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Nevada Hospital Engagement Network Monthly Report

November 12, 2013

Centers for Medicare & Medicaid Services Partnership for Patients Initiative

CONTRACT:

HHSM-500-2012-00016C

CONTRACTOR:

Nevada Hospital Association (NHA)

5250 Neil Road, Suite 302

Reno, NV 89502

PROJECT MANAGER:

Marissa Brown, MHA, BSN, RN

5250 Neil Rd. #302

Reno, NV 8950

Office: 775-827-0184

Email: [email protected]

mailto:[email protected]

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INDEX

Section Page Numbers

High-Level 30-Day Executive Summary ................................................................................................................. 1-3

Health Services Advisory Group (HSAG) - Table 1 ................................................................................................. 4

Patients Saved from Harm & Potential Cost Savings – Table 2 ......................................................................... 5

Adverse Drug Events (ADE) ..................................................................................................................................... 6-10

Catheter Associated Urinary Tract Infections (CAUTI) ............................................................................... 11-17

Central Line Associated Bloodstream Infections (CLABSI) ....................................................................... 18-21

Early Elective Delivery (EED) ................................................................................................................................ 22-23

Falls with Significant Injury ................................................................................................................................... 24-28

Obstetrical Adverse Events (OB).......................................................................................................................... 29-32

Pressure Ulcers ........................................................................................................................................................... 33-36

Readmissions ............................................................................................................................................................... 37-42

Surgical Site Infections (SSI) .................................................................................................................................. 43-46

Ventilator-Associated Pneumonia/Event (VAP/VAE) ................................................................................. 47-51

Venous Thrombo Embolism (VTE) ..................................................................................................................... 52-55

Patient and Family Engagement ........................................................................................................................... 56-58

Leadership Engagement .......................................................................................................................................... 59-60

Forward Look for the Next 30 Days ........................................................................................................................... 61

Partnerships and Collaboratives ................................................................................................................................. 62

Financials and Attachments .......................................................................................................................................... 63

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HIGH LEVEL 30 DAY EXECUTIVE SUMMARY

This report describes the progress of the Nevada Hospital Engagement Network (NV HEN) in reducing hospital acquired condition and readmissions. The NV HEN is composed of 25 Partnership for Patient (PfP) eligible facilities (18 Acute Care Hospitals and 7 Critical Access Hospitals) and 9 non-PfP facilities (8 Long Term Acute Care Facilities and 1 Rehabilitation Hospital). Data used in this report was obtained from self-report, National Healthcare Safety Network (NHSN) and medical billing data from the Center of Health Information Analysis (CHIA). In this current report period, 9 HACs and readmissions have 80% or more participation for PfP-eligible facilities (Figure 1). Five of these HACs are showing 40% or greater reduction compared to baseline in PfP-eligible facilities within the NV HEN (Figure 2).

Figure 1: Participation rate of PfP eligible facilities per HAC plus readmission. Solid black line indicates the 80% participation threshold and dashed black line indicates 60% participation threshold.

Figure 2: % improvement in each HAC and readmission rate for PfP eligible facilities. Solid black line indicates the 40% reduction threshold.

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HIGH LEVEL 30 DAY EXECUTIVE SUMMARY

(NOTE: we have assigned random blinded letters & numbers to identify individual network hospitals in order to protect their facility-specific identification while still relaying their stories)

SUCCESSES: • PARTICIPATION RATE: We are successfully reporting above the 60% threshold for 11 of the 11

Hospital Acquired Conditions (HACs) and Readmissions and 80% for 10 of 11 HACs for PfP-eligible facilities.

• IMPROVEMENT RATES: Six HACs are showing overall improvement rates of 40% or greater within the group of HACs that had 80% or greater reporting level (PfP-eligible facilities).

• SITE VISITS: On-site visits to 5 facilities including 1 rural facility • HARM REDUCTION IMPACT: We estimate that the reductions in harm achieved by our facilities

will save 1,472 patients from harm and more than $18.9 million annually (Table 2) • PATIENT-FAMILY ENGAGEMENT (PFE), ADVERSE DRUG EVENTS (ADE) and READMISSIONS

PROGRAM: We are collaborating with the NV QIO to co-sponsor a “Brown Bag” event in Henderson, Nevada (adjacent to Las Vegas) on November 12, 2013. The target audience is predominantly seniors, but all are welcome. The QIO is coordinating with the Roseman College of Health Sciences to provide the medication counseling. During the event, informational posters will be displayed and the QIO will provide take-away education materials and pillboxes for attendees. The HEN is sponsoring speakers from the Touro University Falls Assessment Team and Rest of Your Life Planning, who will talk throughout the day and interact with attendees.

• PATIENT-FAMILY ENGAGEMENT RESPRESENTATIVE: A patient from Southern Hills Hospital patient advisory board attended the IHI Person- and Family-Centered Care: Transforming the Patient Experience Seminar on October 15-16 in Chicago (attendance underwritten by Weber-Shandwick). His blog regarding PFE is an attachment to this report.

• MONTHLY HEN CALL – The focus topics for our October call was CUSP CAUTI ED recruitment and program overview. Two of our NV HEN facilities shared their story on why they decided to participate in this program and a guest speaker from the South Carolina HEN spoke about their HENs challenges and successes with this program. The program is part of our ongoing “Call to Action” and race car competition that is located on our website (See CAUTI section for link).

• FALLS (with injury) rate has reduced 45% from baseline. We are working with facilities to obtain self-report data on falls. On behalf of the NV HEN, Suzanne Brown, RPT from Touro University will be available to perform Falls Assessments on attendees at the Brown Bag session on November 12.

• OB HARM has reduced by 47% from baseline and EED has reduced by 85% from baseline. The 4 facilities engaged in the University of Nevada School of Medicine program completed Advanced Life Support in Obstetrics (ALSO) training. We plan to offer ALSO and TeamSTEPPS training to 8 additional hospitals and CareTeamTM OB training to 4 hospitals in Option Year 1 (if awarded).

• PRESSURE ULCER (Stage III and V) is showing a 51% decrease from baseline. The NV HEN assisted in organizing the northern and southern Pressure Ulcer advisory committees. The committee has grown in attendance with every meeting. The advisory group offers the opportunity to learn from experts who discuss strategies and provides a product review session to improve prevention and treatment plans. For more details, see the Pressure Ulcer section of this report.

• READMISSION RATES FOR NON-PFP FACILITIES are showing marked improvement well above target in both All-Patient cohorts (37% improvement and 47% improvement). We are learning from their discharge planning strategies to improve the outcomes of our PfP eligible facilities. Our two cohorts of PfP eligible hospitals have reduced readmissions by an overall 7% from baseline.

• VENTILATOR ASSOCIATED PNEUMOINIA (VAP) has trended down by 77% from baseline. All of our facilities who submit NHSN data have reverted to the VAE criteria data input.

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HIGH LEVEL 30 DAY EXECUTIVE SUMMARY • VENOUS THROMBEMBOLISM EVENTS (VTE) – Indicates a 34% decrease for “All Patients” and a

37% decrease for “Surgical” patients only. • Submitted the Annual Draft Report by deadline • Submitted the Technical and Business Proposal for Option Year 1 by deadline.

AREAS FOR IMPROVEMENT: • ADVERSE DRUG EVENTS (ADE) Although we have reached the 60% overall participation rate, our

aggregate analysis shows a 3% improvement from baseline. We are encouraging our hospitals to evaluate the all harm potential and particularly anticoagulant harm, which has the largest deficit. We are also working with our hospitals to enable data collection from additional hospitals. For more details, see the ADE section of this report.

• CATHETER ASSOCIATED URINARY TRACT INFECTIONS (CAUTI) is showing an overall 3% increase over baseline in this period. Catheter Utilization rate has declined by 14% in non-ICU units, but increased by 51% in the ICUs. Based upon last month’s negative trend and the national increase in CAUTI rates, we have asked for commitments from our facilities to review their bundles and determine whether staff are compliant with these bundles. This Call to Action was presented in August and reinforced all through September and October – we are not letting our guard down! We recently presented the opportunity to enroll in a CUSP CAUTI ED project to focus on a challenging area to reduce the use of catheters in the hospitals.

• CENTRAL LINE ASSOCIATED BLOOD-STREAM INFECTIONS (CLABSI) is now showing 2% increase from baseline. We are working with our facilities to look for breaches in bundle-adherence for insertion. We are sharing an analysis by another local HEN member that they have drilled down to determine that the root cause of their CLABSI increase is failure to follow disinfection protocols pre- and post- medication administration. We are asking our hospitals to validate this part of the bundle for compliance. Additionally, we will leverage our Level 5 (Hospital 2 & 8) hospitals’ strategies with their peers and work to establish relationships for peer-to-peer learning.

• READMISSIONS NV HEN aggregate data is showing 7% improvement in the All Payer 30-day readmission rate for PfP eligible facilities. The Medicare 30-day readmission PfP eligible rate shows 9% improvement. We have been partnering with our QIO to advance strategies across the continuum of care. We are also engaging case managers into the NV ADE advisory committee to assist in information collection regarding post discharge medication follow-up and medication-related readmissions. For more information, see Readmission section of this report.

• SURGICAL SITE INFECTIONS (SSI) has 94% participation rate and a 17% overall reduction. Currently, 2 hospitals within the NV HEN are engaged in SUSP – Cohort 3. Two additional hospitals have enrolled in SUSP Cohort 4. The SUSP program is now allowing facilities to add teams for other surgical procedures (i.e. orthopedic, abdominal and cardiac, etc.), and we are polling our hospitals for interest in domains other than colorectal or hysterectomy surgery.

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HEALTH SERVICES ADVISORY GROUP (HSAG) TABLE TABLE 1: SUMMARY OF PARTICIPATION RATE AND IMPROVEMENT BY HAC FOR PFP ELIGIBLE FACILITIES (ACHS AND CAHS)

Benchmark/Current time period



ADE (15 unique PfP facilities)

60% 3%Self-Report: Insulin (10/25): 6% increase

B: 1Q 2012 C: Jun-Aug'13

Self-Report: AntiCoag (12/25): 12% increase

B: 1H 2012 C: Jun-Aug'13

Self-Report: Narc (12/25): 17% decrease

B:1Q 2011C: Jun-Aug'13

NHSN, ICU only

CAUTI (13/25): B: 1.45; C: 1.8226% inc

B: 1H 2012C: Jun-Aug 2013

Cath Utilization: B: 45%; C: 67%51% inc

B: 1H 2012C: Jun-Aug 2013

NHSN, non-ICU only

CAUTI (14/25): B: 1.14; C: 1.5132% inc

B: 1H 2012C: Jun-Aug 2013

Cath Utilization: B: 23%; C: 20%14% dec

B: 1H 2012C: Jun-Aug 2013

Self-Report, combined units, PfP-eligible

CAUTI (5/25): B: 3.4; C: 0100% dec

B: 4Q 2011 C: May-Jul'13

Cath Utilization: B: 25%; C: 22%11% dec

B: 4Q 2011C: May-Jul 2013

PfP: Self-Report (5/22): 14% increase

B: Q1 2011C: Jun-Aug'13

NHSN, CLABSI, ICU (13/22): 3% decrease

B: Q1 2011C: Jun-Aug'13

NHSN, CL Ut , ICU (13/22): 0% increase

B: Q1 2011C: Jun-Aug'13

EED

83% 85%PfP: Self-Report (10/12): 85% decrease

B: 2011 AvgC: 2Q 2013

Falls with Injury92% 45%

PfP: CHIA (12/25): 45% decrease

B: 1Q 2010C: 2Q 2013

PfP: Self-Report (11/25): 45% decrease

B: 1Q 2013C: Jul-Sep'13

OB other100% 47%

CHIA: (12/12)Inj to Neo100% decrease

B: 1H 2010C: 2Q 2013

CHIA: (12/12) OBT w/Inst 25% decrease

B: 1H 2010C: 2Q 2013

CHIA: (12/12) OBT w/o Inst: 16% decrease

B: 1H 2010C: 2Q 2013

Pressure Ulcers

88% 51% PfP: CHIA (21/25): 52% decrease

B: 1H 2010C: 2Q 2013

non-PfP: CHIA (6): 81% decSelf(2): 28% inc

Readmissions92% 7%


B: 1H 2010C: 2Q 2013

PfP: Self (1/25): 37% decrease

B: 2011 AvgC: 3Q 2013

SSI94% 17% NHSN COLO

(15/18): 11% decrease

B: Q1 '12 AvgC: Jun-Aug 2013

NHSN HYST (12/18): 193% increase

B: Q1 '12 AvgC: Jun-Aug 2013

Self-Report : ALL Type of SSI (5/18): 36% decrease

B: 1H 2010 C: Mar-May'13

VAP/VAE95% 77%


B: 1H 2010C: 2Q 2013

PfP: Self (3/20): 100% decrease

B: 2010 AvgC: Jul-Sep'13

VTE

88% 34% PfP: CHIA (22/25): 34% decrease

B: 1H 2010C: 2Q 2013

(surgical only) PfP: CHIA (18/18): 37% decrease

B: 1H 2010C: 2Q 2013

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PfP: Self-Report (1/25): One facility showing 32% decrease between 2012 and 3Q 2013.

Number of HACs with Participation Rates >=60%Number of HACs meeting both criteria =

Number of HACs with Participation Rates >=80%

Notes:

November60

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subm

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82% -2%CLABSI

CAUTI/Catheter Utilization 80% 3%

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PATIENTS SAVED FROM HARM AND POTENTIAL COST SAVINGS TABLE 2: NUMBER OF PATIENTS SAVED FROM HARM PER HAC AND COST SAVINGS FOR PFP ELIGIBLE AND NON-PFP ELIGIBLE FACILITIES

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ADVERSE DRUG EVENTS TABLE 3: SUMMARY OF ADVERSE DRUG EVENTS RATES

PfP-Eligible Hospitals Participating: 15/25 (60%)

Measure Baseline Current % Decrease (Negative value indicate increase)

Insulin ADE Rate per 1,000 doses administered (Self-report)

January-March 2012 16.5

June-August 2013 17.5

-6%

Anti-Coagulant ADE Rate per doses administered (Self-report)

January-June 2012 0.024

June-August 2013 0.027 -12%

Narcotics ADE Rate per 1,000 doses administered (Self-report )


June-August 2013 4.6 17%

One PfP eligible facility reports ALL Medication Errors per number of doses dispensed since 2011.

January-December 2011 July-September 2013 97%

Overall ADE Rate n/a n/a 3%

DATA ANALYSIS AND RESULTS FOR PFP ELIGIBLE FACILITIES: The Nevada HEN tracks insulin, anticoagulant and narcotic rates related to adverse drug events and these rates are self-reported to the HEN by the facilities. Insulin rate is calculated as the number of below range blood glucose level divided by 1000 insulin doses. Anticoagulants rate is calculated as the number of out of INR range divided by the number of doses administered. The narcotics rate is calculated as the number of reversal naloxone for morphine or hydromorphone per 1000 dose of morphine and hydromorphone administered.

There are 15 unique PfP eligible facilities reporting at least one or more ADE outcome measure in the current time period. Although we have obtained ADE outcome measures since 2010, this cohort was too small to compare 2010 rates to the current time period (less than 1/3 of the facilities reporting in 2010). Thus, we have chosen a baseline time period for each of the ADE outcome measure that captures at least 85% of the number of facilities reporting in the current reporting period. We calculated the overall rate of ADE improvement for PfP eligible facilities by calculating the weighted average of the percent change from the 3 outcome measures and the 1 facility self-reporting a Medication Error rate (Table 1). In the current time period, the net overall ADE rate is showing 3% improvement.

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ADVERSE DRUG EVENTS (ADE)

Figure 3: Rate per 1000 insulin doses administered (blue line) for PfP eligible facilities (Baseline=8 facilities; Current= 10 facilities). In current reporting period, the insulin rate increased 6% from a baseline rate of 16.5 to a rate of 17.5. The red line is a linear trend line that is fit to the baseline insulin rate and current insulin rate.

Figure 4: Rate per anticoagulant dose administered (blue line) for PfP eligible facilities (Baseline=13 facilities; Current= 12 facilities). In current reporting period, the anticoagulant rate increased 12% from a baseline rate of 0.024 to a rate of 0.027. The red line is a linear trend line that is fit to the baseline anticoagulant rate and current anticoagulant rate.

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Figure 5: Rate per 1,000 narcotic doses administered for PfP eligible facilities. In current reporting period, the narcotics rate decreased 17% from a baseline rate of 5.5 to a rate of 4.6. The red line is a linear trend line that is fit to the baseline narcotics rate and current narcotics rate. (Baseline=13 facilities; Current=12 facilities)

NOTES:

• One PfP eligible facility (hospital T) is reporting alternative metrics. This facility reports ADE Insulin as number below range blood glucose (BG) results/number of BG readings and ADE Anticoagulants as the number out-of-INR/number of INR readings. This facilities has not yet supplied enough historical data to establish a trend.

• One PfP eligible facility (hospital V) reports on ADEs using the metric they use internally. Their data shows a 97% decrease in Medication Errors per 10,000 doses of medication dispensed in the 3rd quarter of 2013 compared to a 2011 benchmark.

DATA ANALYSIS AND RESULTS FOR NON PFP-ELIGIBLE FACILTIES: • We have 1 non-PfP eligible facility (hospital 2) reporting on all 3 ADE outcome measures. They

have had no ADEs related to Narcotics during the past 10 months. • Another non-PfP facility (hospital 8) reports all ADEs over Medication Doses dispensed which

shows 60% improvement 2013 (1st 4 months) vs. 2010 baseline. • 3 non-PfP facilities (hospitals 3, 4, and 5) report ADEs per 1,000 patient days which have

decreased 35% comparing 2012 and 2013 (4 mos.)

HARM AVOIDED AND PROJECTED COST SAVINGS: We are currently re-evaluating our methodology on reflecting the ADE savings parameters to account for individual patient impact, not a per dose methodology.

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STRATEGIES AND SUCCESSES TO DATE: • Five facilities have reached level 4 status; six facilities have reached level 3 • The NV HEN has met the participation threshold - currently 60% of our PfP eligible network is

providing data,. We continue to work with our hospitals (especially the pharmacists and labs) to further increase participation and improve the quality of data reported. While we stress the importance of tracking and reducing the 3 chosen ADE metrics, we have also been flexible in ADE data collection. This practice has resulted in a variety of cohorts, but has allowed us access to more data that we can use to help the facilities target areas for improvement.

• Hospital Y has placed Pharmacists in their Emergency and Oncology departments in order to catch prescribing errors and consult on appropriate medication selection. National impact of these direct intervention programs shows positive impact in preventing medication errors and improving appropriate drug selection and dosing to improve outcomes.

OPPORTUNITIES FOR IMPROVEMENT: • Insulin has recently shown a 6% increase over baseline (10 unique facilities reporting this period).

This may be attributed to the conversion of many of our hospitals to EndoTool or other similar technology in the ICUs and ORs to ensure tight control of patients’ blood sugar levels. With the EndoTool, monitoring is more frequent (usually hourly) for a minimum of 1 or 2 days. If repeat testing detects low blood sugars, insulin would not be dosed (denominator), but the low blood sugar would be reportable (numerator) – thus increasing the overall rate. This trend appears to be normalizing over the past 5 months.

• Warfarin (INR) data is showing a 12% increase from baseline with 12 unique facilities reporting current data within the past rolling 6 months (Figure 4). We will continue working with our facilities to improve screening and monitoring, use of evidence-based protocols that are translated to pre-printed (or electronic) order sets and move to newer pharmaceutical products with less harm potential (cost/benefit analysis).

• The Nevada HEN ADE Advisory Committee we will be inviting case managers to this group to provide input on post discharge medication counseling and analysis of medication–related readmissions. This group has developed a short questionnaire for multiple stakeholders across the healthcare continuum, in preparation for the joint meeting with the case managers to discuss key elements of medication reconciliation improvement.

HEN STRATEGIES FOR IMPROVEMENT: • During our “Taking Stock” site visits, we assess whether our facilities have up-to-date INR

protocols, blood-glucose protocols and evidence based order sets, have adjusted their hydromorphone dosing parameters, and the availability and proper use of Smart-pumps (built in lockout thresholds by service line and age/weight) and patient-controlled analgesia (PCA) pumps

• The HEN is collaborating with the QIO and the Roseman College of Pharmacy to co-sponsor a Brown-Bag event on November 12, 2013. Pharmacy consults will help the patients gain a better understanding of their current medications and they will be provided recommendations to take back to their Primary Care Physicians to maximize safety and efficacy of their medication regimen. Patient/Family engagement will also be a big part of the collaborative Brown Bag event. Further establishing the HENs relationship with patient and family members will enable us to do a better job at outreach and include the patient perspective on multiple levels.

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ADVERSE DRUG EVENTS (ADE) • Encourage our facilities to establish screening criteria that includes the option of non-

pharmaceutical intervention for VTE prophylaxis. These tools have been shared with the hospitals and many are incorporating them into their EMR or pre-printed order sets.

• Encourage hospitals to collect data on medication related events related to Readmission – pilot is ongoing with a volunteer hospital.

• Bring community stakeholders together to analyze the medication reconciliation process, prioritize topics of action, and work together to resolve disconnects with Medication Reconciliation and follow-up within 5 days post discharge.

• Partner with the Nevada QIO to assist with their PSPC goals and in a Readmission Care Transition Pilot (that includes a medication component). The HEN is assisting by adding more stakeholders and strategies that will interface with their project. The intent is not duplication, but rather expansion of scope and including the expertise and perspective of hospital-based professionals so that we can align our activities and action plans.

• Partnership with the “Do My Part” campaign that focuses on the Medicare claims population to detect discharge risks related to patients who contest their discharge from a facility. Analysis shows that approximately 64% of these patients end up back in the hospital within the 30-day time period, even if they meet medical criteria for discharge.

HOSPITAL STRATEGIES FOR IMPROVEMENT: • Continue creation of evidence-based protocols and order sets (not just limited to the 3 primary

data collection groups, but also other high-risk medications i.e. oxytocin, chemotherapeutics, etc.) • Focus on “Teach-Back” methodology – which has shown very positive national results. • Collaborate with community effort to improve Medication Reconciliation across the continuum • Team Rounding and Interdisciplinary Plan of Care documentation to coordinate and communicate

with other team members • Work toward methodologies to contact high-risk patients within 5 days of discharge regarding

medication safety interventions. • Hand-off communication & electronic medical records (EMR) documentation enhancements • True dosing “double checks” of syringes and pumps – use of Smart Pumps • Validate Point of Care test results prior to dosing – incorporate into EMR processes • Reducing insulin product varieties in stock • Considering formulary options that have less risk than Warfarin • Move toward unit of use and away from multi-dose vials, when possible • Include ADE topics in the Patient and Family education and advisory board discussions.

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CATHETER-ASSOCIATED URINARY TRACT INFECTIONS (CAUTI)

TABLE 4-A&B: SUMMARY OF CAUTI AND CATHETER UTILIZATION RATES

4-A: PfP-Eligible Hospitals Participating: 20/25 (80%)


CAUTI Rate ICU only per 1,000 device days (NHSN)


June-August 2013 1.82 -26%

CAUTI Rate non-ICU only per 1,000 device days (NHSN)


June-August 2013 1.51 -32%

CAUTI Rate per 1,000 device days (self-report)

October-December 2011 3.4

May-July 2013 0 100%

Overall CAUTI Rate n/a n/a 3%

Catheter Utilization Rate ICU-only per 1000 patient days (NHSN)


June-August 2013 0.67 -51%

Catheter Utilization Rate non-ICU only per 1000 patient days (NHSN)


June-August 2013 0.20 14%

Catheter Utilization Rate per 1000 patient days (self-report)

October-December 2011 0.25

May-July 2013 0.22 11%

Overall Catheter Utilization Rate

n/a n/a -11%

4-B: Non-PfP-Eligible Hospitals Participating: 9/9 (100%)

Measure Baseline Current % Decrease

(Negative value indicate increase)

CAUTI Rate per 1,000 device days (Self-Report)


May-July 2013 7.1 -91%

Catheter Utilization Rate per 1000 patient days (self-report)


April-June 2013 0.39 18%

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DATA ANALYSIS AND RESULTS FOR PFP-ELIGIBLE FACILITIES: CAUTI rate and catheter utilization rates were obtained from NHSN database and from facilities providing self-report data. CAUTI rate was calculated as the number of CAUTI events (as defined by NHSN guidelines) divided by 1000 catheter days. Catheter utilization rate was calculated as number of catheter days divided by the number of patient days. CAUTI and catheter utilization rates were calculated separately for ICU and non-ICU units. The NV HEN receives data from 15 unique PfP-eligible facilities from NHSN.

Figure 6: CAUTI rate for ICU only (blue line) for NHSN data over entire reporting period of PfP-eligible facilities (Baseline=14 facilities; Current= 13 facilities). In current reporting period, the CAUTI rate increased 26% from a baseline rate of 1.45 to a rate of 1.82. The red line is a linear trend line that is fit to the baseline CAUTI rate and current CAUTI rate.

Figure 7 CAUTI rate (blue line) for non-ICU NHSN data over entire reporting period of PfP-eligible facilities (Baseline=13 facilities; Current= 14 facilities). In current reporting period, the CAUTI rate increased 32% from a baseline rate of 1.14 to a rate of 1.51. The red line is a linear trend line that is fit to the baseline CAUTI rate and current CAUTI rate.

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Figure 8: CAUTI rate (blue line) for self-report data over entire reporting period of PfP-eligible facilities (Baseline= 4 facilities; Current= 4 facilities). In current reporting period, the CAUTI rate decreased 100% from a baseline rate of 3.4 to a rate of 0. The red line is a linear trend line that is fit to the baseline CAUTI rate and current CAUTI rate.

Figure 9: Catheter utilization rate (blue line) for ICU only from NHSN data over the entire reporting period for PfP eligible facilities (Baseline=14 facilities; Current= 13 facilities). Current reporting period, the catheter utilization rate increased 51% from a baseline rate of 0.45 to a current rate of 0.67. The red line is a linear trend line that is fit to the baseline catheter utilization rate and current catheter utilization rate.

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Figure 10: Catheter utilization rate (blue line) for non-ICU only from NHSN data over the entire reporting period for PfP eligible facilities (Baseline=13 facilities; Current= 14 facilities). Current reporting period, the catheter utilization rate decreased 14%from a baseline rate of 0.23 to a current rate of 0.2. The red line is a linear trend line that is fit to the baseline and current catheter utilization rate.

Figure 11: Catheter utilization rate (blue line) from self-report data over the entire reporting period for PfP eligible facilities (Baseline= 4 facilities; Current= 4 facilities). In current reporting period, the catheter utilization rate decreased 11% from a baseline rate of 0.25 to a current rate of 0.22. The red line is a linear trend line that is fit to the baseline catheter utilization rate and current catheter utilization rate.

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DATA ANALYSIS AND RESULTS FOR NON PFP-ELIGIBLE FACILTIES: Nine non-PfP-eligible facilities, consisting of LTACs and Rehab hospitals, self-reported CAUTIs, catheter days and patient days. The CAUTI rate and catheter utilization rate are calculated using the same method as described above for PfP-eligible facilities.

Figure 12: CAUTI rate (blue line) over entire reporting period of non-PfP-eligible facilities (Baseline= 9 facilities; Current= 9 facilities). In current reporting period, the CAUTI rate increased 91% from a baseline rate of 3.7 to a current rate of 7.1. The red line is a linear trend line that is fit to the baseline CAUTI rate and current CAUTI rate.

Figure 13: Catheter Utilization rate (blue line) over entire reporting period of non-PfP-eligible facilities (Baseline= 5 facilities; Current= 6 facilities). In current reporting period, the catheter utilization rate decreased 18% from a baseline rate of 0.47 to a rate of 0.39. The red line is a linear trend line that is fit to the baseline Catheter Utilization rate and current Catheter Utilization rate.

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STRATEGIES AND SUCCESSES TO DATE: • 11 PfP facilities and 4 non-PfP facilities have achieved level 3 or 4 status. • Collaboration with the QIO program and CUSP CAUTI to reduce the CAUTI rate in Nevada.

Beginning as early as 2011, 15 hospitals have joined the in the QIO and NHA CUSP CAUTI cohorts and are receiving coaching on how to identify and properly report CAUTIs.

OPPORTUNITIES FOR IMPROVEMENT: • We are currently recruiting for the next CAUTI CUSP initiative geared toward reducing catheter

utilization in emergency departments. We had a speaker from South Carolina Hospital Association talk to membership on October monthly conference call about their success with this initiative.

• HEN staff have developed a Call to Action Campaign to turn around rising CAUTI and CLABSI trends within the NV HEN cohort.

o Using the Signature Style method, we asked leaders to review bundle adherence and confirm these bundles are spread to all departments. Each week a task is presented in the newsletter and participation is charted on our website (http://healthinsight.org/nevada-2/nv-providers/hospital-engagement-network/167-locations/nevada/health-care-providers/hospital-engagement-network/486-clabsi-and-cauti-progress-chart). Hospitals participate by contacting us to share their plan of action to reduce CAUTI and CLABSI.

o HEN staff presented this Call to Action at 5th Friday Club of Southern Nevada (August 30th) sponsored by the Nevada Hospital Association and Nevada Organization of Nurse Leaders, the Nevada Patient Safety Committee (Sept 17th) for local infection control staff and by request at one of the hospitals (Sept 20th) within the HEN network. The HEN will actively look for opportunities to speak to front line staff about the rising trends and encourage action plans that reverse the trend.

o We are encouraging hospitals to participate through our Taking Stock visits and will be reaching out to non-participating hospitals in the next month.

HEN STRATEGIES FOR IMPROVEMENT: • Share information and tools from the National Content Developer via newsletter, learning sessions,

and Health Community website. We are providing resource page for reducing CAUTI and CLABSI on our website.

• Share best practices of high performing hospitals with other hospitals via monthly calls (CAUTI was the topic of our May HEN Monthly Membership Call and the Call to Action has been the topic of August, September and October monthly calls) and at plenary sessions (July 2013).

• Spread successful strategies from other HENs with NV HEN facilities during 1:1 site visits. Examples include daily evaluation of catheter use and Nurse-Driven removal protocols from Carolina HEN and CUSP website.

• Encourage hospitals to spread CUSP or facility-based unit-specific success to all units of the facility – concentrate on areas of challenge (i.e. Emergency Departments; Surgery, etc.).

http://healthinsight.org/nevada-2/nv-providers/hospital-engagement-network/167-locations/nevada/health-care-providers/hospital-engagement-network/486-clabsi-and-cauti-progress-chart



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HOSPITAL STRATEGIES FOR IMPROVEMENT: • Evaluate new product lines such as Foley securement devices that require less tubing

manipulation; silver-coated Foleys, soaps and washcloths, etc. • Update processes such as do not reuse wash basins; consider order of cleaning from cleanest to

dirtiest, nurse removal protocols, etc. • Use of UV light room terminal clean and Bio-guard room curtains • Consider Nurse-Driven Catheter Removal Protocols • Utilization of Silver-Coated insertion devices: Some of our hospitals stopped using these for cost

containment with a resulting increased infection rate. Therefore, they are re-instituting the use of these catheters to determine if this process-related change will reduce infection rate.

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CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTIONS (CLABSI)

TABLE 5-A&B: SUMMARY OF CLABSI RATES



CLABSI Rate per 1,000 device days (Self-report)


June-August 2013 1.83 -14%

CLABSI Rate per 1,000 device days (NHSN) ICU ONLY


June-August 2013

1.35 3%

Overall CLABSI Rate n/a n/a -2%

Central Line Utilization Ratio

January-March 2011 58.5%

June-August 2013

58.5% 0%




CLABSI Rate per 1,000 device days (Self-Report)


May-July 2013 0.85 -97%

DATA ANALYSIS AND RESULTS FOR PFP ELIGIBLE FACILITIES: The NV HEN has two sources of data for PfP eligible facilities: self-reported data and NHSN data. The CLABSI rate is calculated as number of CLABSI events divided by the number of central line days multiplied by 1000. For the facilities reporting into NHSN, the baseline CLABSI rate was calculated using January-March 2011 and the current CLABSI rate is calculated over June-August 2013. The NHSN cohort represents 64% of our PfP eligible facilities and is showing a 3% decrease. Utilization of central lines over the same time period shows no change.

Five additional PfP-eligible facilities self-report CLABSI data bringing our total participation rate for this HAC to 82%. The baseline period for self-report CLABSI rate was January-March 2011 and the current time period for the PfP-eligible self-reported data is June-August 2013. This cohort is showing 14% increase in CLABSI rate.

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Figure 14: CLABSI rate per 1000 central line (blue) for self-reported PfP eligible facilities (Baseline=4 facilities & Current= 5 facilities). In current reporting period, the CLABSI rate increased 14% from a baseline rate of 1.6 to a current rate of 1.8. The red line is a linear trend line that is fit to the baseline CLABSI rate and current CLABSI rate.

Figure 15: CLABSI rate per 1000 central line days (blue) for NHSN PfP eligible facilities (Baseline= 14 facilities & Current=13 facilities). In current reporting period, the CLABSI rate decreased 3% from a baseline rate of 1.39 to a current rate of 1.35. The red line is a linear trend line that is fit to the baseline CLABSI rate and current CLABSI rate.

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DATA ANALYSIS AND RESULTS FOR NON-PFP ELIGIBLE FACILITIES: The NV HEN also has 8 non-PfP eligible facilities (LTACs & rehab) who self-report CLABSI data in the current time period (May-June 2013) and the 4 facilities are in the baseline period (January-March 2013). The non-PfP eligible facilities are showing 97% increase in CLABSI rates. It is important to note that these facilities are quite small with very low CLABSI rates to start – so even one incident can spike their numbers. Nonetheless, we are engaging them on our Call To Action to reassess bundles compliance and other process measure to see why the incident rate is rising.

Figure 16: CLABSI rate per 1000 central line days (blue) for non-PfP eligible facilities. In current reporting period, the CLABSI rate increased 97% from a baseline rate of 0.43 to a current rate of 0.85. The red line is a linear trend line that is fit to the baseline CLABSI rate and current CLABSI rate. (Baseline= 4 facilities & Current=8 facilities)

STRATEGIES AND SUCCESS TO DATE: • 3 facilities achieved level 3 status, 6 facilities achieved level 4 status and 1 facilities achieved a level

5 status on the participation grid • Hospital 2 (an LTAC) has achieved level 5 status. We have shared their best practices for across the

board HAI prevention via success stories, poster sessions, and panel presentations. Although, not PfP eligible, they are a model in our HEN for addressing the HAI issue aggressively.

• Nevada State Health Division has offered the voluntary data collection of Hemodialysis Catheter infection data to NHSN (not officially required until 2014). We are encouraging our hospitals to embrace this opportunity to look at this high risk population early to proactively begin problem solving and intervention implementation - so far four hospitals have made this commitment and data collection began on April 1, 2012.

OPPORTUNITIES FOR IMPROVEMENT: CLABSI is part of our Call to Action campaign to encourage NV HEN facilities to know their rates, validate their processes and take corrective action appropriate to their findings.

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HEN STRATEGIES FOR IMPROVEMENT: • A Call to Action: During our NV HEN monthly call (9/26), the NV HEN team initiated a Call to

Action campaign using the Signature Styles method to motivate our members to reduce both CLABSI and CAUTI rates. We presented a DECLARATION in the form of a patient experience video to get our audiences’ attention, followed by an overview of the current data trends (NV HEN and national) to ASSERT that there is a true problem and OFFER to assist our facilities in analysis or information. Then we REQUESTED our attendees to COMMIT to actions (verify bundle compliance, spread CUSP CLABSI to other units, verify sterilization techniques, etc.). We are using a race-car visual to help the hospitals see how they compare to others, This campaign has continued throughout October.

• Although CUSP CLABSI ended in September 2012, we still strive for commitment and action from our facilities to ensure bundle compliance and spread best practices to other areas not previously involved with CUSP.

• During “Taking Stock” we ensure that the CLABSI toolkits and interventions are applied to all settings, not just selected units. If not, set timelines and targets for the spread to all units.

• Spread our Level 5 hospital’s strategies with other Nevada HEN facilities.

HOSPITAL STRATEGIES FOR IMPROVEMENT: • Institute and monitor the use of the CLABSI bundles – look at process measures for compliance;

use CUSP principles to implement, spread and sustain improvement. • Use CUSP ICU-based strategies in all areas of the facility to spread the safety concept. • Implement daily rounds to assess appropriateness of the catheter. Team consults for strategies,

which can accelerate removal or avoidance • BioPatch Disc site-coverings as a prevention strategy. • UV light room terminal clean and Bio-Guard curtains.

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EARLY ELECTIVE DELIVERY (EED)

TABLE 6: SUMMARY OF EED RATES



EED Rate per patient delivering newborn >= 37 and <39 weeks of gestation (Self-report)

Average over year 2011 7.3%

April-June 2013 1.1% 85%

DATA ANALYSIS AND RESULTS: The NV HEN has 12 facilities with obstetrics departments and all 12 of these facilities are PfP eligible. Ten of the 12 facilities have self-reported data in the current time-period of 2nd quarter 2013 resulting in an 83% participation rate. The EED rate was calculated using the 2011 average as the baseline reporting period. There are 9 facilities in the baseline time period of 2011, four of these hospitals provided 2010 and 2011 data that was originally self-reported for the Leapfrog project. The Leapfrog data provided a rate of elective deliveries for a sample of mothers delivering newborns with >=37 weeks and <39 weeks of gestation completed. Since this sample should be representative of the population, we projected our 2010 and 2011 benchmark numbers by multiplying the Leapfrog rates by the actual total number of mothers giving birth to babies at these facilities with >37 weeks and <=39 weeks of gestation completed in 2010 and 2011. The remaining facilities reported baseline data from their internal reporting systems. In the current time period, ten NV HEN facilities have decreased EED rate by 85% from baseline and have achieved a rate of 1.1% which is below the national benchmark level (2%).

Figure 17: Early elective deliveries (blue line) over entire reporting period of PfP-eligible facilities. In current reporting period, the EED rate decreased 85% from a baseline rate of 9.6 to a current rate of 1.4 (Baseline= 9 facilities & Current=10 facilities). The red line is a linear trend line that is fit to the baseline EED rate and current EED rate.

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EARLY ELECTIVE DELIVERY (EED)

HARM AVOIDED AND PROJECTED COST SAVINGS: A study published in the American Journal of Obstetrics and Gynecology found that babies born by EED were 4.8% more likely to go to the NICU than full-term babies. The estimated the cost of NICU stay is $15,172 (Table 2). We estimate that in the current time period our facilities prevented 4 babies from being admitted to the NICU saving more than $60,688 (Table 2). We further estimate a projected annual cost savings of $242,758.

STRATEGIES AND SUCCESS TO DATE: • 85% reduction in EEDs when current time period is compared to baseline (Figure 17) • Four of our hospitals have obtained a grant from the March of Dimes to establish programs striving

to reduce/eliminate preterm birth and adverse birth outcomes. These programs include: smoking cessation classes, increasing health education, home visits, health equity programs, enhanced care through prenatal model and initiation of quality improvement program.

• 9 facilities have achieved a level 3 status or higher. o Four facilities have achieved level 5 status by reducing their EED rates by more than 40%,

having current rates lower than 2% and implementing and enforcing a Hard Stop Guideline.

OPPORTUNITIES FOR IMPROVEMENT: • Strengthen our working relationship with new Strong Start Initiative in Nevada to look for

synergistic ways to advance the goals. This will also apply to Option Year 1 (if awarded) with preeclampsia early detection and treatment.

• Continue to increase the number of hospitals reporting current and historical data to obtain 100% participation. Currently are setting up meetings with hospitals that have not submitted data to investigate how we may obtain EED rates.

HEN STRATEGIES FOR ADDED SUCCESS: • Distributed March of Dimes patient education materials to all the hospitals with OB services and

their affiliate physician offices – completed June 2013 • Continue OB Advisory Group meetings with hospitals to discuss additional strategies to sustain

reduction in EED and other OB topics. • Participate in the Maternity Affinity Group to share and obtain best practices.

HOSPITAL STRATEGIES FOR ADDED SUCCESS: • High performers are sharing their best practices with other hospitals via posters, panel discussions

at learning sessions, and within the Advisory Committee. • Developing Exclusion Criteria and Physician Champions to move toward Hard Stop strategy (2

hospitals remain). • Make Patient Education Materials and pre-natal counseling available to parents.

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FALLS WITH SIGNIFICANT INJURY

TABLE 7: SUMMARY OF FALLS TRAUMA RATES

7-A: PfP-Eligible Hospitals Participating: 22/25 (88%) Measure Baseline Current % Decrease

Falls Trauma Rate per 1,000 discharges (CHIA)


April-June 2013 1.1

45%

Falls with Injuries per 1,000 days (self-report)

June-August 2012

0.35

July-Sept 2013 0.19

45%

Overall Falls Rate n/a n/a 45%




Falls Trauma Rate per 1,000 discharges (CHIA)


April-June 2013 3.4 8%

Falls with Injuries Rate per 1,000 days (self-report)

Jan-April 2013 0.48

May-July 2013 1.39 -191%

DATA ANALYSIS AND RESULTS FOR PFP ELIGIBLE FACILITIES: The NV HEN obtains Falls Trauma data according to the CMS HAC definition using the CHIA database. We selected the CMS HAC definition for three reasons:

1. It is consistent with the methodology used by CMS therefore directly correlates with national trends

2. Only a very few hospitals in our network are National Database Nursing Quality Indicators (NDNQI) participants and thus, data from NDNQI does not provide a representative sample for assessing fall rate trends in Nevadan hospitals

3. The outcomes of serious injury could be reliably identified using CHIA billing code data

For the 3rd year of the project, we are investigating opportunities to use self-reported data from the hospitals that mimic the NDNQI definition. We have already begun querying our facilities to determine data access and we believe many of our facilities will be able to provide number of falls/number of patient days. We already have a small cohort of self-reported data that follows NDNQI Falls with Injury/patient days definition. (Figures 19 and 21).

Twenty-three PfP-eligible facilities reported Falls Trauma data through the CHIA database and by self-report to the HEN in this reporting period. For the PfP-eligible facilities reporting via CHIA, baseline falls trauma rate was calculated using the first 3 months of 2010 and the current fall trauma rate was calculated

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FALLS WITH SIGNIFICANT INJURY using Q2 2013 (Figure 18). Within this cohort, falls trauma rate improved by 45% in the current time

period compared to baseline. For the facilities self-reporting Falls with Injuries, baseline was calculated using the 1st quarter 2013 and the 3rd quarter 2013 (Figure 19) Within this cohort, falls with injury rate improved 45%.

Figure 18: Falls trauma rate per 1000 patient discharges over the entire reporting period for PfP eligible facilities reporting in CHIA. In current reporting period, the falls trauma rate decreased 45% from a baseline rate of 1.9 to a rate of 1.1 (Baseline = 13 facilities & Current = 12 facilities). The red line is a linear trend line that is fit to the baseline Falls Trauma rate and current Falls Trauma rate.

Figure 19: Falls with Injuries rate per 1000 patient days over a 12 month reporting period for PfP eligible facilities. In current reporting period, the falls with injuries rate decreased 45% from a baseline rate of 0.35 to a rate of 0.19 (Baseline = 8 facilities & Current = 11 facilities). The red line is a linear trend line that is fit to the baseline Falls with Injuries rate and current Falls with Injuries rate.

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FALLS WITH SIGNIFICANT INJURY DATA ANALYSIS AND RESULTS FOR NON-PFP ELIGIBLE FACILITIES:

For non-PfP facilities, Falls Trauma rate is obtained from self-report data and the CHIA database. The baseline period for the CHIA cohort (4 facilities) was the first quarter of 2010 and the current reporting period was defined as Q2 2013. Within this cohort, falls trauma rate improved by 8% in the current time period compared to baseline. We have 5 other non-PfP eligible facilities not included in current time period of CHIA data that are self-reporting falls with injury data. For the facilities self-reporting Falls with Injuries, baseline was calculated using the 1st quarter 2013 and the 3rd quarter 2013 (Figure 21) Within this cohort, falls with injury rate has increased significantly.

Figure 20: Falls trauma rate per 1000 patient discharges over the entire reporting period for non-PfP eligible facilities. In current reporting period, the falls trauma rate decreased 8% from a baseline rate of 3.7 to a rate of 3.4 (Baseline = 6 facilities & Current = 5 facilities). The red line is a linear trend line that is fit to the baseline Falls Trauma rate and current Falls Trauma rate.

Figure 21: Falls with Injuries rate per 1000 patient days over an 8 month reporting period for non- PfP eligible facilities. In current reporting period, the falls with injuries rate increased 191% from a baseline rate of 0.48 to a rate of 1.39 (Baseline = 4 facilities & Current = 5 facilities). The red line is a linear trend line that is fit to the baseline Falls with Injuries rate and current Falls with Injuries rate.

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HARM AVOIDED AND PROJECTED COST SAVINGS: Assuming the cost of a serious fall is approximately $11,250* we estimate that the hard work of our PfP and non-PfP facilities prevented 12 patients from harm during the current quarter with a total projected annual cost savings of $540,000 PfP-eligible facilities

*Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorston K, Chan L. Falls in the Medicare population: incidence, associated factors, and impact on health care. Physical Therapy, 2009. 89(4):1-9.

STRATEGIES AND SUCCESSES TO DATE: • 17 facilities achieved level 3 status or 4 status • 4 Facilities (MountainView, Renown Regional, Northern Nevada Medical Center, and St Mary’s)

have been acknowledged for their success by receiving “Bright Spots in the Silver State” awards. These success stories have also been shared with CMS to spread best practices.

• We focused on this HAC during our June Monthly HEN Call. We presented the AHRQ Falls toolkit and had two hospitals present their success stories and strategies and challenges to the NVHEN.

OPPORTUNITIES FOR IMPROVEMENT: • The geriatric-psych population has been a challenge for some of our facilities. We offer an

evidence-based Falls assessment and prevention program through the Touro University Geriatric Medicine Program to assist with this challenge

• Share best-practice information regarding this specialty population. Tap into QIO resources from Skilled Nursing Facilities to share with the hospitals.

• Relate medication profiles to fall risk assessment and RCA follow-up of falls • Revise data collection methodology – ask hospital to self-report falls with injury.

HEN STRATEGIES FOR ADDED SUCCESS: • Even though our data collection measures and tracks the high-harm events, our interventions

strive to eliminate all falls. During visits with hospitals, we encourage the facilities to use a multi-pronged approach to prevent falls including increased staff coverage during fall risk periods; scheduled toileting; risk assessment and identification of high risk patients; alarms or other electronic monitoring; sitters and patient/family engagement, etc.

• We provide additional assistance as needed to facilitate RCA for all falls with serious injury to identify and mitigate future high-harm events (Workshops were conducted in May 2013)

• Offer Touro University’s evidenced based “Falls” training to struggling facilities • Representatives from Touro University will provide Falls assessment for attendees of the

November 12th Brown Bag event. The aim of the Falls assessment is to identify balance deficits and offer education on fall prevention and balance training.

• Share information from pacing events, national toolkits and success stories on the monthly calls, monthly newsletter, and educational sessions.

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HOSPITAL STRATEGIES FOR ADDED SUCCESS: • Patient-Family Engagement strategies geared towards educating patients and family members in

falls prevention • Utilize root cause analysis (RCA) for falls. (RCA training was offered in May 7th & 20th 2013).

Explore possible causes such as medication usage. • Conduct assessment to identify high risk patients. Identify high risk patients with signage and

special garments. For high risk patient utilize bed alarms and/or other assistive devices. Use of sitters or scheduled toileting for at-risk patients.

• Create an environment where ALL staff share responsibility for falls prevention • Indicating lift/transfer requirements on white boards and or signage • Always conduct Post Fall Huddles as soon as possible following an event • Certified Nursing Assistant Champions

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OBSTETRICS ADVERSE EVENTS

TABLE 8: SUMMARY OF OBSTETRICS ADVERSE EVENTS RATES



Injury to Neonates Rate per 1,000 live births (CHIA)


April-June 2013 0

100%

OB Trauma: Vaginal Delivery with Instruments rate per 1,000 deliveries with instruments (CHIA)

January-June 2010 150

April-June 2013 113

25%

OB Trauma: Vaginal Delivery without Instruments rate per 1,000 deliveries without instruments (CHIA)


April-June 2013 22

16%

Overall OB Adverse Event Rate n/a n/a 47%

DATA ANALYSIS AND RESULTS: The NV HEN has 12 facilities with OB departments and all are PfP-eligible. The NV HEN uses PSIs 17, 18 and 19 from medical billing data extracted from the CHIA database. Three outcome measures related to OB adverse events are tracked by NV HEN that includes: injury to neonate, injury due to vaginal births with instruments and injury due to vaginal births without instruments. Currently, 100% of NV HEN OB facilities are participating in reporting data. Baseline reporting period for all three measures is January-June 2010 and the current report time period is April-June 2013. We calculate the overall improvement rate of 47% for other OB Adverse Events by taking an average of the 3 outcome measures.

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Figure 22: Birth Trauma: Injury to Neonates (blue line) over entire reporting period of PfP-eligible facilities. In current reporting period, the rate of Birth Trauma: Injury to Neonates decreased 100% from a baseline rate of 0.16 to a current rate of 0.00 (Baseline = 12 facilities & Current = 12 facilities). The red line is a linear trend line that is fit to the baseline Birth Trauma: Injury to Neonates rate and current Birth Trauma: Injury to Neonates rate.

Figure 23: OB Trauma: Vaginal Delivery with Instruments (blue line) over entire reporting period of PfP-eligible facilities. In current reporting period, the rate of OB Trauma: Vaginal Delivery with Instruments decreased 25% from a baseline rate of 150 to a current rate of 113 (Baseline = 12 facilities & Current = 12 facilities). The red line is a linear trend line that is fit to the OB Trauma: Vaginal Delivery with Instruments rate and current OB Trauma: Vaginal Delivery with Instruments rate.

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Figure 24: OB Trauma: Vaginal Delivery without Instruments (blue line) over entire reporting period of PfP-eligible facilities. In current reporting period, the rate of OB Trauma: Vaginal Delivery without Instruments decreased 16% from a baseline rate of 26 to a current rate of 22 (Baseline = 12 facilities & Current = 12 facilities). The red line is a linear trend line that is fit to the OB Trauma: Vaginal Delivery without Instruments rate and current OB Trauma: Vaginal Delivery without Instruments rate.

HARM AVOIDED AND PROJECTED COST SAVINGS: Assuming a $3000 cost for an adverse OB event (AHRQ estimate), we estimate that in the current time period our facilities avoided injury or trauma in 24 babies resulting in a cost savings of $72,000 in Q2 2013 (Table 2). We further estimate an annual projected cost savings of $288,000.

STRATEGIES AND SUCCESSES TO DATE: • ALL of our facilities with OB departments achieved a level of 3, 4 or 5 for at least 1 of our “Other

OB” metrics. • Three of our facilities have achieved level 5 status. These hospitals have all demonstrated

improvement greater than 40% or sustained a 0 rate for greater than 12 months in at least 1 of our OB metrics. In addition, these facilities have demonstrated broader improvement efforts that include the implementation of Pitocin protocols, shoulder dystocia protocols, use of a hemorrhagic cart and staff who participate in regular simulation training.

• NV HEN has sponsored several of our facilities to participate in Advanced Life Support in Obstetrics (ALSO) training provided via University of Nevada, School of Medicine (UNSOM).

O This training provided hospitals with tools to conduct periodic drills for OB emergencies that could result in injury. Staff are encouraged to spread tools within their own organization as well as between organizations.

O The NV HEN sponsored an EMT from one of our rural facilities to become an ALSO master trainer. This person now trains other emergency responders in Life Support for Obstetrics.

• The use of mid-wives in 2 of our facilities (Hospitals X and J) has decreased the number of births with instruments.

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OPPORTUNITIES FOR IMPROVEMENT:

• The Nevada HEN OB Advisory Committee participation has diminished. We are meeting with OB staff at the HEN facilities to identify areas of training need or topics of interest.

• Further develop the partnership between the NV HEN, the Strong Start Initiative in Nevada and March of Dimes.

• Working with UNSOM staff, to encourage hospitals to participate in the ALSO training in the 3rd year and develop training for rural facilities that do not have OB department but develop babies in emergency situations.

• Informed our hospitals of webinars such as Pacing Events, IHI and March of Dimes events

HEN STRATEGIES FOR ADDED SUCCESS: • This year we started a two-phase training program for the OB staff at our hospitals. These sessions

are co-sponsored by the University of Nevada, School of Medicine. o The first phase was ALSO and Care Team OB trainings. Nurses participating in the ALSO

training obtained practical skills to use in the event of an obstetrical emergency like a breech delivery or a severe post-partum bleed. The Care Team OB session focused on providing the nurses communication skills to use in the delivery of care.

o In July, OB staff from hospitals within the HEN attended TeamSTEPPS training to improve their teamwork in the obstetrical unit. Representatives from the hospitals that participated in the initial sessions took part in these classes. These attendees returned to their hospitals, equipped to train their staffs. (This action applies to all 3 of the OB Adverse Events)

o ALSO training addresses the management of OB Hemorrhage (Option Year 1 focus) • Investigate NICU and OB Patient engagement activities and work with the March of Dimes to

collaborate on developing these committees. • Partner with Strong Start initiative to look for synergy in pre-natal care to avoid high-risk

pregnancies (including early detection and treatment of preeclampsia) which could lead to high risk deliveries

HOSPITAL STRATEGIES FOR ADDED SUCCESS: • The hospitals are continuing to run drills for OB emergencies • Increase patient education and engagement • Pitocin Protocol reviews • Advancing availability of Mid-Wives • Shoulder dystocia Protocols • Established a Hemorrhagic Response Emergency Cart • Engage in UNSOM ALSO, TeamSTEPPS, and OB Care project.

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PRESSURE ULCERS

TABLE 9-A&B: SUMMARY OF PRESSURE ULCER RATES

9-A: PfP-Eligible Hospitals Participating: 23/25 (92%) Measure Baseline Current % Decrease

Pressure Ulcer Rate per 1,000 eligible discharges (CHIA)


April-June 2013 0.45

52%

NOTE: We have had 1 PfP-eligible facility self-reporting data on pressure ulcers since January 2012. Since they do not provide baseline data we have not factored them into the overall HAC improvement rate.

9-B: Non-PfP-Eligible Hospitals Participating: 8/9 (89%) Measure Baseline Current % Decrease

Pressure Ulcer Rate per 1,000 eligible discharges (CHIA)



81%

Pressure Ulcer Rate per 1,000 eligible discharges (self-report)


March-May 2013 2.09

-28%

Overall Pressure Ulcer rate n/a n/a 26%

DATA ANALYSIS AND RESULTS: We track Stage 3 & 4 Pressure Ulcers using the CHIA database and exclude diagnoses according to the AHRQ definition of PSI-03. Currently, 92% of NV HEN PfP facilities and 89% of non-PfP facilities are reporting data. Baseline period is the January-June 2010 and the current report time period is April-June 2013 for both PfP and non-PfP eligible facilities reporting into CHIA. For self-reporting non-PfP eligible facilities, baseline period was January-June 2010 and the current time period was March-May 2013. The overall improvement rate in pressure ulcers is 52% for PfP eligible facilities and 26% reduction in pressure ulcers for non-PfP eligible facilities.

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PRESSURE ULCERS

Figure 25: Pressure ulcer rate per 1000 eligible discharges (blue line) over the entire reporting period for PfP eligible facilities reporting in CHIA. In current reporting period, the pressure ulcer rate decreased 52% from a baseline rate of 0.95 to a rate of .45. (Baseline=24 facilities; Current=22 facilities). The red line is a linear trend line that is fit to the baseline pressure ulcer rate and current pressure ulcer rate.

Figure 26: Pressure ulcer rate per 1000 eligible discharges (blue line) over the entire reporting period for non-PfP eligible facilities reporting in CHIA. In current reporting period, the pressure ulcer rate decreased 81% from a baseline rate of 10.19 to a rate of 1.89. (Baseline=7 facilities; Current=6 facilities). The red line is a linear trend line that is fit to the baseline pressure ulcer rate and current pressure ulcer rate.

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PRESSURE ULCERS

Figure 27: Pressure ulcer rate per 1000 eligible discharges (blue line) over the entire reporting period for non-PfP eligible facilities self-reporting. In current reporting period, the pressure ulcer rate increased 28% from a baseline rate of 1.63 to a rate of 2.09. (Baseline=2 facilities; Current=2 facilities). The red line is a linear trend line that is fit to the baseline pressure ulcer rate and current pressure ulcer rate.

HARM AVOIDED AND PROJECTED COST SAVINGS: Assuming the cost of a serious fall is approximately $33,180* we estimate the PfP and non-PfP facilities prevented harm in 9 patients during the current quarter with a total projected annual cost savings of $1,194,480 ($663,600 PfP-eligible facilities and $530,800 non PfP-eligible facilities)

*Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorston K, Chan L. Falls in the Medicare population: incidence, associated factors, and impact on health care. Physical Therapy, 2009. 89(4):1-9.

STRATEGIES AND SUCCESSES TO DATE: • 25 facilities achieved level 3, 4 or 5 status. • 3 Facilities (North Vista Hospital, Tahoe-Pacific Hospital and Southern Hills Hospital Medical

Center) received “Bright Spot in the Silver State” awards for progress in this HAC • Increased participation in both southern and northern Nevada pressure ulcer advisory committees • HEN facilitated Pressure Ulcer Advisory committee meeting in northern Nevada on October 17th.

OPPORTUNITIES FOR IMPROVEMENT: • Work with the facilities in the NV HEN to self-report pressure ulcer rates and investigating how to

obtain prevalence measures of pressure ulcer rates • Provide educational opportunities to look for signs of deep tissue injury and encourage a look back

24-72 hours to identify causative event and location.

HEN STRATEGIES FOR ADDED SUCCESS: • Convene the Pressure Ulcer Advisory Team (Wound Nurses, Nutritionists, and Physical Therapists)

at least quarterly to encourage collaboration and share best practices and toolkits that they will bring back to their facilities for implementation.

36

PRESSURE ULCERS

• Convene the Products Review subcommittee within the Pressure Ulcer Advisory Team to look for

prevention options and pilot new techniques. Products already reviewed include: o Movin-ez: a device that can be clipped to the patient to collect data on movement over time.

The information is stored on a memory stick and can be viewed by staff to determine whether the patient has been moved over the course of the day or shift.

o MedLine NE1- a standardized and simplified tool to assess and document wounds. o Prevena – an Incision Management System (portable, disposable wound vacuum device)

technology to treat Pressure Ulcers. o KCI wound vacuum system

• Provide additional assistance as needed to facilitate RCA for Stage III, IV pressure ulcers to identify and mitigate future high-harm events (RCA Training Seminar May 7th & 20th)

• Education of nursing students to the importance of skin assessment and proper care to prevent pressure ulcers (Northern Pressure Ulcer Advisory Committee – May 17th)

• Share information from pacing events, toolkits and success stories via newsletter, monthly call and education sessions.

HOSPITAL STRATEGIES FOR ADDED SUCCESS: • Utilize Patient Assessment Teams to determine patients at risk for pressure ulcers • Create an environment where ALL staff shares responsibility for pressure ulcer prevention • Upgrade equipment with adequate accessibility and staff training: Specialty beds, moisture

barriers, pressure point buffers, proper nutrition to assess and prevent pressure ulcers • Increase education of staff to ensure proper coding and wound identification. This is especially

important in EMR to prevent miscoding • Engage patient and family in pressure ulcer awareness and provide patient engagement education

in verbal and written forms so they can partner in prevention. • Utilize root cause analysis following an incident

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READMISSIONS

TABLE 10 A & B: SUMMARY OF READMISSION RATES

10-A: PfP-Eligible Hospitals Participating in All-Payer Readmission Rate: 23/25 (92%) and PfP-Eligible Hospitals Participation in Medicare Readmission Rate: 22/25 (88%)

Measure Baseline Current % Decrease Readmissions Rate per 1,000 discharges (CHIA)

January-June 2010 12%

April-June 2013 11.3%

6%

Medicare 30-Day Readmissions Rate per total discharges (CHIA)

January-June 2010 16.5%

April-June 2013 15.0% 9%

NOTE: We have 1 other PfP eligible facility not included in CHIA who is self-reporting All-Payer Readmissions as "Returns to Tertiary Setting". They are showing a 37% reduction in readmissions between 2011 and June-August 2013.

10-B: Non-PfP-Eligible Hospitals Participating: 7/9 (78%) and Non-PfP Eligible Hospitals Participation in Medicare Readmission Rate: 7/9 (78%)

Measure Baseline Current % Decrease Readmissions Rate per 1,000 discharges (CHIA)

January-June 2010 20%

April-June 2013 12.0%

37%

Medicare 30-day Readmissions Rate per total discharges(CHIA)

January-June 2010 20.6%

April-June 2013 11.0% 48%

NOTE: Two additional non-PfP facilities are self-reporting data on 30-day readmissions. One of these facilities is showing a 71% reduction between 2010 and April-June 2013 and the other facility is showing an increasing rate.

DATA ANALYSIS AND RESULTS FOR PFP ELIGIBLE FACILITIES: Our primary data source for 30-day all-payer readmissions is the CHIA database. From the database, the NV HEN calculates the 30-day all-payer readmission rate and 30-day Medicare readmission rate. The method used to calculate these readmission rates is similar to the method used by the National Coordinating Center for Care Transitions. Using customized SAS code (SAS Institute, Gary NC), patients who were admitted to a hospital within 30 days of a discharge were identified by their unique patient code. From this sample, same day readmissions, transfers, rehab visits, visits without unique patient identifiers, and children were excluded. In the current reporting period (April-June 2013), a 6% reduction in all-payer readmissions rate was found for PfP-eligible facilities when compared to baseline period (January-June 2010; Figure 28-a). The overall all-payer readmissions rate of 6% was calculated by taking a weighted average of the 22 PfP-eligible facilities in the CHIA database and the 1 PfP-eligible facility self-reporting readmissions data. The Medicare readmission rate for NV HEN PfP eligible facilities is 9% improvement in the current time period (April-June 2013) compared to baseline period (January-June 2010; Figure 28-b).

38

READMISSIONS

Figure 28-a: All-Payer 30-Day All-Cause Readmissions rate over the entire reporting period for PfP eligible facilities using the CHIA database. In the current reporting period (Q2 2013), the average readmission rate decreased by 6.0% from the 1H 2010 baseline rate of 12.0% to a current rate of 11.3%. (Baseline=24 facilities; Current= 23 facilities). The red line is a linear trend line that is fit to the baseline readmission rate and current readmission rate.

Figure 28-b: Medicare only 30-day Readmissions PfP Eligible Facilities rate over the entire reporting period for PfP eligible facilities using the CHIA database. In the current reporting period (Q2 2013), the average readmission rate decreased by 9.0% from the 1H 2010 baseline rate of 16.5% to a current rate of 15.0%. (Baseline=25 facilities; Current= 22 facilities). The red line is a linear trend line that is fit to the baseline readmission rate and current readmission rate for Medicare patients.

39

READMISSIONS

DATA ANALYSIS AND RESULTS FOR NON-PFP ELIGIBLE FACILITIES: For non-PfP eligible facilities within the NV HEN, all-payer readmission rates decreased 37% during the current reporting period (April-June 2013) compared to baseline (January-June 2010; Figure 29). The Medicare readmission rate demonstrated larger reductions at 48% decrease in the current time period (April-June 2013) when compared to the baseline period (January-June 2010).

Figure 29-a: All-Payer 30-Day All-Cause Readmissions over the entire reporting period for non-PfP eligible facilities using the CHIA database. In the current reporting period (Q2 2013), the average readmission rate decreased 37% from baseline rate of 20.0% to a current rate of 12.0% (Baseline=8 facilities; Current= 6 facilities). The red line is a linear trend line that is fit to the baseline readmission rate and current readmission rate.

Figure 29-b: Medicare 30-Day Readmissions (non-PfP eligible facilities) using the CHIA database. In the current reporting period (Q1 2013), the average readmission rate decreased 48% from baseline rate of 20.6% to a current rate of 11.0% (Baseline=8 facilities; Current= 7 facilities). The red line is a linear trend line that is fit to the baseline readmission rate and current readmission rate (for Medicare eligible patients)

40

READMISSIONS

HARM AVOIDED AND PROJECTED COST SAVINGS: Assuming a cost of $9,600 per readmission, we estimate that PfP eligible facilities prevented 189 patients from readmission to the hospital resulting in a projected cost saving of $1,814,400 in Q2 2013. We further estimate an annual projected cost savings of $7,257,600 (Table 2). Among non-PfP facilities, we estimate that facilities potentially saved 29 patients from a hospital readmission resulting in a cost savings of $278,400 in Q2 2013. We further estimate a projected annual cost savings of $1,113,600 (Table 2) for non-PfP eligible facilities.

STRATEGIES AND SUCCESSES TO DATE: • 16 of our PfP facilities have achieved a level 3 or 4 on the Participation Grid. • One non-PfP-eligible facility (Hospital 6) has successfully reduced their readmissions rate by 37%

comparing their 2011 and July-September 2013 averages. This facility has made reducing readmissions a top priority over the past year. At the end of 2011, this hospital initiated an Improvement Plan which included interventions like using critical data from referring facilities to help them detect signs and symptoms that could result in readmissions, re-vamping Rapid Response Teams, using Teach-Back to ensure patients understand discharge instructions, and re-engineering medication reconciliation and discharge processes. The NV HEN awarded this facility a Bright Spot in the Silver State award.

• Hospital V has reported a 23% readmissions rate reduction since 2011. This PfP eligible facility has a Readmissions Task Force that reviews 100% readmissions that occur within 24-48 hours of discharge. The plan included:

o A 6-week training program for nursing staff on Pre-Admission Hand-Offs. GOAL: to learn how to identify signs and symptoms that could trigger readmissions.

o Encouraged physicians to conduct a thorough assessment prior to discharge o Adopted the Primary Nursing Model (clear accountability for each patient’s care plan) o Redesigned the Medication Reconciliation and Discharge processing forms to prevent

medication related readmissions, adverse events and improve discharge planning o Conduct weekly team conferences to learn from any issues during the past week o Implemented Teach-Back validation to ensure patients truly understand instructions and

can perform essential functions O Case Management involved in the discharge process by arranging all appointments and

conducting follow up calls 24-48 hours post discharge to check on patient condition. • Marissa Brown presented the NV HEN strategies for accomplishing Post-Discharge Medication

Counseling within 5 days of discharge during the August 5 National Pacing Event.

OPPORTUNITIES FOR IMPROVEMENT: • At an overall 6% improvement rate for our PfP eligible facilities, we need to accelerate the

decrease of our readmissions rate to achieve our goal of 20% reduction by the end of 2013. • Engage Case Managers in ADE advisory committee to identify readmissions related to medication • Engage and obtain commitment of hospital leadership in the reducing readmission campaign

41

READMISSIONS

HEN STRATEGIES FOR IMPROVEMENT: • Work with our facilities during taking stock visits to understand what actions they are taking to

reduce readmissions and spread best practices. • We have requested that our facilities break down their readmissions by type in order to develop

specific avoidance action plans. Because of the large national impact of medication-related return, we have prioritized that data regarding readmissions related to medication use be analyzed. We have already approached one facility (that is part of our QIO Care Transitions community based model) to act as a pilot in this regard so that a methodology can be developed and spread.

• We identified several in-network facilities (6, V, L, M, F & X) and 1 out-of-network facility (facility 9) whose strategies might help others. We tell these stories during our Taking Stock visits.

• The NV HEN collaborates with many community stakeholders to analyze the process, prioritize topics of action and work together to resolve the problem of hospital readmissions. For example:

o Working with QIO to attack the problem across the health care continuum by pursuing standardized communication tools; improving skill mix in step-down settings; and partnering with community pharmacies and other 3rd party providers.

o Collaborating with the QIO on their new outreach program started 8/1/13. In this program, patient advocates will follow-up with Medicare clientele who appeal their discharge to identify how hospitals can improve their discharge planning and processes. This program was created after a study showed that 64% of Medicare patients who appeal their discharge were readmitted to the hospital within 30-days.

o Piloting of a SBAR hand-off tools from discharging physicians to receiving physicians to enhance communication to support transition of care.

o Coordinating with the Admission and Transitions Optimization Project (ATOP) to improve the skill mix in Nursing Home settings that will help to prevent acute care readmissions.

o Working with The ROYL (Rest of Your Life planning) group to pilot the use of their program in 1-2 ACH and CAH to show results that will allow us to spread throughout the network.

• Modeling within State Legislative Guidelines: The Physician Orders for Life Sustaining Treatment (POLST) bill recently passed in the Nevada legislature. This bill allows the documentation of a patient’s wishes regarding life -sustaining treatment in the form of a physician’s order. Statutory language has not yet been released, as soon as the methodology is released for implementation, we will assist with coordination of training and provision of tools that support and empower clinicians to have effective and caring conversations regarding end-of-life.

• In September, we collected the contacts of all our Case Management Directors to include them in Readmission and ADE initiatives.

HOSPITAL STRATEGIES FOR IMPROVEMENT: • Appointment facilitation -

o Some hospitals are setting up post-discharge appointments for patients with their physicians (Z,U,L,M,Q,R,S,T,Y,X,1,2,6,7,8)

o Coordinate with the Health Information Exchange (HealtHIE Nevada) to maximize the potential of Primary Care Physician messaging regarding their patient’s hospital discharge.

o Some facilities use a call center to follow up with patients about primary care appointments

42

READMISSIONS o Increase involvement of case management

o One of our facilities has created a heart failure clinic to assist patients with this diagnosis who cannot get an appointment with their physician within 72 hours of discharge

• Prior to discharge strategies: o Some hospitals are executing Multidisciplinary Discharge Planning Rounds (6,R,S,A,Y,Z) o One hospital has created a “Discharge Lounge”- where counseling and coordination are

organized, validated and facilitated (Z) o Several of our facilities use the Teach-Back technique to engage patients and have them

repeat their discharge instructions to verify their comprehension. (6,Z,Q,R,S,A) o Hospital T is giving patients a medication reconciliation and Immunization status wallet

card. They are seeing patients return for other services with an updated card in hand. • Technology: Hospital 6 will develop and implement an eTool by the end of 2013. This eTool will

provide hospital staff with the most current and comprehensive list of patient education materials. • Root Cause Analysis (RCA) – when processes do not achieve optimum results, a team convenes to

analyze the reasons and designs alternative processes that will achieve results. (ALL)

43

SURGICAL SITE INFECTIONS (SSI)

TABLE 11: SUMMARY OF SSI RATES



SSI Rate per colon procedures (NHSN)



17%

All SSI Rate (self-reported) January-June 2010 0.011

March-May 2013 0.007

36%

Overall SSI Rate n/a n/a 17% SSI Rate from hysterectomy (NHSN)



-193%

DATA ANALYSIS AND RESULTS: We have three outcome measures for this HAC: SSIs from colon procedures (NHSN), SSIs from hysterectomies (NHSN) and an ALL SSIs from all surgical procedures (self-reported). The NV HEN has 18 facilities that perform surgeries and all are PfP eligible. The baseline time-period used to calculate the number of SSIs from COLO procedures and the rate of SSIs from HYST procedures was January-March 2012. The current time period used to calculate the rate of SSIs from COLO procedures and SSIs from HYST was June-August 2013. For the self-report data, the rate of SSIs from ALL surgical procedures was calculated over the baseline period of January- June 2010 and over a rolling three month period (March-May 2013).

We calculated the overall SSI improvement by taking a weighted average of the SSI colon and the ALL SSI outcome measures. We omitted the SSI HYST measure because this trend is misleading. During the baseline time-period, 2 SSIs for 372 hysterectomy procedures were reported from a total of 12 hospitals within the HEN. During the current time-period (June-August 2013), 8 SSIs for 507 hysterectomy procedures were reported. This rate (1.6%) is low when compared to published research on the AHRQ website that estimates between 2% and 13% of patients experience an SSI following a hysterectomy*. Therefore, with only 8 SSIs from hysterectomies, it seems that the NV HEN facilities reporting data to NHSN are doing quite well. For that reason, our focus has been on maintenance of low rates and spreading of best practices to the other types of surgery within our facilities.

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Figure 30: The number of SSIs from Colon (COLO) procedures per 100 COLO procedures over the entire reporting period for NHSN PfP eligible facilities. In current reporting period, the number of SSIs from COLO procedures decreased 11% from a baseline rate of 0.041 to a rate of 0.036. (Baseline=15 facilities; Current=15 facilities) The red line is a linear trend line that is fit to the baseline SSI rate and current SSI rate.

Figure 31: The number of SSIs from hysterectomies (HYST) procedures per 100 HYST procedures over the entire reporting period for NHSN PfP eligible facilities. In current reporting period, the number of SSIs from HYST procedures increased 193% from a baseline rate of 0.005 to a rate of 0.016 (Baseline = 12 facilities; Current = 12 facilities). The red line is a linear trend line that is fit to the baseline SSI rate and current SSI rate.

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Figure 32: The number of SSIs from ALL procedures per total number of surgical procedures over the entire reporting period for self-reported PfP eligible facilities. In the current reporting period, the number of SSIs from ALL procedures decreased 36% from a baseline rate of 0.011 to a current rate of 0.007. (Baseline = 4 facilities; Current = 5 facilities). The red line is a linear trend line that is fit to the baseline SSI rate and current SSI rate.

HARM AVOIDED AND PROJECTED COST SAVINGS: In the current time period, facilities within the NV HEN have avoided 1 potential SSI associated with colon surgery resulting in an estimated cost savings of $20,000* and an annual projected cost savings of $40,000 (Table 2). *Scott RD. “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention.” Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases Coordinating Center for Infectious Diseases Centers for Disease Control and Prevention. Web. 4 Dec 2012. http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

STRATEGIES AND SUCCESSES TO DATE: • COLO SSI RATE from facilities reporting in NHSN - 15 facilities, 11% decrease from baseline

(Figure 30) • Self-Report - [All SSI]/[All Surgeries], 5 facilities, 36% decrease from baseline (Figure 32). Two of

these facilities are not included in the NHSN data. • 13 facilities achieved level 3 status or higher • Our Antibiotic Stewardship/HAI Steering Committee has agreed on a strategy to help focus

infection control efforts that will affect SSI and other HACs. Currently, they are performing a cost and task proposal to justify a regional prevalence study on virulent agents (C. Diff and CRE). Additionally, they are collaborating with the Southern Nevada Health District to acquire grant funding to sponsor the staff needed to produce a Regional Antibiogram. Educational Programming is also under development for Physicians, Advanced Nurse Practitioners and Physician Assistants regarding proper prescribing guidelines and de-escalation of therapy based on pathology results.

http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

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OPPORTUNITIES FOR IMPROVEMENT:

• Continue to work toward our goal of zero surgical site infections for all facilities and all type of surgery.

• Continue to organize the Antibiotic Stewardship/HAI Steering Committee and support their efforts • Increase our tracking of SSI rates in NV HEN facilities by obtaining permission from facilities to

gain access to NHSN data related to SSI from CABG, hip joint replacement and knee joint replacement surgeries.

• Engage more hospitals in SUSP – we currently have 4 enrolled. SUSP recently announced that they are opening up to other service lines (i.e. joints, abdominal, cardiac, etc.) - this may attract other facilities. We will have our SUSP hospitals share their lessons learned and strategies for improvement with the collective HEN.

HEN STRATEGIES FOR ADDED SUCCESS: • Share best practices and toolkits that they will bring back to their facilities for implementation. • We share the strategies of successful hospitals with the others to spread best practices. • We share information from pacing events, toolkits and success stories via newsletter, monthly call

and education sessions. • The HEN is sponsoring two hospitals in the SUSP project (Cohort 2) that are now engaged in NHSN

data upload to SUSP. Two additional hospitals have committed to cohort 4 of SUSP. • Coordinating with the QIO to gain access (via our data use agreements with the hospitals) access to

metrics on joint and coronary by-pass graph surgical infections.

HOSPITAL STRATEGIES FOR ADDED SUCCESS: • Participation in the SUSP project. • Most of our facilities use of Chlorhexadine wipes, silver impregnated dressings, MRSA

decolonization and/or SCIP. • One of our facilities has started using Xenex (a disinfection robot). If this new tool is successful, we

will have them share their experience with other facilities. • Reassess the use of warming blankets during Ortho and Spinal surgeries. Part of this device sits on

the floor and may transfer floor dirt into the sterile area. This adheres to the bone mass and forms a biofilm which is impervious to antibiotics and may be a significant risk for infection.

• Reassess patient engagement tools to involve the patient in pre- and post-operative care by explaining the risks and how to minimize infection. Provide patients with information and basic products to prep and maintain sterile areas.

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VENTILATOR ASSOCIATED PNEUMONIA/ EVENT (VAP/VAE)

TABLE 12-A&B: SUMMARY OF VAP/VAE RATES



VAP Rate per 1,000 ventilator days (CHIA)



73%

VAP Rate per 1,000 ventilator days (self-report)

2010 Average 6.56

July-September 2013 0 100%

Overall VAP Rate n/a n/a 77%



VAP Rate per 1,000 ventilator days (CHIA)

January -June 2010 1.81


70%

VAP Rate per 1,000 ventilator days (self-report)


June-August 2013 0 100%

DATA ANALYSIS AND RESULTS FOR PFP FACILITIES: We calculate the VAP rate use CHIA data and self-report data. Twenty of our PfP eligible facilities have ventilator capabilities and we have 19 PfP eligible facilities in the current time period of our data resulting in a 95% participation rate for this HAC. The VAP rate for the PfP-eligible facilities reporting into CHIA is calculated over a baseline reporting period of the first six months (January-June) of 2010 and the current reporting time period of April-June 2013. For those PfP facilities self-reporting, VAP rate was calculated over a baseline period of the year 2010 and the current reporting period of July-September 2013; this cohort has had no VAPs for 5 months. The overall VAP rate of 77% improvement was calculated by taking a weighted average of the improvement rates from the two PfP-eligible cohorts (self-report and CHIA).

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Figure 33a: VAP rate per 1000 device days over the entire reporting period for PfP eligible facilities reporting in CHIA. In current reporting period, the VAP rate decreased 73% from a baseline rate of 6.04 to a rate of 1.65. (Baseline=16 facilities; Current=16 facilities). The red line is a linear trend line that is fit to the baseline VAP rate and current VAP rate

Figure 33b: VAP rate per 1000 device days over the entire reporting period for self-reporting PfP eligible facilities. In current reporting period, the VAP rate decreased 100% from a baseline rate of 6.56 to a rate of 0.00. (Baseline=3 facilities; Current=3 facilities). The red line is a linear trend line that is fit to the baseline VAP rate and current VAP rate.

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DATA ANALYSIS AND RESULTS FOR NON-PFP FACILITIES: For non-PfP eligible facilities, the VAP rate was calculated for the CHIA cohort over a baseline period of January-June 2010 and the current reporting period of the second quarter 2013 (April-June 2013). We also have 3 non-PfP facilities that self-report a zero VAP rate for two years.

Figure 34: VAP rate per 1000 device days over the entire reporting period for non-PfP eligible facilities reporting in CHIA. In current reporting period, the VAP rate decreased 70% from a baseline rate of 1.81 to a rate of 0.54. (Baseline=7 facilities; Current=5 facilities). The red line is a linear trend line that is fit to the baseline VAP rate and current VAP rate.

Figure 35: VAP rate per 1000 device days over the entire reporting period for non-PfP eligible facilities self-reporting data. The two facilities reporting have maintained a zero rate for 12 months (Baseline=2 facilities; Current=2 facilities). The red line is a linear trend line that is fit to the baseline VAP rate and current VAP rate.

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HARM AVOIDED AND PROJECTED COST SAVINGS: In the current time period, PfP facilities avoided 28 potential VAP related events corresponding to a cost savings of $1,204,000*. We estimate an annual cost savings of $4,816,000 (Table 2). Non-PfP eligible hospitals avoided 4 potential VAP events in this current period with an annual projected savings of $688,000.

* $43,000 per event: Tablan OC, Anderson LJ, Besser R, et al. CDC Healthcare Infection Control Practices Advisory Committee. Guidelines for preventing health care-associated pneumonia, 2003: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004 Mar)

STRATEGIES AND SUCCESSES TO DATE: • 2 PfP facilities achieved level 3 status, 10 PfP facilities achieved level 4 status and 1 PfP facility

achieved level 5 status. • Hospital H achieved a level 5 status due their zero VAP rate over the past 3 years and their

continued commitment to reduce harm that includes actively reducing ventilator days and implementing sedation vacations every morning.

• All of our NHSN facilities are now tracking ventilator associated events (VAE), since VAP reporting is no longer available on NHSN

OPPORTUNITIES FOR IMPROVEMENT: • Obtain permission from facilities to have access to NHSN VAEdata related to IVAC and VAC. We will

continue assessment of facilities for implementation and understanding of new NHSN criteria during Taking Stock visits. When we access the VAE statistics, a new baseline will need to be established for this new criterion. There is a risk that facilities will stop reporting VAE/VAC since the state of Nevada has removed it from their new sentinel event reporting requirement – we will monitor and encourage them to continue.

• Emphasize sedation vacations, ambulation, and other strategies to allow more effective ventilator care.

• Encourage hospitals to incorporate daily rounds to assess and intervene, as needed.

HEN STRATEGIES FOR ADDED SUCCESS: • Share best practices and toolkits for our members to bring back to their facilities to implement. • Share the strategies of our successful hospitals with others to spread best practices. • We share information from pacing event, toolkits, and success stories, via newsletter, monthly call

and plenary sessions. • During “Taking Stock” visits, speak to facilities about their ability to input data to NHSN for VAE.

Our Respiratory Advisory Committee has agreed to network and assist each other during this conversion period – so we will pair hospitals to learn from each other.

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HOSPITAL STRATEGIES FOR ADDED SUCCESS:

• Implement daily rounding to assess ventilator pathway and utilization • Conduct multi-disciplinary rounding (including nursing, respiratory therapists, dieticians,

physicians, etc.) to assess and execute weaning and infection surveillance • Encourage ventilator vacations • Continue to reinforce and validate the use of toolkits and bundles • Continue to implement and educate staff on cutting edge tools and activities to prevent VAP

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VENOUS THROMBOEMBOLISM (VTE)

TABLES 13-A&B: SUMMARY OF VTE RATES

13-A: PfP-Eligible Hospitals Participating in VTE rate: 22/25 (88%) and in VTE rate for surgical units only: 18/18 (100%) Measure Baseline Current % Decrease

VTE Rate per 1,000 discharges in medical and surgical units (CHIA)


April-June 2013 2.64 34%

VTE Rate per 1000 surgical discharges (CHIA)


April-June 2013 4.43 37%

13-B: Non-PfP-Eligible Hospitals Participating: 6/9 (67%) Measure Baseline Current % Decrease

VTE Rate per 1,000 discharges (CHIA)


April-June 2013 10

57%

DATA ANALYSIS AND RESULTS FOR PFP ELIGIBLE FACILITIES: We calculate the VTE rate by querying pulmonary embolisms (PE) and deep vein thrombosis (DVT) from the CHIA database of PfP and non-PfP eligible facilities. The VTE rate for medical and surgical units was calculated using January-June of 2010 as baseline period and April-June 2013 as the current reporting period. The VTE rate for the surgical unit only consisted of 18 PfP eligible facilities that perform on-site surgery. This rate was calculated using the January-June of 2010 as baseline period and April-June 2013 as the current reporting period.

Figure 36: VTE rate per 1000 discharges for PfP eligible facilities. In current reporting period, the VTE rate decreased 34% from a baseline rate of 4.02 to the current rate of 2.64. (Baseline=24 facilities; Current=22 facilities). The red line is a linear trend line that is fit to the baseline VTE rate and current VTE rate.

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Figure 37: VTE Rate per 1000 Surgical Discharge for PfP eligible facilities. In current reporting period, the VTE rate for surgical patients decreased 37% from a baseline rate of 7.04 to the current rate of 4.43. (Baseline=18 facilities; Current=18 facilities). The red line is a linear trend line that is fit to the baseline surgical VTE rate and current surgical VTE rate.

DATA ANALYSIS AND RESULTS FOR NON-PFP ELIGIBLE FACILITIES: VTE rate was calculated over the total number of discharges for non-PfP eligible facilities using data from the CHIA database. In the current time period of Q2 2013, 6 facilities reported data and these facilities showed a 57% decrease in VTE rate compared to baseline period of January-June 2010.

Figure 38: VTE rate per 1000 discharges for non-PfP eligible facilities. In current reporting period, the VTE rate decreased 57% from a baseline rate of 24 to the current rate of 10. (Baseline=7 facilities; Current=6 facilities). The red line is a linear trend line that is fit to the baseline VTE rate and current VTE rate.

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HARM AVOIDED AND PROJECTED COST SAVINGS: In the current time period, PfP facilities avoided harm in 57patients corresponding cost savings of $570,000*. The annual projected cost savings is $2,680,000 (PfP eligible facilities; $2,280,000 and non-PfP facilities; $400,000; Table 2) * Maynard G and Stein J. "Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement." Society of Hospital Medicine, Agency for Healthcare Research and Quality. US Department of Health & Human Services, Web. 5 Dec 2012 http://www.ahrq.gov/qual/vtguide/vtguideapa.htm

STRATEGIES AND SUCCESSES TO DATE: • 8 PfP facilities and 3 non-PfP facilities achieved level 3. Six PfP facilities achieved level 4 status • 34% decrease in VTE rate for medical and surgical discharges from baseline in PfP eligible facilities

(Figure 36) • 37% decrease in VTE rate for surgical discharges from baseline in PfP facilities (Figure 37) • 57% decrease in VTE rate from baseline for non-PfP eligible facilities (Figure 38)

OPPORTUNITIES FOR IMPROVEMENT: • Encourage our facilities to enhance program to achieve benchmark status • Combine efforts to decrease VTE rate with ADE efforts to minimize adverse drug events when

anticoagulants are indicated. • Identifying relationships between VTE and Pressure Ulcer prevention by re-assessing use of TED

hose or other devices

HEN STRATEGIES FOR ADDED SUCCESS: • We shared the VTE AHRQ Tool-Kit with our membership, and will continue bring to their attention

cutting edge tool kits, studies and success stories through our weekly newsletter, 1x1 meetings, monthly NV HEN calls and other education settings.

• We share the strategies of our successful mentor hospitals with others to spread best practices • Provide VTE Risk Stratification guidelines to be incorporated into paper or electronic order sets • Provide additional assistance as needed to facilitate RCA for VTE events to identify causes and

solutions to mitigate future high-harm events. RCA Training was presented in May 2013. • Establish VTE Advisory Committee of appropriate stakeholders to share best practice strategies.

HOSPITAL STRATEGIES FOR ADDED SUCCESS: • Conduct root cause analysis following any VTE incident • Always conduct patient risk assessment on patient intake to guide treatment plan. Use multi-

disciplinary team rounding to re-assess patient on a regular basis. • Use of both pharmaceutical and non-pharmaceutical interventions • Deploy criteria based order sets with electronic medical records (EMR) prompts to increase

adherence.

http://www.ahrq.gov/qual/vtguide/vtguideapa.htm

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• Implementation VTE risk mitigation strategies to all patients (not just surgical patients) • Engage patients and family members in VTE awareness by providing patient education regarding

VTE risks and preventions in verbal and written forms. • Reinforce the use of toolkits, order sets and bundles • Continue to research cutting edge tools and activities and reeducate staff to prevent VTE • Strive towards use of mechanical VTE interventions

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PATIENT AND FAMILY ENGAGEMENT

Patient and Family Engagement Report Method: Self-Report via Taking Stock Interviews

STRATEGIES AND SUCCESSES TO DATE: • In the beginning of 2012, there were NO existing Advisory Committees and now 68% (17 out of

25) of our PfP eligible members are meaningfully engaged in this valuable partnership. o Boulder City Hospital has a Patient & Family Advisory Committee (PFAC) that is

facilitated by the consumers with the goal of discussing quality issues from the customer perspective. This committee is chaired by a community member with hospital representation.

o With the help of the NV HEN, Southern Hills Hospital now has a functional Patient and Family Advisory Committee that meets quarterly. As a committee member, the NV HEN remains closely involved and able to spread best practices across the HEN. This committee’s goal is to involve past patients or family members to discuss “lessons learned” and implement change as needed to address quality issues. Physicians are also actively participating in this group. Several changes influenced by patient comments at these meetings have already been implemented at hospital including changes in signage, visitor hour policies, discipline of staff and other procedure changes. Kim Anderson, CEO, presented his facility’s model to the NV HEN during our September NV HEN call.

o The Valley Health System is in the process of developing PFACs in all 5 of their facilities. They are also implementing the ILLUNINATE call system that sends an automated call to patients post-discharge. This call system is programed to know when to refer the patient for follow-up by a live hospital member. It also records the verbal comments verbatim and may be a good source to screen for potential PFE Advisory members.

o Hospitals T and Hospital G (CAH) are in their planning and membership recruitment phases. o One NV HEN hospital has partnered with NICHE (Nurses Improving Care for Health-

system Elders) in order to move forward on patient-family engagement; o Two hospitals in the Northern part of the state have requested assistance in starting

Advisory committees. They have been provided the AHRQ toolkit and additional resources. o One NV HEN hospital is partnered with PlaneTree which focuses on patient-centered care. o We also met with one of our LTACs that is very small and shares many resource challenges

that the CAHs have. We are working with them to develop an “inventory” of their current (and extensive) patient and family interaction through their pre-admit tours, welcome and patient rights packet, bedside rounding and conferences that involve patient/family, etc.

o At least eight of the hospitals (H, V,2, 6, X, W, M, L, and J)have Leadership who conduct weekly rounds at their facilities that have direct interaction with the patient.

o At six facilities (H, 2, 3, 4, 5 & 6) the clinical staff conducts an interdisciplinary team meeting to discuss patient cases. Patients and their families are invited to attend these sessions and ask questions.

• One of our CAHs and one of our Acute Care Facilities are partnering with the ROYL (Rest of Your Life Planning) to pilot the program in regards to Life Planning and POLST and to help educate patients and engage them in their own care. We are currently piloting this effort with Hospitals K and O before rolling it out to the others. It is also noteworthy that some of the ROYL Q&As about Life Planning are now also available on the Sharecare.com website, endorsed by Dr. Oz and Oprah Winfrey: https://www.sharecare.com/group/the-rest-of-your-life/answers?match=37

https://www.sharecare.com/group/the-rest-of-your-life/answers?match=37

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• The NV HEN sponsored the keynote speaker (Dr. Tim MacDonald) for the Nevada NHA Annual

meeting - See Leadership Engagement for more details. • A patient from one of our network’s established PFACs (Southern Hills Hospital) attended the IHI

Person- and Family-Centered Care: Transforming the Patient Experience Seminar on October 15-16 in Chicago (patient attendance underwritten by Weber-Shandwick). He will be discussing his experience with other patient advisors at various venues; December plenary, PFE Advisory committee, and His sponsoring PHAC.

OPPORTUNITIES FOR IMPROVEMENT: • Work with Risk Managers and Leadership to embrace the value of Patient/Family engagement • Help hospitals interpret HCAHPS (consumer satisfaction) scores as they relate to PFE activities.

Continue to reinforce that this is a monitoring tool and not the basis for the committee topics. • Continue to expand our visibility, interaction and contact base within the community. We have

obtained some resources for outreach directly to patients and are currently pursuing partnerships with them to help advance this goal.

• Directly engage patients in HEN activities and provide information on Patient/Family Engagement • NV HEN will convene a Patent/Family Engagement advisory group (consisting mostly of

representatives from NV HEN facilities) so that as our facilities develop their own PFACs they have a forum to network and share strategies and successes. First meeting is expected November 2013.

• We have started a process with Valley Health System (5 ACH) to profile their receipt of a Human Quality Award from LGBT (Lesbian, Gay, Bi-sexual, Transgender) group. We emphasize their story of barrier removal and sensitivity training in servicing this disparate population’s needs.

HEN STRATEGIES FOR ADDED SUCCESS • Partner mentor hospitals with the others facilities and provide additional 1:1 assistance as needed

to facilitate implementation of PFACs. • Promote the Southern Hills Hospital and Medical Center as a best practice and promote peer

interaction across senior leadership. • Partner with Vidant and Cleveland Clinic to present (at numerous forums throughout the contract

years) about Patient and Family Engagement. Also partner with PlaneTree, NICHE and The ROYL to directly reach the patients and families.

• We share information from Pacing Events, articles and success stories through the monthly calls, weekly newsletter, and educational sessions.

• Brown Bag Event on November 12 –the HEN is the main facilitator of the patient engagement activities – we are sponsoring 2 speakers – Suzanne Brown, RPT from Touro will lead a team of Physical Therapy students to conduct Fall Risk Assessments and talk with Patients and Families regarding fall prevention in the home and community settings. Dr. Philip Lisagor will present lectures on Life Planning strategies and web-based tools to assist with execution and education.

HOSPITAL STRATEGIES FOR ADDED SUCCESS • Mentor hospitals will share strategies for improvement with other hospitals • Incorporate PFE goals and initiatives in strategic planning • Allocate resources to initiate and maintain a PFE program

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• Patient-Family Engagement strategies geared towards preventing falls • Increase transparency of care through bedside huddles and interdisciplinary rounding in the

presence of patients and families to promote engagement. • Enhance patient and family education efforts during the patient’s stay and at time of discharge. • Leadership involvement to commit to and participate in PFE activities • Daily patient rounding by senior leadership, department directors and managers • Clinical rounding by interdisciplinary team at set times to enhance patient and family involvement

and Bedside Huddles to allow patient and family to observe and participate in care decisions. • Research and design strategies to improve service to underserved, disparate populations • Development of Patient and Family Engagement Advisory Committees

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LEADERSHIP ENGAGEMENT

Leadership Engagement Report Method: Self-Report via Taking Stock Interviews

STRATEGIES AND SUCCESSES TO DATE: • 26 PfP facilities achieved level 4 status. • Champion CEO – Kimball Anderson presented the attributes and support of PfP/HEN program and

the value it has brought to his institution to 17 of his peers at an ACHE (American College of Healthcare Executives) local chapter meeting and at a HEN monthly call. A second topic is also being developed for a future meeting.

• We are sharing data with HSAG from almost ⅓ of our PfP eligible hospitals who have achieved “Harm Across The Board” success (level 3, 4 or 5 in 5 or more HACS or 50% of applicable HACs).

• The NV HEN sponsored Dr. Tim MacDonald to speak at the Nevada Hospital Association (NHA) Annual Meeting in Lake Tahoe, NV (September 4 & 5). Attendees were C-Suite and board members from Nevada hospitals. Our goal was to engage leadership and stress the importance of PfP and HEN goals and Patient Family Engagement. During the meeting, our Bright Spots success stories were displayed and Marissa Brown presented an overview of NV HEN accomplishments.

• Sponsored C-Suite individuals to attend the Leadership Lecture by Dr. Reinertsen in San Mateo – attendance was small, but those who went had tangible action plans when they returned – we will arrange an In-State Lecture (same as San Mateo) by coordinating with our ACHE chapters so that we have more attendance and peer-to-peer interaction.

• Invited C-Suite members to participate in Essential Hospitals HEN WebEX Leadership series – led by Dr. Reinertsen.

OPPORTUNITIES FOR IMPROVEMENT: • Having more facilities achieve “Harm Across the Board” success. • Increase attendance of leadership at plenary sessions and webinars. We are trialing the auto-

appointment process to get the events onto their calendars without extra registration effort.

HEN STRATEGIES FOR ADDED SUCCESS: • We will partner the mentor hospitals with the others to share best practices • Provide peer-to-peer education and interaction to inspire investment in patient safety and PFE. • Promote the “Harm Across the Board” achievers as a best practice and promote peer interaction

across senior leadership • Provide additional 1:1 assistance as needed to facilitate improvement of across our network • Share information from Pacing Events, articles and success stories through the monthly calls,

weekly newsletter, and educational sessions. • Leveraging the competitive nature of the market to inspire action • The IHI “WalkRounds “concept was presented at the September HEN call • Inviting leadership to attend WebEX HEN Series by Dr. Reinertsen, sponsored by Essentials HEN.

HOSPITAL STRATEGIES FOR ADDED SUCCESS • Mentor hospitals will share strategies for improvement with other hospitals • Senior Leadership to promote quality vision across organizational levels and be physically present

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LEADERSHIP ENGAGEMENT

to engage front line employees, patients and families • Engage bed-side staff in safety initiatives (e.g. newsletters, Town Hall Meetings). • “Guardian Angel” bedside visits by Senior Staff to discuss care with the patients/family • Pursuit of “Magnet” status or similar affiliation (i.e. PlaneTree; Virginia Mason, NICHE) • Daily patient rounding by senior leadership, department directors and managers

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FORWARD LOOK FOR THE NEXT 30 DAYS

• Convene the first meeting of the NV HEN Patient/Family Engagement Advisory Committee. Solicit for Patient participation through various contact bases. Schedule first meeting in November 2013.

o Assist ROYL with pilot parameters for ACH and CAH models of engagement o Engage one PFE Advisory Board member to attend (or participate via WebEX) the Nov 11,

IOM meeting in Washington, DC • Invite C-Suite members to the Essential WebEX HEN Series by Dr. Reinertsen • Get feedback from our 3 Hospital Leaders who attended the Leadership Conference in San

Mateo on Oct 7. • “Taking Stock “1:1 meetings to stimulate data flow, provide tools, and best-practice in areas in

need of improvement. • Finalize data collection parameters with the CAHs who report to NRHP • Continue our CAUTI-CLABSI Call to Action Campaign

o Focus on more recruitment to CUSP CAUTI ED –lots of barriers and resistance to overcome – identify champions, Dr. Berliner (HEN Medical Director/Champion) to reach out to ED Physicians

• Continue monthly teleconference for participants – focus on providing education, speakers, tools and technical assistance to assist in attaining the goals (October topic – CUSP CAUTI ED; December topic - CLABSI).

• When legislative statute is published, interweave POLST toolkit training to prepare clinicians to discuss end-of-life with patients and family.

• Continue Weekly Nevada HEN Newsletter - expand distribution list to reach as many people as we can (including patients and family that are engaged with our facilities and our HEN) to spread good news of what the HEN is accomplishing, the cost impact and helpful links to best-practices and national PfP news.

• Continue SUSP program and associated NHSN data entry – kick-off for the hospitals enrolled in upcoming cohort 4.

• Access VAE/IVAC data from NHSN, when made available (currently under sequestration) • Determine new cost and lives saved parameters for ADE • Address increasing trend for CLABSI – start with process measurement and daily rounding

assessment. • Access data on joint and coronary artery by-pass graph procedures (current DUA is adequate

– just need to have them confer rights to access that data) • Review the last CPARS Performance Evaluation when available. • Complete the upcoming Performance Self-Evaluation • Complete and submit the final Annual Report by the end of November. • Prepare metrics shift for the new Scoring Guidelines.

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PARTNERSHIPS AND COLLABORATIVES

COLLABORATION WITH OTHER ORGANIZATIONS LIKE, BUT NOT LIMITED TO QIO, STATE HEALTH DEPTS, COMMUNITY CARE TRANSITIONS PROGRAMS & OTHER HENS:

• HealthHIE Nevada (Health Information Exchange) • Northern Nevada Infection Control Committee • NHA Hospital Patient Safety Committee • Adverse Medication Events (Community) • Health Information Exchange • Transitional Care • Nevada Division of Health (NV HAI) • Nevada Hospital Association • Nevada QIO and QA division • Nevada Rural Hospital Partners • Rural Hospital Affinity Group • SpeakerLink – Empowered Patient Coalition • HONOReform NV • AARP • NICHE (Nurses Improving Care for Health-system Elders) • Nevada Geriatric Education Consortium • Touro University evidence-based Falls program • American College of Healthcare Executives (Nevada chapter - ACHE) • University of Nevada School of Medicine (Obstetrics) TeamSTEPPS training, ALSO program Team

Care OB • Roseman College of Pharmacy and Nursing • Greater New York Hospital Association (HAI success) • CDC – Get Smart for HealthCare Campaign • Safe Maternity Care Coalition • Nevada Partnership for Value-Driven Healthcare • Nevada Geriatric Education Consortium • Medication Safety Affinity Group (MSAG) • NV Association of Healthcare-System Pharmacists • University of Nevada Center for Health Information Analysis (CHIA) • POLST (Palliative Care) Initiative • Strong Start • Governor’s Office of Consumer Health Assistance • Office of Minority Health • Patient and Family Advisors and Leaders Network • Nevada Action Coalition • HEN Rural Affinity Group • Project ECHO NV – focused on Rural and CAH education • LiCON (Liability Cooperative of Nevada) • Vidant – Patient Engagement Program • Cleveland Clinic – Office of Patient Experience • American College of HealthCare Executives (ACHE) Nevada Chapter • Southern Nevada Health District • Nevada State Epidemiologist • The ROYL ( Rest of Your Life) Planning

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FINANCIALS AND ATTACHMENTS

FINANCIALS (PER COR REQUEST): TOTAL AWARDED (BASE PERIOD): $2,162,676 EXPENSES: OCTOBER 1-31, 2013: $113,824 BALANCE-TO-DATE: $190,832

ATTACHMENTS** 1. List of Hospitals/Participation Grid

2. NV HEN Measure Reporting Template - Outcome measures

3. NV HEN Measure Reporting Template - Process measures

4. HEN Aggregate dashboard template

5. Table 1: Cost Table

6. Table 2: Summary Table

7. Bob Hallman – Patient Advocate Representative from Southern Hills Hospital - his blog following attendance at the IHI PFE conference (October 2013, Chicago).

** NOTE: due to the size and volume of the attachments, the above attachments will come via two (or more) emails

Disclaimer: “The analyses upon which this publication is based were performed under Contract Number HHSM-500-2012-00016C, entitled, “Hospital Engagement Contractor for Partnership for Patients Initiative.” 10SOW- NV-2013-00-12

Documents

Nevada hospital engagement network - HealthInsighthealthinsight.org/Internal/hen/nvhennovembermonthly... · 2013. 11. 11. · report, National Healthcare Safety Network (NHSN) and