Download - 2014 K-HEN Commitments
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Title Block2014 K-HEN Commitments
Elizabeth Cobb
Donna Meador
Dolores Hagan
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Welcome!
Thank you so much for your support throughout this project so far, and for helping us gain approval for continuing in 2014!
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Agenda 1. Discussion of Commitments for 2014:
a. Data Submission Requirements in the 10/11 clinical focus areas
b. Continued work on Patient & Family Engagement, Leadership, Teamwork, and Communication, and Measurement
c. Add/begin component of Health Care Disparities
2. Incentives to continue:
a. Data Submission Incentive (quarterly)
b. Improvement Incentive (mid-year and at end of project)
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Agenda, continued c. Harm Across the Board Incentive
-(replacing monthly progress report)
3. Education and Activities Planned for 2014
4.Improvement Leader Fellowship changes for 2014
5.Q & A, Feedback
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1. Commitments for 2014Data Submission Requirements:
- all applicable topic areas - standardized (aligned) measures for each
topic – we will prescribe a minimum submission requirement & a higher level for increased incentive
- data submission schedule
- data submission tool will be coming out-
All 2014 data will be submitted directly to K-HEN via the tool instead of the CDS
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Measures by Area
Adverse Event Area (AEA)
Measures
Adverse Drug Events (ADE)
• Excessive anticoagulation (EOM-12)• Glucose control (EOM-13)• Opioid safety (EOM-111)• An overall measure of ADEs*
Falls • Falls with or without Injury (EOM-37)• Falls with injury (minor or greater) (EOM-38)
Pressure Ulcer • Stage II or Greater hospital acquired (EOM-58)• Stage III or IV greater subset (AHRQ PSI 3) (EOM-61)
VTE • Post-op PE or DVT (AHRQ PSI 12) (EOM-105)• Potentially preventable VTE (EOM-104)
EED • Early Elective Delivery (JC PC-01) (EOM-40)
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AEA Measures
Other OB • Birth Trauma Rate – Injury to Neonate (AHRQ PSI 17) (EOM-48)
• OB Trauma rate-vaginal delivery with instrument (AHRQ 18) (EOM-54)
• Birth Trauma Rate-vaginal delivery without instrument (AHRQ 19) (EOM-55)
• OB Hemorrhage*• Preeclampsia treatment and management to prevent morbidity and mortality*
Readmissions • Diagnosis specific 30-Day readmission rate
• AMI (EOM-76); Heart Failure (EOM-77); Pneumonia (EOM-78)
• 30-Day All Cause readmission rate (EOM-75)
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AEA Measures
CAUTI • CAUTI Rate (NHSN/NDNQI) – ICU only (EOM-19)
• CAUTI Rate (NHSN/NDNQI) – All Units (EOM-18)
• Catheter utilization ratio (catheter days/patient days) (EOM-21d)
• ED Catheterization rate*
CLABSI • CLABSI rate (NHSN/NDNQI) ICU only (EOM-25)• CLABSI rate (NHSN/NDNQI) All Units (EOM-24)• Days Since Last CLABSI*
SSI • Surgical site infection rate (NHSN) for colon and abdominal hysterectomy procedures within 30 days of procedure(EOM-89)
• Surgical site infection rate (NHSN) for four or more procedures within 30 days of procedure**
VAE/VAP • VAC (NHSN) (EOM-96a or EOM-96d)• IVAC (NHSN) (EOM-96b or EOM-96e)• Possible/Probable VAP (NHSN) (EOM-96c or EOM-96f)
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Incentive Requirements
• Both minimum and full participation require timely data submission– Data is due at the end of the month for the
previous month (exceptions: Readmissions and SSI)
– Full participation requires either submission or attestation that at least one corresponding process is being collected
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Commitments cont’d.Continued work on Patient and Family
Engagement and Leadership– we will
continue to submit data to HRET on 5 elements of PFE and 4 elements of Leadership; we will continue to offer education and resources related to patient safety, teamwork, and communication; we will continue to
work with hospitals on data/measurement/reporting
Add/begin HealthCare Disparities Component - for now this will consist of 2 surveys throughout the year from HRET for each hospital
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2014 Incentive Structure2014 Funding for all of the HENs based on
data submission and improvement structure –
• We will be implementing a 2-tiered quarterly bonus/incentive strategy based on completing minimum and maximum requirements
• Mid-year and end-of-project bonus/incentive based on improvement levels
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Incentive Structure cont’d.• Monthly progress reports will now be
submitted as “Harm Across the Board” reports – moving from focus on single harm to harm across the board – we will incentivize hospitals who submit at least one HAB report each qtr.
(we will provide more info on the HAB report later)
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2014 Education and Activities K-HEN: 1. Coaching Calls monthly and bi-monthly depending on
topic
2. Site Visits to all hospitals
3. Annual KHA/K-HEN Quality Conference 3/18-19
4. TeamSTEPPS webinars and workshops
5. Patient Safety Hero Awards
6. OB Advisory Committee Meetings
7. Periodic focused meetings, such as K-HEN or HRET staff meeting with local community coalitions
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2014 Educ. & Activities cont’d 8. Sponsorships to national meetings –
AHA Rural Conference, NAHQ, IHI, NPSF Congress, AHA Quality and Safety Roadmap, etc.
9. Regional Meetings
10. Other Suggestions/Needs?
11. Improvement Leader Fellowship education and activities (next slide)
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2014 Educ. & Activities cont’dHRET:
1.Updated Change Packages - each topic
2.2-3 day Boot Camps dedicated to data, OB, Readmissions, ADE, C-Diff, and Sepsis; each will be repeated during the same week
3.ILF program with in-person meetings & monthly live-streamed meetings
4.Other events in process
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2014 Improvement Leader Fellowship
Great program in 2012 and 2013 – changes to design make more beneficial to hospitals
• Currently 1200+ fellows (8 in KY)• 27 ILF meetings held, 533 registered for IHI Open School • Feedback from fellows has been very positive
2014 – Junior, Senior, and Champion levelsGoal – build skills in improvement in SHA and HEN
hospital quality leaders through continuous learning & coaching on improvement methods & tools as applied to the Partnership for Patients content areas.
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2014 Improvement Leader Fellowship
2014 Plans:1.In-Person Regional Meetings
– 22 meetings March-November
- on-site meetings specifically designed to combine clinical knowledge with improvement techniques, ½ day in length, for networking & shared learning, at State Hosp. Assoc. offices (KHA?)
2. Monthly live-streamed meetings, 1-3 CT every third or fourth Wednesday of the month
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2014 Improvement Leader Fellowship
Fellowship education led by IHI Faculty
Attendance requirements – 1 in-person meeting, 8 of 10 virtual meetings
HAB completion
Pre-work assignments
Specific assignments for each level*Secondary goals for KY – build improvement capacity
for ongoing quality work, foster systems thinking knowledge, keep the enthusiasm going!
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Questions?
Feedback?
Thank you!