MHA: Strategic Quality What’s Up Wednesday|Lunch and LearnYour clinical quality, process improvement resource

Jessica Rowden, RN, BSN, MHA

Director of Clinical Quality

http://web.mhanet.com/strategic-quality/

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October Topics of Interest

Brief handwashing overview

Mercy

MHA Update

Qualaris

NHSN (ICD10 and confer rights)

Transparency update

Immersion project update

HEN 2.0 update

Recognition opportunities

Upcoming events

Handwashing

Meet Infection Control Barbie, Ami

Links to Hand WashingResources

Centers for Disease Control and Prevention

Institute for Healthcare Improvement

The Joint Commission

World Health Organization

Hospital Spotlight

Mercy

Hospital Springfield

Blood Utilization Review Committee (BURC) 1235 East Cherokee

Springfield, Missouri 65804

October 7, 2015

Blood Utilization and Resource Conservation

Amy Loehr, MT (ASCP), MBA Manager-Transfusion Services

Mercy Hospital Springfield

July 2014 – June 2015

Tertiary hospital and Level 1 trauma center:

34,062 Acute discharges

12,437 Inpatient surgery cases

25,789 Outpatient surgery cases

92,836 Emergency Department visits

Blood Products: Risks/Costs

Adverse effects/Risks

• Transfusion reactions

• Immunosuppression

o Dose (#units) dependent

increased risk of infection

• TRALI, TACO

• Anaphylaxis

• Death

• Transmission of infectious

diseases

• Graft-vs-host reactions

• Other rare effects

Dose dependent risks• Each extra unit increases

risks significantly!

Acquisition costs • 21.5% of total cost

Total cost of RBC• $1,158 (2007 value)

• 40.6% indirect overhead

• 34.0% total transfusion

process cost

• by Shander et al

RBC Transfusion Recommendations

The Right Patient

Hemodynamically stable anemic

The Right Indication

Hemoglobin Trigger < 7 g/dL

The Right Dose

Give 1 unit and recheck Hgb

Started ECMO—January 2014

Started VAD—September 2014

September

Blood Utilization Improvements Multidisciplinary team with two physician champions and a strong

commitment to improve transfusion practices

Obtain transfusion data at the provider level and analyze clinical

appropriateness of transfusion

Education—Physician, Advance Practice Professional, Nursing and

Blood Bank

Develop educational posters and rack cards

Article submission: Healing without Harm, In Touch, Monday Morning

Leadership rounding specific to transfusion practices

Storytelling

Enhancement to electronic health record

EHR Improvement

for Blood Utilization

Higher is Better

Rate

Baseline - March 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Springfield: Single RBC Transfuse Orders

Mercy Hospital Springfield

Hemoglobin result before transfusion order

0%

10%

20%

30%

40%

50%

60%

70%

80%

Aug-14 Sept-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15

< 7 g/dL 7 - 7.9 g/dL 8 - 8.9 g/dL Total > 8.9 g/dL No Hgb

Blood Wastage Improvements

Developed blood wastage reports by

nursing unit

Real time feedback to provider includes

reason for wastage and cost of wasted

product

Blood bank developed a color coded

tracking system to identify products

closest to expiration

2015 Transfusion Service Wastage Tracking

Month Specific Wastage Reason: Cost of Blood Product Units

Total Cost

for Month

Exp

ired

on S

helf

Bag

Bro

ke /

Spi

ked

Ret

urne

d o

ut o

f Tem

p

Can

celle

d/E

xp o

n S

helf

Pat

ient

Exp

ired/

Exp

on

She

lf

Ret

urne

d in

Coo

ler/

Tem

p no

t

OK

Irra

diat

ed E

xpire

d on

She

lf

Ret

urne

d in

Wro

ng C

oole

r

Use

d fo

r Q

C

Tra

nspo

rted

with

pat

ient

/not

tran

sfus

ed

Out

too

Long

/Coo

ler

expi

red

MIS

C

Sto

red

in u

nmon

itore

d fr

idge

January 5210 1670 609 195 195 $7,879

February 2994 195 830 1388 $5,407

March 3365 1835 499 445 975 $7,119

April 2051 305 1685 576 694 $5,311

May 554 915 576 499 195 390 $3,129

June 1163 55 288 $1,506

July 1996 1184 499 885 $4,564

August 2715 1487 1862 193 55 $6,312

September $0

October $0

November $0

December $0

Total $20,048 $500 $9,661 $4,045$1,309 $0 $4,829 $250 $0 $0 $0 $585 $0$41,227

Keys to Success

• Senior leadership support

• Physician champion

• Multi-disciplinary approach to blood utilization

• Involve and seek input from frontline co-workers

• Storytelling

• Monitoring adherence and provide feedback

• Transparency of data

Contact Information

Amy Loehr, MT (ASCP), MBA

Manager-Transfusion Services

417-820-2883

amy.loehr@mercy.net

MHA Update

Qualaris

Qualaris Informational Video

Video Link

Qualaris

Falls Immersion Pilot Project process data collection

CAUTI Immersion Pilot Project process data collection

Apps are open to those hospitals not participating in the Falls and CAUTI projects

Qualaris Q&A Session

NHSN

Confer Hospital NHSN rights

Confer rights to HIDI (not HRET)

Only 21 hospitals have completed this step…130 to go

NHSN Data

Why?

To provide you the most robust data portfolio

To better assist you with more improvement opportunities

See the Instructional Guide

Decrease the amount of time spent submitting data!

NHSN ICD-10 Update

NHSN uploaded Excel documents to assist facilities in preparing for the upcoming changes to procedural coding with the ICD-10 transition, as they impact surgical site infection surveillance and reporting to NHSN. The documents are located in the “supporting materials” section of the website. There are excel documents for both acute care facilities and ambulatory facilities.

NHSN ICD-10 update NHSN will not have the ability to receive the ICD-10 codes until

the January 2016 NHSN release.

Beginning October 1, 2015 and continuing until the January 2016 NHSN release, when entering surgical procedure (denominator) data into NHSN for SSI surveillance, facilities should enter the NHSN Procedure Code (e.g. COLO or HYST) as identified in the new mappings provided, but not enter any ICD-10-PCS/CPT codes associated with the procedure. This includes data that is entered manually, electronically downloaded, or imported via a comma-separated value (CSV) file.

Once the NHSN release takes place in 2016, facilities will once again be able to choose to enter the NHSN Operative Procedure Code category or instead enter one of the ICD-10-PCS or CPT codes, and have NHSN auto-populate the NHSN Operative Procedure Code category.

Transparency

Transparency Update

Immersion Pilot Project Update

Immersion Pilot Projects

MHA lead

Pilot projects (CAUTI, Sepsis, Falls, OB, Readmissions)

Statewide participation, aligned with HEN 2.0, but separate from HEN contract

Guided instruction to implement existing, recommended EBP strategies/bundles

Increase the speed/efficiency of EBP uptake

Increase the effectiveness of EBP uptake

Drive harm/readmissions reductions

Serve as a “force multiplier”

HEN 2.0, MHA transparency measures, VBP, HAC, HRRP

Methodology

We are

here

Kick-off

mtg

Webinars/shared learning

90-day work cycles

MHA convention

2016

Project Timeline

HEN 2.0

CMS

AHA/HRET

MHA

QIN

≥93 hospitals

30 other State Hospital

Associations

16 other National HENs

MHA is part of AHA/HRET’s HEN cohort

Visit the HEN tab on our website for HEN updates

Enrollment Process

Hospitals sign and submit their commitment letter to MHA

MHAs send CDS login and Quick Start Guide & Needs Assessment

Hospitals complete needs assessment and enter baseline data

Enrollment complete!

MHA walks through onboarding documents and priorities with hospitals

Commitment letters due 11/2/15

Needs Assessment

due 11/16/15;Baseline data due

1/31/2016

Enrollment Process

Hospitals sign and submit their commitment letter to MHA

MHAs send CDS login and Quick Start Guide & Needs Assessment

Hospitals complete needs assessment and enter baseline data

Enrollment complete!

MHA walks through onboarding documents and priorities with hospitals

Commitment letters due 11/2/15

Needs Assessment

due 11/16/15;Baseline data due

1/31/2016

Hospital Commitment Letter

Commitment will require

Focus on readmission and CAUTI reductions

CEO and HEN lead signatures and contact information

Commitment to:

– Work on all applicable topics

– Submit data on all applicable topics

– Collaborate and share

– Participate in a MHA lead immersion pilot project

Hospital Commitment Letter“By signing this commitment letter, Hospital agrees to be an active and engaged participant in this initiative and agrees to the following:

Work on all applicable topic areas including the core topics, other topics and operational metrics. Hospital agrees to commit to specifically prioritizing:

Catheter-associated Urinary Tract Infection (CAUTI) reduction in all units where catheters are utilized, including the emergency department—this includes a commitment to decrease unnecessary urinary catheter placement in the hospital; and

Reducing 30-day all-cause readmissions.

Submit required data on all applicable topics including:

Project kick-off needs assessment by November 16, 2015;

Baseline data by January 31, 2016;

Monthly monitoring data for the duration of the project.

Commit to Collaboration

Participate in and share success stories and lessons learned with other HEN hospitals via LISTSERV®s, webinars and in-person meetings; and

Participate in site visits by MHA and the AHA/HRET HEN team.”

CMS encourages:

Better pursue the reduction of all-cause harm: increasingly add topics beyond the original list of 11 “core topics”

Introduce the concept of nationally-standardized measures for the core areas of harm, yet retain some flexibility

Collect and report hospital level data

Increased attention to eliminating health disparities as they contribute to adverse events and readmissions

CMS “Thing One”: Focus on RESULTS

Priority #1: Generate results on the PfP Aims

Get in action fast

Pin down hospital recruitment right away; meet or exceed your targets in this area

Get your hospitals actively engaged and reporting on multiple harms (all 10) and readmissions --make “reducing harm across the board” real in your HEN

Generate improvements in harm rates and readmissions

CMS “Thing Two”: Being and Culture Building

Results-focused: harm reduction, improved health, lower costs

Actively teaming with QIOs and others

Surfacing the joy in our work, and the work of caring for patients

Rapidly learning and evolving together –embracing emergent strategy

Inclusive of Patients and Families as partners –Customer Centered

Respectful & embracing of successful front-line practitioners’ knowledge and leadership

All Teach, All Learn

Inclusive of Multiple Disciplines & Roles in Practices

Potential HEN Data Measures

Pending CMS Feedback:• Additional outcome measures may be added per CMS • Process measures TBD and submission is expected per CMS• Additional improvement work and data submission on

“Other” topics TBD per CMS/HRET• Baseline measurement timeframe to be finalized by CMS

Baseline Data

Pending CMS approval: baseline data timeframe will be 3rd quarter 2015 –or– 2010 or more recent pending availability

Successful submission of baseline data (of all abstracted/applicable topics) before deadline of January 31, 2016, hospital will be awarded $2,000.

Per HRET:

Measures as outlined in EOM are a go!

Updated EOM will be released ASAP

Baseline & monitoring timeframes

Baseline 3Q 2015 (Jun 1-Sep 30 2015)

– Additional data pending confirmation from CMS

Monitoring, monthly Oct 2015 forward

Process measure data will be expected

Additional topic measures TBD

Sepsis, C. Diff are strongly recommended

CAUTIFocus Area Required Outcome Measure(s)

Catheter‐associated

urinary tract infections

(CAUTI), in all hospital

settings, including

avoiding placement of

catheters in the

emergency room and in

the hospital.

For hospitals reporting data to the National

Healthcare Safety Network (NHSN):

CAUTI Standardized Infection Ratio (SIR)

(NQF 0138) reported for

o Intensive Care Unit (ICU) Units, excluding

Neonatal Intensive Care Units (NICU)

o ICU + Other units

Urinary catheter utilization ratio (catheter days

/ patient days)

For hospitals NOT reporting data to NHSN1:

CAUTI Rates (CAUTIs per 1,000 catheter days,

CAUTIs per 10,000 patient days) reported for

o ICU Units, excluding NICU

o ICU + Other inpatient units

Urinary catheter utilization ratio (catheter days

/ 10,000 patient days)

CLABSIFocus Area Required Outcome Measure(s)Central-line associated

bloodstream infections

(CLABSI), in all hospital

settings

For hospitals reporting data to NHSN1:

CLABSI SIR - (NQF 0139) reported for

o ICU Units, including NICU

o ICU + Other units

Central Line utilization ratio (central line days /

10,000 patient days)

For hospitals NOT reporting data to NHSN1:

CLABSI Rates (CLABSIs per 1,000 central line

days, CLABSIs per 10,000 patient days) reported

for

o ICU Units, including NICU

o ICU + Other inpatient units

Central Line utilization ratio (central line days /

patient days)

FallsFocus Area Required Outcome Measure(s)Falls Falls with injury (NQF 0202) all acute care

units*

*this is an abstracted measure

OB/EEDFocus Area Required Outcome Measure(s)

Obstetrical (OB)

adverse events

Early elective deliveries (EED) (PC-01, NQF

0469)*

Vaginal deliveries with instrument (Agency

for Healthcare Research & Quality [AHRQ]

PSI 18)**

Vaginal deliveries without instrument (AHRQ

PSI 19)**

*this is an abstracted measure

**AHRQ’s data system is not supporting ICD-10 – discussions taking

place between MHA/HIDI/HRET/CMS/AHRQ on contingency plan to

obtain this data without additional hospital abstraction

Pressure UlcerFocus Area Required Outcome Measure(s)Pressure ulcers

(PrU)

PrU rate, Stages 3+ (AHRQ PSI-03)**

PrU prevalence (hospital-acquired), Stage 2+

(NQF 0201)*

*this is an abstracted measure

**AHRQ’s data system is not supporting ICD-10 – discussions

taking place between MHA/HIDI/HRET/CMS/AHRQ on contingency

plan to obtain this data without additional hospital abstraction

SSIFocus Area Required Outcome Measure(s)

Surgical site

infections

(SSI)

For hospitals reporting data to NHSN:

SSI SIR (NQF 0753), reported for

o Colon surgeries

o Abdominal hysterectomy

o Total hip replacements

o Total knee replacements

For hospitals NOT reporting data to NHSN:

SSI Rates reported for

o Colon surgeries

o Abdominal hysterectomy

o Total hip replacements

o Total knee replacements

VAP/IVACFocus Area Required Outcome Measure(s)Ventilator-

associated

events (VAE)

For hospitals reporting data to NHSN:

Ventilator-Associated Condition (VAC)

Infection-Related Ventilator-Associated

Complication (IVAC)

For hospitals NOT reporting data to NHSN:

Ventilator-Associated Condition (VAC)

Infection-Related Ventilator-Associated

Complication (IVAC)

VTEFocus Area Required Outcome Measure(s)

Venous

thromboembolism

(VTE), all surgical

settings

Post-Operative pulmonary embolism (PE)

or deep vein thrombosis (DVT) rate

(AHRQ PSI-12)**

**AHRQ’s data system is not supporting ICD-10 – discussions

taking place between MHA/HIDI/HRET/CMS/AHRQ on contingency

plan to obtain this data without additional hospital abstraction

ADEFocus Area Required Outcome Measure(s)Adverse drug events (ADE),

including, at a minimum, opioid

safety, anticoagulation safety

and glycemic management for

both adult and pediatric

populations.

ADEs per 1,000 patient days*

*this is an abstracted measure

ReadmissionsFocus Area Required Outcome Measure(s)

Readmissions All cause 30‐day readmissions

Other and Operational TopicsOther Topics Operational Metrics

Severe sepsis and septic shock Patient and Family Engagement (PFE)

Hospital culture of that fully

integrates patient safety with

worker safety

Health Care Disparities (HCD)

Iatrogenic delirium Engaging Leadership and Governance

Clostridium difficile (c.diff)

including antibiotic stewardship

Undue exposure to radiation

Airway safety

Failure to rescue

Pay for Performance ModelPay for performance model of stipend distribution based on improvement and data submission

6 months into HEN (April) review of data

Data submission – all preferred/aligned measures data submission must be ≥ 85% to be eligible

Performance Stipend sliding scale

Hospital achieves 17.6-39% harm reduction and/or achieves 10-19% readmission reduction

$1,500

Hospital achieves ≥40% harm reduction or maintains zero baseline and/or achieves ≥20% readmission reduction

$3,000

End of HEN project review of data

Data submission – all preferred/aligned measures data submission must be ≥ 85% to be eligible

Performance Stipend sliding scale

Hospital achieves 17.6-39% harm reduction and/or achieves 10-19% readmission reduction

$1,500

Hospital achieves ≥40% harm reduction or maintains zero baseline and/or achieves ≥20% readmission reduction

$3,000

$6,000 is maximum pay for performance amount + $2,000 for complete baseline submission = $8,000 per hospital

Additional Data Support

Quality Collections User Guide

1:1 support

Excel templates for data collection and submission

HRET List-serv

http://www.hret-hen.org/inc/dhtml/listserv.dhtml

Important HEN dates

October 15th: HEN kick-off in Columbia

Monday, November 2, 5 PM CT: Hospital commitment is due in

Following confirmation of commitment - you will be sent CDS login information.

Monday, November 16: Hospital needs assessment is due

Hospitals will need to complete this in CDS; all subsequent data will be entered in HIDI Quality Collections

Sunday, January 31, 2016: Baseline data is due

Abstracted measures are due in HIDI Quality Collections

MHA will upload your claims measures into CDS

Recognition Opportunities

National: Quest for Quality Award

Nomination form www.aha.org/questforquality – due October 11, 2015

Prize honors are

One winner; up to two finalists; and up to four Citations of Merit honorees.

The winner will receive $75,000; each finalist will receive $12,500. The awards will be presented at the AHA-Health Forum Leadership Summit (July 17-19, 2016) in San Diego.

2015 John M. Eisenberg Patient Safety and Quality Awards

The Eisenberg Awards recognize major achievements by individuals and organizations to improve patient safety and healthcare quality, consistent with the aims of the National Quality Strategy: better care, healthy people and communities, and affordable care. Better care, in particular, focuses on improving overall quality by making healthcare patient centered, reliable, accessible, and safe.

In 2015, awards will be given in the following categories:

Individual achievement

National - System Innovation in Patient Safety and Quality

Local - System Innovation in Patient Safety and Quality

Submissions will be accepted from September 8, 2015, through October 30, 2015. Winners will be notified by February 1, 2016.

Member Resources and Support

Website Resources

Missouri Quality Snapshot – Quarterly

Past webinar recordings and presentations

MHA Resources

guides, IPPS updates, toolkits, Quality Resource Briefs, OB

AHRQ and IHI toolkits and guides

Upcoming event registration

VISIT HRET’s HEN WEBSITE FOR ADDITIONAL RESOURCES AND SEE UPCOMING EVENTS

Monthly Newsletter

Upcoming Events

Important HEN dates

October 15th: HEN kick-off in Columbia

Monday, November 2, 5 PM CT: Hospital commitment is due in

Following confirmation of commitment - you will be sent CDS login information.

Monday, November 16: Hospital needs assessment is due

Hospitals will need to complete this in CDS; all subsequent data will be entered in HIDI Quality Collections

Sunday, January 31, 2016: Baseline data is due

Abstracted measures are due in HIDI Quality Collections

MHA will upload your claims measures into CDS

Upcoming Events

November 3-6 – MHA Convention

November 10, from 2 - 3 p.m. - MHA's Price and Quality Outcome Transparency Initiative Webinar

November 11, from Noon to 1 p.m. – What’s Up Wednesday

November 18, from Noon to 1 p.m. – MHA Clinical Quality Quarterly Webinar

December 2, from Noon to 1 p.m. – What’s Up Wednesday

Pencil me in… IP webinars:

December 3rd 11-12 – Sepsis Immersion Project webinar December 3rd 1-2 – Falls Immersion Project webinar January 4th 11-12 – Readmission Immersion Project webinar January 5th 11-12 – CAUTI Immersion Project webinar January 5th 1-2 – OB Immersion Project webinar

March 22nd 11-12 – Sepsis Immersion Project webinar March 22nd 1-2 – Falls Immersion Project webinar March 23rd 11-12 – Readmission Immersion Project webinar March 24th 11-12 – CAUTI Immersion Project webinar March 24th 1-2 – OB Immersion Project webinar

June 14th 11-12 – Sepsis Immersion Project webinar June 14th 1-2 – Falls Immersion Project webinar June 15th 11-12 – Readmission Immersion Project webinar June 16th 11-12 – CAUTI Immersion Project webinar June 16th 1-2 – OB Immersion Project webinar

Pencil me in…

Monthly HEN webinars

Scheduled soon to correlate with data updates

Monthly What’s Up Wednesday

First Wednesday of the month at noon

Pencil me in…

HEN 2.0 mid-year conference

March 9, 2016, Hilton Garden Inn, Columbia, MO

HEN 2.0 end-of-year conference

August 25, 2016, Hilton Garden Inn, Columbia, MO (might push this back d/t later than expected contract award…stay tuned)

Because this is a federal grant, food/drinks cannot be provided at conferences. At the time of registration,

you have the option to pay for your lunch that will be provided on-site.

Collaboration with the QIO

https://www.tmfqin.org/

Join the group for free and get access to more resources!!

MHA:SQI – http://web.mhanet.com/strategic-quality/

Leslie Porth, Ph.D., R.N.,

MSN

Senior Vice President of

Strategic Quality Department

Triple Aim

Population Health

Oversight of division (Quality Improvement, Quality Works,

Emergency Preparedness)

MONL

Alison Williams, R.N., BSN, MBA-

HCM

Vice President of Clinical Quality Improvement

Dana Downing,

B.S., MBA-H, CPHQ

Vice President of Quality Program

Development

National quality measures

Quality outcome transparency

Electronic clinical quality measures

FLEX grant

MOAHQ facilitation

Stephen Njenga, MPH, MHA, CPHQ

Director of Performance

Measure Compliance

MBQIPData Management

and analytics

HEN projects

Performance measurement

Quality Works grant projects, education

MOAHQ

Jessica Rowden, R.N.,

BSN, MHA

Director of Clinical Quality

Clinical quality SME

Data management and analytics

HEN/AHRQ grant projects

TeamSTEPPSmaster trainer

Host of WUW|LNL

MOAHQ

MONL

Social Media

Cheryl Eads

Executive Assistant of

Quality Improvement

Provides support to the SQI team

Coordinates webinars,

conference calls and meetings

Distributes correspondence and

communication

Assists in maintaining reports

Lporth@mhanet.com573/893-3700x1305

Awilliams@mhanet.com573/893-3700x1326

Ddowning@mhanet.com573/893-3700x1314

Jrowden@mhanet.com573/893-3700x1391

Ceads@mhanet.com573/893-3700x1382

Clinical quality SME

Oversight of Quality Improvement

Grant management

Collaborative management

Patient & Family Engagement

MONL

MOAHQ

Snjenga@mhanet.com573/893-3700x1325

Thank You for Joining Us

Please fill out the evaluation

Give feedback and offer suggestions

Debrief: tell us what went well and what didn’t

What topics would be beneficial to your organization

Be a featured hospital speaker during WUW 2016

See you next month October 7 at noon

Blood transfusion improvements at Mercy

Contact Information

Jessica Rowden, R.N., BSN, MHA

Director of Clinical Quality

Missouri Hospital Association

jrowden@mhanet.com

(573) 893-3700, ext. 1391