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Georgia Hospital Engagement Network Cohort Coaching Call June 18, 2014. Cohort 2 + Cohort 3 + Cohort 4 = Cohort “9”. Framing. Status Report HEN Measure by Measures R eviewing data, Sharing successes and barriers Offers and Request Disparities Spread C. diff prevention Sepsis prevention - PowerPoint PPT Presentation
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GEORGIA H
OSPITA
L ENGAGEMENT
NETWORK
COHORT C
OACHING C
ALL
JUNE 1
8, 2014
CO
HO
RT
2 +
CO
HO
RT
3 +
CO
HO
RT
4 =
CO
HO
RT
“ 9”
FRAMING
• Status Report HEN Measure by Measures • Reviewing data, • Sharing successes and barriers• Offers and Request
• Disparities• Spread
• C. diff prevention• Sepsis prevention• Worker’s Safety
• Calendar Review
DA
TA S
NA
PS
HO
T
Measure Most Recent Period
Number of hospitals reporting
this measure
Target rate
Number of hospitals meeting
benchmark/ goal for this
measure
Number of hospitals
reporting “0” for most recent
reporting period for this measure
Current adverse event
rate for this measure
Number of hospitals reporting that they have a prevention bundle in place for
this AEA (BPSS) based on Q2-2014 BPSS
Anticoagulant Control ADE March 2014 95 2% 70 42 0.91% 85 of 87
Glycemic March 2014 97 0.60% 66 33 0.50% 82 of 87
Opioid ADE March 2014 80 Not Available n/a 39 1.95/1000 74 of 87
Falls with Injury March 2014 96 0.50 65 52 0.43/1000 84 of 87
EED March 2014 52 2% 46 46 1.49% 35/42
PrU Q1 2014 109 0.33 87 87 0.62 71 of 87
PE/DVT Q1 2014 109 4.05 63 53 5.09 77/87
Injury to Neonate PSI17 Q1 2014 60 1.208 39 39 2.18 34/42
OB AE with Inst-PSI18 Q1 2014 57 84.86 22 16 125.85 34/42
OB AE w/o Inst- PSI19 Q1 2014 62 13.7 19 14 22.94 34/42
CAUTI March 2014 84 0.48 62 62 2.29 85/87
CLABSI March 2014 82 0.48 69 69 0.79 74/79
SSI:Colon March 2014 39 1.7 34 34 3.05 44/73
SSI:Hyst March 2014 32 0.9 30 30 0.81 44/73
Readmission All Payer Q1 2014 111 9.24% 31 1 11.48% 67/87
Readmission Medicare January 214 110 15.24% 43 7 17.07% 67/87
FALL
S W
ITH
INJU
RY
FALLS AND TRAUMA
HOSPITAL ACQUIRED PRESSURE ULCERSSTAGE III-IV
HOSPITAL ACQUIRED PRESSURE ULCERS
STAGE II ONLY
PO
ST
OP
PE
/DV
T (
PS
I-12
)
AD
E –
GLY
CE
MIC
CO
NT
RO
L
OPIOID RELATED ADVERSE EVENTS
Current Rate/1000
4.0 15
reporting
Alternative Numerator #1: Number of orders for sedation or opioid reversal administration per month outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o. Alternative Denominator #1: Total number of narcotics (opioids) orders outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o.
1.60 41
reporting
Alternative Numerator #2: Number of opioid reversal doses administration per month outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o. Alternative Denominator #2: Total number of narcotics (opioids) doses administered outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o.
12.2 24
reporting
Alternative Numerator #3: Number of opioid reversal doses administration per month outside of the operating rooms, procedure rooms or ED for all adult inpatients >18 y.o. on “PCA Pumps” (pain control pump). Alternative Denominator #3: Total number of adult inpatients >18 y.o. placed on a pain(PCA) pump with narcotics (opioids) doses administered outside of the operating rooms, procedure rooms or ED
1.95 80
reporting
Overall rate based on the number of opioid related adverse events per 1000 X the total exposures to potential opioid related events.
AD
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E E
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E E
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MIS
SIO
NS
DISPARITIES
CDC -- ACTION TO REDUCE DISPARITIES
Conclusion and Future Directions: CDC Health Disparities and Inequalities Report — United States, 2013
• http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a32.htm?s_cid=su6203a32_w
DISPARITIES BOLD AIM
The Census Bureau predicts that racial and ethnic minority populations in the U.S. will grow to become half of the U.S. population in three decades.
Georgia’s Hospital Engagement Network wants to work with hospitals
across the state to address the increasing health needs of racial and ethnic
minorities, rural and urban poor, and other medically underserved
populations in the midst of efforts to strengthen the healthcare system and
improve access to care for millions of Americans. Eliminating health
disparities is a priority for GHA and involving diverse communities and
partners will be critical in its effort directed at achieving health equity in
America.
GEORGIA ADVANCED PRACTICE PROJECT
Spreading Best Practices for:
• C. diff Prevention and Sepsis Resources https://
quality.gha.org/Home/HospitalEngagementNetwork/LEAPTGAPP/Resources.aspx
• Worker’s Safety https
://quality.gha.org/Home/HospitalEngagementNetwork/LEAPTGAPP/WorkerSafety.aspx
GHA’S WORKER SAFETY INITIATIVE1. Multi disciplinary Advisory Council / 5 Topic Hospitals
2. Establish Best Practices through Rapid Cycle Improvement
3. Determine Outcomes / Metrics
4. Identify and Share Worker Safety Resources
(OSHA , LUCIAN LEAPE, CDC, NIOSH, TJC, LEAPT ENTITIES)
5. UPCOMING EVENTS:
- June 26, 2014 Coaching Call: Sharps Injury Prevention
- Team STEPPS Regional Training:
June 17-19, 2014 Cuscowilla on Lake Oconee
June 24-26, 2014 UGA Tifton Conference Center
July 8-10, 2014 GHA Education Center
- July 29, 2014 “Enhancing Caregiver Resilience”
- Ergonomic / Safe Patient Handling “Train the Trainer” Workshop (Date TBD)
PATIENT AND FAMILY ENGAGEMENT
PATIENT AND FAMILY ENGAGEMENT
1. Prior to admission, hospital staff provides and discusses a discharge planning check list with every patient that has a scheduled admission, allowing questions or comments from the patient or family.
2. Hospital conducts shift change huddles and does bedside reporting with patients and family members in all feasible cases.
3. Hospital has a person or functional area, who may also operate within other roles in the hospital, that is dedicated and proactively responsible for Patient and Family Engagement and systematically evaluates Patient and Family Engagement activities.
4. Hospital has an active Patient and Family Engagement Committee OR at least one former patient that serves on a patient safety or quality improvement committee or team.
5. Hospital has at least one or more patient(s) who serve on a governing or leadership board and serves as a patient representative.
LEADERSHIP
MARK YOUR CALENDAROBAE Affinity Call – June 25
PFE/PFCC Learning and Action Collaborative- In-Person June 25
Regional TeamSTEPPS Train the Trainer 2 ½ day Sessions June 24-26 UGA Tifton Conference Center 15 RDC Road Tifton, GA July 8-10 GHA Educational Center – wait list only
Georgia Hospital Association Summer Annual Meeting – July 8-11
Data and Assessment Submission Deadlines:
• Leadership and Patient and Family Engagement Assessment – June 30
• HEN HAC, EED, and HAI – May data due July 15th
Next Coaching Call – July 16, 2014
Don’t forget your evaluation: : http://survey.gha.org/n/cohort234061814.aspx