Transition Year: 2016 Program Kick Off!2016/01/21  · Program Kick Off! ----- How to participate in...

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 datacenter@cmqcc.org

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

jfischer@hqinstitute.org

Alicia Munoz, FACHE

Vice President of Quality Improvement & Patient Safety

Hospital Association of San Diego & Imperial Counties (HASDIC)

TEL: (858) 614-1541

amunoz@hqinstitute.org

Julia Slininger, RN, BS, CPHQ

Vice President of Quality & Patient Safety

Hospital Association of Southern California (HASC)

TEL: (213) 538-0766

jslininger@hqinstitute.org

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 jfischer@hospitalcouncil.net 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: jslininger@hasc.org

SCPSF COLLABORATIVE – HASC Calendar of Events

NHF Database Contact Mia Arias, MPA Program Director Marias@nhfca.org (213) 538-0743

CMQCC Contact Valerie Cape Program Manager vcape@stanford.edu (650) 497-7643

Data/Measures for HASC & HCNCC Specifications Saleema Hashwani MS, PhD Data Consultant shashwani@hasc.org shashwani@hospitalcouncil.net (818) 274-1643

Data/Measures for HASDIC Alicia Munoz Vice President of Quality Improvement & Patient Safety amunoz@hqinstitute.org TEL: (858) 614-1541

Contact Info

Access slides and recording at: www.nhfca.org/PSF

Thank you for joining us!