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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/
Housekeeping
Interactive networking platform
Press *1
Type questions in the question box feature of the webinar platform
Please fill out the evaluation
Give feedback
Offer suggestions of what would be beneficial to your organization
Be a featured hospital speaker!
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
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
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