis Identification and Treatment in Post-Acute Care Setting
1 p.m. to 2 p.m. Thursday, July 26, 2018
Register
AHA Physicians Alliance | Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families
2 p.m. to 3 p.m. Wednesday, August 1, 2018
Register
PfP — PFE Learning Event | From Patient and Family Advisory Council (PFAC) to Hospital Board: Building on Metric 4 to Achieve Metric 5
Noon to 1 p.m. Thursday, August 2, 2018
Register
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HRET HIIN | Sepsis Readmission Fishbowl Series, Part 5
11 a.m. to Noon August 7, 2018
Register
AHA Team Training | From the Cockpit to the Operating Room: Strategies to Empower Leaders to Lead
Noon to 1 p.m. August 8, 2018
Register
HRET HIIN | Rural CAH Readmissions Event Sequel: The Power of Personalized Care Transitions in a CAH Setting
11 a.m. to Noon August 16, 2018
Register
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Upcoming Virtual Events
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2 p.m. Tuesday, November 27
Topic: Patient Family Engagement
Learning Objectives:
– Benefits of patient and family engagement in medication safety.
– Areas to involve Patient/Family Advisors in medication safety.
– Examples of communication tools for patients and families that aid in medication safety.
– Tara Bristol Rouse & Sue Collier
Register
2018 HIIN Huddles
2 p.m. Tuesday, September 25
Topic: Sepsis
Learning Objectives:
– Linking sepsis cases and readmissions.
– Identifying best practices and new strategies to reduce sepsis readmissions.
Register
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Preventing Patient Falls: Getting on the Right Path — What Every Health Care Facility Should Know
9 a.m. to 11 a.m. Tuesday, Aug. 7
Register on or before Wednesday, Aug. 1, to ensure delivery of instructional materials. MHA members — $225
As the number one hospital-acquired condition, falls are an important patient safety and risk management issue. Every hospital should consider having a falls team to look at this important patient safety issue. Preventing falls among patients, especially for today's aging population, requires a multifaceted approach. In addition to how to comply with The Joint Commission and the Centers for Medicare & Medicaid Services’ hospital Conditions of Participation standards on falls, this webinar will discuss recognition, evaluation, assessment, categories of risk, policies and procedures, evidence-based literature, toileting, medication alteration, hourly rounding, post-fall huddles, need to increase mobility, signage, no pass zone, safe room set up, patient education, incident reports, and prevention of falls.
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Upcoming Events
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Orientation for New Quality Improvement Directors Tuesday, Aug. 14, and Wednesday, Aug. 15
Missouri Hospital Association. Register on or before Tuesday, July 31.
This seminar is intended for anyone new to a hospital-based quality director or quality department role within the past 12 to 18 months. Supervisors and leaders interested in gaining a greater understanding of the quality and safety workflow in a hospital also are encouraged to attend.
Key topics covered include the critical tie between quality and finance, understanding regulatory requirements and survey preparation, an overview of quality measure reporting requirements, analyzing and using data to promote process improvement, the culture of safety tenets, and leading and managing improvement teams.
Additionally, participants will be given an overview of hospital safety, population health, and patient and family engagement. This is a novice-level, orientation-based seminar, intended to equip those new to quality roles with the base knowledge and skill set necessary to perform job requirements.
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Excellence In Clinical Care Series — Quality Improvement, Infection Prevention
Wednesday, Sept. 26, to Friday, Sept. 28
Camden on the Lake, Lake Ozark, MO. Register on or before Wednesday, Sept. 12
Wednesday, Sept. 26 — Quality Improvement Only — $299 per person
Thursday-Friday, Sept. 27-28 — Infection Prevention Only —$375 per person
Wednesday-Friday, Sept. 26-28 — Quality Improvement & Infection Prevention — $475 per person
This program will provide key updates regarding quality reporting, pay-for-performance programs, and legislative and regulatory changes critical for health care providers and staff to be successful in the rapidly evolving health care environment.
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Resources
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ICD-10 Codes Released for Human Trafficking The first ICD-10-CM codes for classifying human
trafficking abuse were released in June and enable clinicians to adequately classify a diagnosis for victims of trafficking and plan for appropriate treatment.
Effective for fiscal year 2019, these unique ICD-10-CM codes are available to support identification and data collection related to human trafficking.
AHA/HRET/MHA are encouraging hospitals and health systems to educate caregivers, including physicians, nurses, and other health care providers, and coding professionals about the importance of identifying victims of human trafficking and appropriately collecting data on forced labor or sexual exploitation of individuals. Additional information is available online.
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Rural Opioid Misuse Resource Map
The United States Department of Agriculture (USDA) unveiled a new interactive rural opioid misuse map which displays opioid-related projects by state. The interactive map was created for rural communities to easily access and share opioid prevention and management information with other communities across the nation. Through this map, communities can work together in battling the causes and impacts of rural opioid misuse.
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Mapping Medicare Disparities Tool
Chronic diseases pose a significant problem in the United States resulting in substantial morbidity, mortality, disability, and cost. The CMS Office of Minority Health has designed an interactive Mapping Medicare Disparities Tool to identify areas of disparity between subgroups of Medicare beneficiaries (e.g., racial and ethnic groups) in health outcomes, utilization, and spending.
The tool is an excellent starting point to understanding and investigating geographic and racial and ethnic differences in health outcomes. This information may be used to inform policy decisions and to target populations and geographies for potential interventions. Additional information is available online.
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Statewide PFAC Challenge
MHA's Statewide PFAC challenges every hospital in the state of Missouri to identify at least one non-employee patient or family member serving on at least one committee within the organization by July 2019.
We encourage all hospitals to accept this challenge and achieve this critical PFE goal. Use this Patient and Family Engagement Roadmap as a strategic guide throughout your journey. It outlines and provides links to resources to support hospitals progression in achieving a “yes” answer to all 12 PFE metrics.
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CDC Issues Spanish Version of Antibiotic Stewardship Materials
The Centers for Disease Control and Prevention released Spanish versions of its most popular materials to educate health care providers and consumers regarding the appropriate use of antibiotics and preventing the spread of antibiotic-resistant bacteria. Printed materials also may be ordered online.
Additional tools to prevent antibiotic resistance, including an antimicrobial stewardship toolkit, also are availableonline.
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SME Monthly Spotlights
Adverse Drug Events — Opioid Safety in the Hospital
Falls Prevention
Hospital-Acquired Infections
Patient and Family Engagement
Pressure Ulcer
Reducing Preventable Readmissions
VTE Prevention and Management
Worker’s Safety – sent via email on Monday, July 23
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Adverse Drug Events
Airway Safety
Catheter-Associated Urinary Tract Infection
C. difficile Infection
Central Line-Associated Bloodstream Infection
Culture of Safety
Delirium
Exposure to Radiation
Falls
Multi-Drug Resistant Organisms
Pressure Ulcers
Readmissions
Sepsis
Surgical Site Infection
Ventilator-Associated Event
VTE Change Package
Malnutrition
Change Packages These change packages are a summary of
themes from the successful practices of high performing health organizations across the country.
They have been developed through clinical practice sharing, organization site visits, and subject matter expert contributions.
These change packages include a menu of strategies, change concepts and specific, actionable items that any hospital can implement based on need or for purposes of improving patient quality of life and care.
The change packages are intended to be complementary to literature reviews and other evidence-based tools and resources.
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ListServ
Gain access to other hospitals, national and state subject matter experts, and other resources to avoid reinventing the wheel.
Listserv sign-up is open through the duration of the HIIN. Sign up today!
HRET HIIN topics: ADE, children’s hospitals, data analytics, health care disparities, hospital-wide topics, ICU, infections, level 1 trauma, patient and family engagement, readmissions, rural/critical access hospitals, sepsis, and Spanish.
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Monthly Quality & Safety Update
The Quality & Safety Update provides health care professionals with up-to-date information on current quality improvement projects, resources and quality reporting. The newsletter also highlights announcements and upcoming events that could benefit your organization.
80Past issues are available on MHAnet.com.
Quarterly MHA Trajectories
Trajectories is a quarterly publication of MHA focusing on progress in quality and population health efforts.
May 2018 ─ “Advancing
Population Health: Assessment and Action in
Missouri Hospitals ”
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Questions?
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Missouri HIIN Team
•Jessica Stultz, RN, BSN, MHA, CPHQ
•Director of Clinical Quality
•573/893-3700, ext. 1391
Jessica Stultz
•Amanda Keilholz, CPHQ
•HIIN Program Manager
•573/893-3700, ext. 1405
Amanda Keilholz
•Toi Wilde, RN, BSN, MBA, CPHQ
•HIIN Program Manager
•573/893-3700, ext. 1406
Toi Wilde
•Mary Shackelford, RN, BSN
•Improvement Advisor
Mary Shackelford
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