2014 Silver Award Recipient American Hospital Association (AHA)/Health Research & Educational Trust...

2014 Silver Award Recipient

American Hospital Association (AHA)/Health Research & Educational Trust (HRET)

Hospital Engagement Network (HEN) 2.0 Hospital Kick-off

Tuesday, September 29 &Thursday, October 1, 2015

1:00-3:00 PM CT

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WELCOME AND INTRODUCTIONS

Maulik Joshi, Associate Executive Vice President, AHA Clinical Leadership and Health Improvement; President, HRETJessica (Blake) McNab, Director, HRET1:00-1:10 PM

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First Things First

• Congratulations!• We are excited to have the HEN 2.0 contract• We are looking forward to working with you,

your state hospital associations, your patients and their families

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Agenda for Today1:00-1:10 PM Welcome from the AHA/HRET Team Open and provide housekeeping information.

Welcome and overview of the project along with initial thoughts on keys to success in this project.

Jessica McNabDirector, Clinical QualityMaulik JoshiPresident

1:10-1:15 PM Welcome from CMS Welcome hospitals to the HEN 2.0 project. Shelly Coyle

Nurse Consultant, DHHS, CMS

1:15-1:20 PM Keys to HEN 2.0 Success – Additional Areas of Focus Review additional key strategies for success. Ken Anderson

Chief Operating Officer

1:20-1:30 PM Project Scope and Goals Provide background on the HEN project and the goals for 2015-2016 and benefits to participation. Charisse Coulombe

Vice President, Clinical Quality

1:30-1:50 PM Education Opportunities Outline national education offerings at the national level, including meetings, the fellowship and topic-specific webinars. Jessica McNab

1:50-2:05 PM Data Expectations and Support Introduce data expectations and the support that will be provided by HRET to meet the project aims, including the

Comprehensive Data System.Mariana LesherDirector, Data

2:05-2:15 PM Technical Assistance and Targeted Offerings Summarize opportunities for hospital participants to receive targeted support, including office hours, technical assistance

and affinity groups.Sarah Bender &Marissa KumabeProgram Managers

2:15-2:30 PM What’s Next for You Provide details on how to engage, including the Needs Assessment and HEN 2.0 website. Natalie Erb &

Angela MichalekProgram Managers

2:30-2:40 PM Action Items Discuss any next steps and how we will support you in accomplishing them. Charisse Coulombe

Vice President, Clinical Quality

2:40-3:00 PM Q & A and Closing Questions for the HRET team All


Bold Aims

12-month SPRINT to reduce all-cause preventable inpatient harm by 40% and readmissions by 20%

1. Be in action to support your patients and their families by committing to this project

2. Work to reduce harm across the board 3. Learn together by sharing your hospital stories –

successes and opportunities4. Data is the foundation of all improvement at the unit

level, hospital level, state and national level

5


WELCOME FROM CMS

Shelly Coyle, Nurse Consultant and AHA/HRET’s COR, DHHS, CMS 1:10-1:15 PM

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KEYS TO HEN 2.0 SUCCESS

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Ken Anderson, Chief Operating Officer, HRET1:15-1:20 PM


PROJECT SCOPE AND GOALS

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Charisse Coulombe, Vice President, HRET1:20-1:30 PM


HENs: What are they?

Hospital Engagement Networks 2.0

• Improvement collaborative• Best-practice incubator• Community of peers • Learning cohort

• Quality improvement (QI)• Clinical content

• Similar to the original HEN project from 2011-2014 regarding focus and bold aims

• Different regarding standardized measures and accelerated timeframes


PfP HENs for HEN 2.01. AHA/HRET2. Ascension Health3. Carolinas HealthCare System4. Dignity Health5. Healthcare Assoc. of NY State6. Health Research Education Trust of NJ7. Hosp. & Healthsystem Assoc. of PA8. IA Healthcare Collaborative9. LifePoint Health

10. MI Health and Hosp. Assoc. Health Found.11. MN Hosp. Assoc.12. OH Children’s Hosp. Solutions for Pt. Safety13. OH Hospital Assoc.14. Premier Inc.15. TN Hospital Assoc.16. VHA-UHC Alliance NewCo Inc.17. WA State Hosp. Assoc.

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The AHA/HRET HEN Structure

Patients & Families

Hospital Team

State Hospital Association (SHA) Team

AHA/HRET HEN Team


Core Topics – Aim is 40% reduction

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1. Adverse Drug Events (ADE)2. Catheter-associated Urinary Tract Infections (CAUTI)3. Central line-associated Blood Stream Infections (CLABSI)4. Early Elective Deliveries and Obstetrical (OB) Harm5. Injuries from Falls and Immobility6. Pressure Ulcers (PrU)7. Surgical Site Infections (SSI)8. Venous Thromboembolisms (VTE)9. Ventilator Associated Events (VAE)10. Readmissions (20% reduction)


All Other Forms of Harm

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1. Airway Safety2. Clostridium difficile (C. diff)3. Culture of Safety4. Failure to Rescue5. Iatrogenic Delirium6. Radiation Exposure7. Sepsis


Special Topics of Focus

• Patient and Family Engagement (PFE) • Health Care Disparities (HCD)

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AHA/HRET HEN Team

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Our Partners

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1.State hospital associations (SHAs): Hospital support2.Cynosure Health: Clinical education3.Institute for Healthcare (IHI): Quality improvement education

4.University of Michigan (U of M): CAUTI education5.Operations and Logistics 6.Communications, Graphic Design and 508 Compliance7.Continuing education


The Timeline

12/1/2014 - HEN 2.0 Pre-Solic

itation Release

d

12/8/2014 - HEN 1.0 Ends

2/11/2015 - HEN 2.0 RFP Released

3/27/2015 – AHA/HRET HEN 2.0 Proposal S

ubmitted

7/21/2015 – SHA Convening & Questi

ons from CMS Rece

ived

7/31/2015 – AHA/HRET HEN 2.0 Revise

d Proposal Submitted

9/24/2015 – CMS Execu

tes Contra

ct with

AHA/HRET

HEN 2.0

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9/23/2016 – Project End


What We Know• Project Period

– 12 months

• Aim– Reduce all-cause preventable harm by 40%; readmissions

by 20%

• Required Measures for Core Topics– 17 outcome measures

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AHA/HRET HEN 2.0 Overall Plan

• We have not had an opportunity to discuss these details with CMS– These plans are subject to change pending CMS

feedback– We wanted to share the preliminary details to help you

understand the support we plan to provide• As soon as we can, we will provide you and your

SHA with additional details for project components, such as finalized adverse drug event (ADE) measures, etc.

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Stay tuned!


Our Commitment

• To leverage HEN 1.0 successes and learnings• To communicate early and often via our main

communication tool - the HRET HEN 2.0 website• To support you and your state hospital

association in the best way possible to achieve the project goals

• To move as quickly as we can to achieve the 40 / 20 percent reduction in harm!

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EDUCATION OPPORTUNITIES

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Jessica (Blake) McNab, Director, HRET1:30-1:50 PM


Visit Our New Website!


Where to Find Your SHA Details

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Overview of Our HEN 2.0 Plan

Biweekly 90-minute Topic-specific Webinars

Two Annual National Scientific In-person Meetings

Monthly Data Webinars

Bimonthly Rural/CAH Affinity Group Webinars

Foundational HEN Action Leader Fellowship

Experienced HEN Action Leader Fellowship

SHA-led M

eetingsSite Visits

Hospital-level Improvement

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Topic and Data Webinars

• Topic webinars– We have designed shorter, mid-day webinars to help you

incorporate education into your (busy!) schedules and to keep your focus in the unit

• Approximately twice a week • No more than 90 minutes long

– Topics will be prioritized based on our direction from CMS and project data, including a needs assessment (which will be explained in more detail)

• Data webinars – Will cover how you can use project data to inform quality

improvement, including baseline statistics– Approximately once a month

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Fellowship• Foundational HEN Action Leader Fellowship: Track offered for new

HEN participants or those new to quality improvement • Experienced HEN Action Leader Fellowship: Track offered to

experienced HEN participants or those who have been focused on quality improvement and patient safety for more than five years

• Details for each include:– Monthly webinars building on learnings throughout the project– Action Learning Projects (ALPs) that will highlight individual or hospital

progress toward HEN project goals– Opportunity to meet and network with other Fellows at in-person

national scientific meetings– Sharing of ALPs on website upon completion– Certificate of completion upon project submission

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Registration details will be communicated soon!


Hospital Onboarding Checklist


Education This Month

September 29, 1-3 PM CT – Hospital Kickoff WebinarOctober 1, 1-3 PM CT – Hospital Kickoff Webinar (repeat)October 6, 11-12:30 PM CT – Hospital Data Intro WebinarOctober 8, 11-12:30 PM CT – Hospital Data Intro Webinar

(repeat)October 13 & 15, 11-12:30 PM CT – Tentative

Readmissions and CAUTI WebinarsOctober 20 – Tentative Fellowship Kickoff

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√√


Chat Us!

What are you most excited about in HEN 2.0?

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DATA DETAILS

30

Mariana Lesher, Director, HRET1:50-2:05 PM


Measurement Philosophy

• Simple, straightforward, explainable• Capitalize on existing data where possible• Use standardized measures • Be responsive to unique needs

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HEN 2.0 Data Components

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Component Frequency / date dueNeeds assessment Once, upon enrollment, by Nov 16Baseline outcome and process measures data

Once, upon enrollment (timeframe TBD)

Monitoring outcome and process measures data

Monthly, by last day of month following close of month (except readmissions)Start date TBD

Operational items Monthly, by last day of month following close of month


Needs Assessment – by Nov 16

• Basic hospital information• HEN topic prioritization and measurement practices• Quality improvement efforts• Patient and family engagement practices• Leadership and governance activities• Disparities data collection efforts• Cultural competency practices• HEN contacts

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Program Evaluation MeasuresFocus Area CMS Required Evaluation Measure(s)

CAUTI

NHSN1 Reporting Facilities: CAUTI Standardized Infection Ratio (SIR) (NQF 0138) o Intensive Care Unit (ICU) Units, excluding Neonatal Intensive Care Units (NICU)o ICU + Other units

• All Facilities: CAUTI Rates (CAUTIs /1,000 catheter days, CAUTIs / 10,000 pt days) o ICU Units, excluding NICUo ICU + Other inpatient units

All Facilities: Urinary-catheter utilization ratio (catheter days / 10,000 pt days)

CLABSI

NHSN1 Reporting Facilities: CLABSI SIR - (NQF 0139)o ICU Units, including NICUo ICU + Other units

All Facilities: CLABSI Rates (CLABSIs / 1,000 central line days, CLABSIs / 10,000 pt days)o ICU Units, including NICUo ICU + Other inpatient units

All Facilities: Central-line utilization ratio (central line days / patient days)

[1] Hospitals reporting CAUTI, CLABSI, SSI and VAE data may confer rights to their data to the AHA/HRET or another group to meet the measurement requirements for this topic. All other hospitals are expected to follow the NHSN definitions of the measures and will submit numerators and denominators. Rates will be calculated based on numerators and denominators.


Program Evaluation Measures, cont’dFocus Area CMS Required Evaluation Measure(s)

Falls Falls with injury (NQF 0202)

Obstetrical (OB) adverse events

Early elective deliveries (EED) (PC-01, NQF 0469) Vaginal deliveries with instrument (Agency for Healthcare Research &

Quality [AHRQ] PSI 18) Vaginal deliveries without instrument (AHRQ PSI 19)

Pressure ulcers (PrU)

PrU rate, Stages 3+ (AHRQ PSI-03) PrU prevalence (hospital-acquired), Stage 2+ (NQF 0201)

Surgical site infections (SSI)

NHSN1 Reporting Facilities: SSI SIR (NQF 0753)o Colon surgerieso Abdominal hysterectomyo Total hip replacementso Total knee replacements

• All Facilities: SSI Rates (# infections / # surgeries)o Colon surgerieso Abdominal hysterectomyo Total hip replacementso Total knee replacements

[1] Hospitals reporting CAUTI, CLABSI, SSI and VAE data may confer rights to their data to the AHA/HRET or another group to meet the measurement requirements for this topic. All other hospitals are expected to follow the NHSN definitions of the measures and will submit numerators and denominators. Rates will be calculated based on numerators and denominators.


Program Evaluation Measures, cont’d

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VAE Ventilator-Associated Condition (VAC) Infection-Related Ventilator-Associated Complication (IVAC)

VTE Post-Operative pulmonary embolism (PE) or deep vein thrombosis (DVT) rate (AHRQ PSI-12)

Adverse drug events (ADE)

ADEs per 1,000 patient days ADEs due to opioids Excessive anticoagulation with warfarin Hypoglycemia in patients receiving insulin

Readmissions All cause 30-day readmissions

Other outcome and process measures may be added, as well as other topic measures.


Setting Up for Success

Education Encyclopedia of Measures

Data Intro Webinars

Monthly Data

Webinars

Technical Support

[email protected] Office Hours

CDS Platform Enhancements

Data validation Reports

Other Resources

Improvement Calculator

Harm Across the Board

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Comprehensive Data System (CDS)

• Secure, web-based data collection and reporting system for HRET projects

• Will support all hospital-level data submission and reporting for HEN 2.0

• Expanded and enhanced features since HEN 1.0

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Immediate Next Steps for Data

1. Review resources from your SHA / website– Encyclopedia of measures– Needs assessment– CDS Quick Start Guide

2. Join a Data Intro Webinar next week– Tues Oct. 6 and Thurs Oct. 8, 11-12:30 PM CT

3. Return your signed commitment letter for access to CDS

4. Start collecting and submitting data!

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TECHNICAL ASSISTANCE AND TARGETED OFFERINGS

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Sarah Bender, Program Manager, HRETMarissa Kumabe, Program Manager, HRET2:05-2:15 PM


Technical AssistanceDon’t worry! We’re here to help!

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AHA/HRET offers two types of technical assistance:• Shared inboxes• Office hours


AHA/HRET Shared Inboxes

• HEN Inbox ([email protected]): – Available for any technical or national project support

needs. Emails to be reviewed and responded to within two business days.

• HRET Data Support Inbox ([email protected]): – Available for data-specific questions about the project,

including CDS, which will be responded to within two business days.

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mailto:[email protected]



AHA/HRET Office Hours

• Data: – Twice monthly opportunities to speak with the

HRET data team for troubleshooting around data in CDS, reports and any measure specification questions.

• Quality improvement: – Twice monthly opportunities to speak to quality

improvement advisors for troubleshooting around your facility projects and how to overcome barriers.

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Targeted Offerings

• Rural and Critical Access Hospitals (CAH)– Affinity group webinars

• Offerings every other month to address issues that are unique to rural and CAH hospitals

– Customized materials:• Rural/CAH Data Collection Tool• Rural/CAH LISTSERV®• Others, as needed or identified…

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Your SHAs

And obviously, your SHA contacts will be wonderful resources to you as you go through

the project!

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WHAT’S NEXT FOR YOU

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Angela Michalek, Program Manager, HRETNatalie Erb, Program Manager, HRET2:05-2:15 PM


LISTSERV® Update• The HEN 1.0 LISTSERVs® will sunset this week, and the HEN 2.0

LISTSERVs® will launch• Hospital participants will need to sign up through the website

(no one will be automatically subscribed)• Committed hospitals will be subscribed

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http://www.hret-hen.org/inc/dhtml/listserv.dhtml


LISTSERVs®

• Subscriber-based email group• Each email group covers a different topic or

group of topics• Ideal for:

– Peer-shared learnings– Asking questions about barriers– Sharing data-collection opportunities– Clarifications about measures or

inclusion/exclusion criteria

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Site Visits

• Your SHA will contact you to set up a mutually agreeable date and time for them to visit and review the project, data and your organization’s goals

• During site visits:– Complete a site-visit action plan with the SHA

• After site visits:– Your SHA will submit the site-visit action plan into our CDS, where you

will be able to view it and track progress

• We will be using this information to help us report on the quality and quantity of site visits, a crucial part of our HEN 2.0 strategy

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Commitment Letter

Will be filled in for you

Summary of you and your

team's commitment to

achieve the HEN 2.0 project

goals

Summary of CMS required measures for

quick reference


Commitment Letter

Summary of CMS required measures for

quick reference


Commitment Letter

Summary of optional topics

HRET commitments to you and your team

SHA will have their contact information included so you can

have their information as a quick

reference

You and your team to complete and sign and return to your

listed SHA


Commitment Letter Details

• Contact your SHA for a copy of your state’s commitment letter

• Due date is at the discretion of your SHA• Commits to: 1) working on all applicable topics; 2)

submitting data on all applicable topics (and required measures); and 3) collaboration and sharing

• Summarizes CMS requirements• Collects CEO and HEN lead signature and contact

information


Next StepsAssemble your team.

Recruit an executive champion, physician champions, a project lead, data support and multidisciplinary support from across your organization.

Access resources on www.hret-hen.org. Search for resources by topic or type of resource Access SHA information

Register for events. Watch the Upcoming Events page for webinars that are relevant to you.

Celebrate! You are committing to an extraordinary national initiative to improve care.

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http://www.hret-hen.org/

http://www.hret-hen.org/events/index.dhtml#event6


ACTION ITEMS

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Charisse Coulombe, Vice President, HRET2:30-2:40 PM


Re-cap of Action Items Assemble your team and celebrate!

Join a hospital kick-off webinar, data kick-off webinar and other

upcoming events as they are scheduled

Get on HRET-HEN website

Review project and data resources

Submit your Letter of Commitment to your SHA

Complete your Needs Assessment in CDS

Schedule your first SHA site visit

Submit baseline and monitoring data into CDS

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√√


What and Who

• General ?s: [email protected] • Data ?s: [email protected]• Clinical ?s: Topic LISTSERVs®• And, of course – Your SHA




Questions

Questions?

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2014 Silver Award Recipient American Hospital Association (AHA)/Health Research & Educational Trust...

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