transition year: 2016 program kick off!2016/01/21 · program kick off! ----- how to participate in...
TRANSCRIPT
Transition Year: 2016 Program Kick Off!
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How to participate in today’s
Webinar presentation
1. Overview of 2016 PSF Measures
2. Potential New Initiatives in 2017
3. Data definitions and database review
4. Q & A , Data Support, and Contact Information
5. Patient Safety First Calendar in the 3 Regions
Presentation Overview
Patient Safety First…a California Partnership for Health
One of the largest State-wide Patient Safety Collaboratives in the nation, launched in 2010.
Funded by Anthem Blue Cross
A partnership between: HASC
HASDIC
HCNCC
NHF
ABC
And ALL OF YOU!
Sepsis Mortality
Perinatal Safety NTSV Cesarean Rate
Obstetric Hemorrhage
___________________________________________
HQI/CalHEN is your continuing partner for C. Diff and Surgical Safety – Stay tuned!
Patient Safety First Initiatives - 2016
Pre-polling question:
Please enter your answer into the Question box
What one or two topics- areas of clinical or operational improvement- would be helpful for a PSF Collaborative focus in 2017? Think of your hospital’s strategic planning discussions, or areas of concern discussed in QI, Patient Safety, or Medical Staff meetings…
Potential New Initiatives
Polling Question #1
Which of these topics would be most helpful (Your #1 choice) for PSF Collaborative support in 2017?
A) Most Appropriate Care/Choosing Wisely
B) Enhanced Recovery after Surgery
C) Population Health
D) Advance Care Planning
Potential New Initiatives
Polling Question #2
Which of these topics would also be helpful (Your #2 choice) for PSF Collaborative support in 2017?
A) Most Appropriate Care/Choosing Wisely
B) Enhanced Recovery after Surgery
C) Population Health
D) Advance Care Planning
Potential New Initiatives
PSF Measures & Data Entry Process
Mia Arias, MPA
Director of Programs
Measure Goal
Sepsis Mortality Decrease sepsis mortality by 10% from
baseline (2015)
Cesarean Section Rates Target 23.9% for Low-risk First-birth (NTSV)
Cesarean Birth Rate
Obstetrical Hemorrhage Achieve a 0% rate of cases with 4 or more
units of RBC
2016 PSF Goals
Importance of Data Submission
Requirement for participation in PSF Enables us to monitor success and report on lives
saved, quality outcomes and cost reductions
Used to report progress to our funder
Helps ensure the most effective and beneficial program is provided to hospitals
PSF Data Submission Info
Quarterly data submission is requested for all clinical areas your hospital is working on.
Baseline data requested is from 2015- for all 4 quarters.
Data will always be reported in aggregate (regional or statewide level)—PSF will not report hospital specific data.
Hospitals can enter or edit data at any time.
Data Definition #1
Numerator: Number of sepsis patients who expired from the denominator.
Denominator: Number of sepsis patients 18 years and over with an ICD-10 principal or other diagnosis code of sepsis, severe sepsis or septic shock.
Data Definition #2
Numerator: Number of sepsis patients who expired from denominator
Denominator: Number of sepsis patients 18 years and over with an ICD-10 principal or other diagnosis code of sepsis, severe sepsis or septic shock excluding those with admitting orders of no code, or comfort care only in a given quarter
Rate= Numerator* 100 /Denominator
Sepsis Mortality
Process Measures
Simulation training participation
Surviving Sepsis Campaign Guidelines/Bundle
CMS Guidelines
Sepsis Cont…
Data Definition
Numerator: Patients with cesarean sections from the denominator
Denominator: Nulliparous patients delivered of a live term singleton in vertex position
Rate= Numerator*100/Denominator
Cesarean Section Rate for Low-Risk First Birth Women (NTSV CS Rate)
Process Measures
Guidelines for Induction for Nulliparous at/after 41 weeks
Protocol/Policies for Labor Management Practices
Staff/Physician Education on avoiding preventable NTSV C-Sections
Patient Counseling/Education (Nulliparous women with unfavorable cervix should be counseled about the risk of C-section and its effects on subsequent pregnancies during the child birth class)
NTSV Cesarean Rate
Data Definition
Numerator: Total number of women in the denominator who received > 4 units of RBCs
Denominator: All women during the birth admission (>20 weeks of gestation) who were discharged in the selected quarter
*Transfusion data is typically provided by the blood bank. Harmonized with the new Joint Commission indicator for Severe
Maternal Morbidity that is effective Jan 2015. An uncommon event (~1/500 births). Submit the number of cases with ≥4 units of RBC per quarter.
Rate Calculation: Rate= Numerator*1000/Denominator
Maternal Hemorrhage Outcome Measure 1 - Rate of mothers transfused with 4 or more units red blood cells
Data Definition
Numerator: Among the denominator, total number of women who experienced Severe Maternal Morbidity defined by a set of ICD-10 diagnosis and procedure codes
Denominator: All women with a birth admission (>20 weeks of gestation) and were discharged in the given quarter who had an obstetric hemorrhage diagnosis
Data Source: Data is collected entirely with submitted ICD-10 codes from Hospital Discharge Diagnosis files.
Rate Calculation: Rate= Numerator*100/Denominator
Measure 2- Severe Maternal Morbidity
(SMM)
Process Measure
Completed Post-hemorrhage debrief forms* for hemorrhage ≥Stage 2 or ≥ 1000 ml Blood loss
• Debriefs following an event was judged by the expert panel to support full implementation of the safety bundle.
• If severe hemorrhages are uncommon on your unit, the debrief form can be completed for lesser hemorrhages.
Maternal Hemorrhage
Hospitals reporting to CMQCC California Maternal Data Center (CMDC) please confer rights to share data for OB measures with PSF/NHF. This will eliminate duplication of data entry for you and your facility. For more information on conferring rights, please contact the CMDC help-desk at [email protected]
Hospitals Reporting OB Data to CMQCC California Maternal Data Center (CMDC)
Data Entry: Key Contacts
The key contact is responsible for ensuring timely and accurate data submission at each hospital
The key contact can disseminate log-in information to appropriate staff within their organization
All individuals responsible for data entry should be
trained to use the database prior to entering data
If the key contact changes, please contact NHF/Mia Arias to update this information in the database
Patient Safety First Database Demo
The PSF database can be found online at:
www.nhfca.org/PatientSafetyFirst/
Anne Castles, Project Manager, CMDC
Valerie Cape, Program Manager, CMQCC, Stanford University Medical School
Partners at CMQCC
: Transforming Maternity Care
Authorizing Data Transfers to PSF
Three Steps
1. One Time: Confer Rights in the MDC
2. Monthly or Quarterly: Submit any necessary data to the MDC
3. Quarterly: Approve Data Release
: Transforming Maternity Care
One Time: Confer Rights through Authorization in the MDC
• Hospital staff with MDC “Administrator” status log into the MDC
at https://datacenter.cmqcc.org
• In the top black bar, click on Admin/Data Releases
• Under “Patient Safety First” program, click “Complete Data
Release Authorization form”
• Per screen shot below, check any of the measures you want
CMQCC to report on your behalf to the program
• Choose the start date from the “Beginning From” drop down
menu (please take care to choose!). Start date 1/1/2015
• Check all the attestation boxes and complete the
information regarding who is authorizing the release.
• Select the staff that will be in charge of making monthly /
quarterly approvals for the data to be transferred to the
reporting program.
• Click the green button “Authorize Release of Data”
Conferring Rights to CMQCC to Transfer Data to External Reporting Programs:
Patient Safety First or the CMS Inpatient Quality Reporting Program
: Transforming Maternity Care
: Transforming Maternity Care
: Transforming Maternity Care
Submit Necessary Data (Monthly or Quarterly)
Patient Discharge Data (PDD) required data file submission for active-
track participants in the CMQCC Maternal Data Center
For the NTSV CS measure, your hospital will only need to have
submitted the PDD for the period.
For the EED and Hemorrhage measures, your hospital will also need to
complete the minimal additional chart review for those measures (in
the Data Entry Status area, listed as “Elective Delivery” and “CPMS:
Hemorrhage”)
View only
participants
will see only
the CPMS
hemorrhage
(and
preeclampsia
data entry
options
: Transforming Maternity Care
Approve Data Release for the Period (Monthly or
Quarterly)
You must approve each period’s results for your
hospital. CMQCC will not transfer data on your behalf
until we have received your approval for that period.
The approval button will appear on the MDC Home
Page after data submissions are complete.
: Transforming Maternity Care
Upon clicking the button, you will see a list of the rates
requiring approval highlighted in yellow. Click the
green button “Approve this Data Release” after
reviewing (and/or correcting the underlying data).
: Transforming Maternity Care
ONLY For CMS Inpatient Quality Reporting
Program (Quality Net)
Please check with your Quality Department before you
authorize releases for the CMS Inpatient Quality
Reporting Program. If you want CMQCC to report to
CMS Quality Net site on your behalf, there is another
important step. In addition to completing the
authorization in the Maternal Data Center, you must
also log into Quality Net and select CMQCC as your
vendor for the perinatal care measure. Otherwise, we
cannot report your data for you. CMQCC is listed
under: Stanford University/California Maternal Quality
Care Collaborative: Vendor ID 100565.
Please raise your ‘hand’ icon and we will open up your line. Be sure you have entered your pin #
-OR-
Type your question into the question pane and we will read it aloud.
Q&A
Regional PSF Contacts
Jenna Fischer, CPPS
Vice President of Quality & Patient Safety
Hospital Council of Northern & Central California (HCNCC)
TEL: (925) 746-5106
Alicia Munoz, FACHE
Vice President of Quality Improvement & Patient Safety
Hospital Association of San Diego & Imperial Counties (HASDIC)
TEL: (858) 614-1541
Julia Slininger, RN, BS, CPHQ
Vice President of Quality & Patient Safety
Hospital Association of Southern California (HASC)
TEL: (213) 538-0766
1/20 & 1/21 Kick Off Webinar – YOU ARE HERE!
Perinatal Safety Webinar April 6 Sepsis Management Webinar April 21 Patient Safety Culture Webinar April 26
Perinatal Safety Webinar August 9 Sepsis Management Webinar August 17 Patient Safety Culture Webinar August 25
Perinatal Safety Webinar October 6 Sepsis Management Webinar October 12 Patient Safety Culture Webinar October 18
Statewide
Webinars
HQI 2016: Annual Conference - November 2-4, 2016 — Hilton San Diego Resort & Spa
Hospital Council (HCNCC) Patient Safety First Programming
April 22nd in-person Luncheon and Education Seminar in Visalia (Central Valley)
May 19th in-person Luncheon and Education Seminar in San Rafael (Marin County)
June 17th Luncheon and Education Seminar in Oakland (Bay Area)
Save these dates on your calendar and let me know if you are interested in showcasing your good work in one of our breakout sessions. Email me at [email protected] or 925-746-5106
January 28th - Regional Quality and Patient Safety Leader Network Meeting
March 1st - 6th Annual Palomar Health Patient Safety Conference--all Hospitals welcome
Keynote is Julie Morath, CEO HQI
More information can be found on HQI Website under events and webinars: http://www.hqinstitute.org/upcoming-webinars-events
Hospital Association of San Diego & Imperial Counties (HASDIC) Patient Safety First Programming
2016 In-Person Meetings 9am-3:30pm at Pacific Palms Resort, City of Industry • March 2nd
• June 9th
• September 8th For more information, contact Julia Slininger: [email protected]
SCPSF COLLABORATIVE – HASC Calendar of Events
NHF Database Contact Mia Arias, MPA Program Director [email protected] (213) 538-0743
CMQCC Contact Valerie Cape Program Manager [email protected] (650) 497-7643
Data/Measures for HASC & HCNCC Specifications Saleema Hashwani MS, PhD Data Consultant [email protected] [email protected] (818) 274-1643
Data/Measures for HASDIC Alicia Munoz Vice President of Quality Improvement & Patient Safety [email protected] TEL: (858) 614-1541
Contact Info
Access slides and recording at: www.nhfca.org/PSF
Thank you for joining us!