Kansas Hospital Engagement Network 2 - · PDF fileKansas Hospital Engagement Network (HEN 2.0)...

Kansas Hospital Engagement Network (HEN 2.0) February 24, 2016

Kansas Healthcare Collaborative 1

Kansas Hospital Engagement Network 2.0

February 24, 2016

623SW10th Ave.● Topeka,KS66409● (785)235‐0763● www.khconline.org

KansasHealthcareCollaborative 2

Agenda

KansasHEN2.0 February24,2016

• Welcome&Announcements

• ConnectingtheProcesstotheOutcome

• Data&MeasuresUpdate

• Resources&UpcomingEvents

• Discussion




PresentersIntroductions

KimWerkmeister,RN,CPHQNationalImprovementAdvisor

[email protected]

MicheleClark,MBA,CPHQ,ABCProgramDirector

[email protected](785)235‐0763x1321

RobRutherford,BASeniorHealthCareDataAnalystKansasHealthcareCollaborativerrutherford@khconline.org(785)235‐0763x1326





ResourcesandEducationalOpportunities

Kansas HEN Sepsis Champion LISTSERV®

KHChaslaunchedanewemailLISTSERVforallKansasSepsisChampions. TheprimarygoalofthisLISTSERVistoprovideparticipantsanengagingcommunitytoseekandshareinformation,practicalstrategies,resourcesandprojectupdatesinsupportofyourcontinuedgrowthinSepsisprevention.

ThisstatewideLISTSERVisco‐moderatedbyhospitalimprovementleadersatWesleyHealthcare: SuzanneFletcher,RN,CMSRN,marketsepsiscoordinator,andBrettHartkopp,RN,BSN,marketdirector,quality,infectionprevention&safety.

Tosubscribe,[email protected]

KansasHealthcareCollaborative

LeanFundamentalsApril12 LeanFundamentals

LeanTeamLeaderTrainingApril13‐14 AdvancedtrainingwithLeantools Leanteammanagementandcoachingskills

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National Caliber Training in Topeka

Lean in Health CareApril 12-14, 2016

LeaninHealthCareTraining

Registrationisnowopenatwww.khconline.orgSpaceislimited.

Allthreedays:$500Orregisterforspecificmodules:Day1$150|Days2‐3$350

RichardTuckerHealthcarePerformancePartners

Gallatin,Tennessee




The Kansas Medical Society is proud to announcethe establishment of its new

KMS Leadership InstituteBydevelopingthisInstituteandprovidingphysiciansasolideducationinstrongleadershipprinciples,webelievephysicianscanbemoreeffectiveintheirprofessionalenvironments,communitiesandotherorganizations.

Theone‐dayexperiencewillbeofferedthreemoretimesin2016attheKansasLeadershipCenter,325E.Douglas,Wichita.

Costis$300perattendee.

March11● June17● September16

TheKMSLeadershipInstituteone‐dayexperiencewillprovidephysicians: Anintroductiontotestedleadershipbehaviors Skillstoeffectivelymanagechange Anopportunitytoapplyprovenleadershipconceptsspecifictohealthcare Post‐programresourcesforongoinglearning

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Registration:www.KMSonline.org/events

Resources


Patient Safety Immersion InitiativeAnnouncingtheKansasHENAwards:

NPSFImmersionInitiative

1. JessicaBuchholz,RNQualityDirector/InfectionPrevention/EmployeeHealth

TregoCountyLemkeMemorialHospital

2. KesaEaster,MBAPatientandFamilyEngagementCoordinator,Quality&AnalyticsDepartment

NewtonMedicalCenter

3. Tereasa DeMeritt,RN,MSN,APRN,NPcDirectorofQualityLabetteHealth

4. NikiGriffith,RN,BSNQualityCoordinator/PatientSafetyOfficerPrattRegionalMedicalCenter

5. BrettHartkopp,BSN,RNMarketDirectorQuality,InfectionPreventionandSafety

WesleyMedicalCenter

6. GreggHolt,RNManagerMed/Surg/OPS,QualityCoordinatorMercy Hospital – Columbus

7. SarahHoy,RN,BSNDirectorofQualityImprovement/RiskManagement,ComplianceOfficer

CoffeyvilleRegionalMedicalCenter

8. ReneeJanssen,RN,BSN,CPHRMDirector,RiskManagementProvidenceMedicalCenter/SaintJohnHospital

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Patient Safety Immersion Initiative Components Community

One‐yearmembershipinAmericanSocietyofProfessionalsinPatientSafety

Education NPSFOnlinePatientSafetyCurriculum NPSFOnlineCPPSReviewCourse

ProfessionalAdvancement– CertificationforProfessionalsinPatientSafety(CPPS) PracticeTest CPPSCredentialingExamination

NPSFImmersionInitiative

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• HyattinWichitaFriday,May6th▫ BreakoutSessions▫ PosterPresentations• LeadershipinQualityAwards▫ SubmissiondeadlineMarch11th▫ Healthcareprovidersandhealthcareorganizationstorecognizeleadershipandinnovationinqualityimprovementandpatientsafety

▫ Kansashealthcareprovidersandorganizationsareeligible▫ Cashawardof$5,000sponsoredbytheKaMMCOFoundationforgrandprize

▫ Meritawardwinnerswillreceiverecognition▫ SixareastodiscussinSurveyMonkey formathttps://www.surveymonkey.com/r/KHCLEADERINQUALITY

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Summit on Quality – May 6th

SummitonQuality




AHA/HRET HEN Change Packages

NewResource

KANSASHEALTHCARECOLLABORATIVE

Accessallchangepackagesand“Top10”checklistsat:www.hret‐hen.org/topics/

C.Difficilewww.hret-hen.org/topics/cdi/HRETHEN_ChangePackage_CDI.pdf

• Up‐to‐dateharmdefinitionandresources• Relevantupdatesinbestpracticesandchangeideas• Aneasy‐to‐use,streamlinedstructure• Informationonhowtousethedriverdiagrams

NEW UPDATE!

Otherupdates:● SevereSepsisandSepticShock

● FallswithInjury● PressureUlcers

● PreventableReadmissions

● AirwaySafety● CLABSI


TherevisedversionoftheImprovementCalculatorenableshospitalstotracka“totalharm”rateinpursuitofSafetyAcrosstheBoard.

Nextsteps:• EnsureyourHENdataiscurrentinQHi andNHSN.• Pre‐registerforMarch1HRETHENwebinar,“HarmAcrosstheBoard”atwww.hret‐hen.org.• ContactRobRutherfordatKHCfordatafile([email protected]).

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HEN 2.0 Improvement Calculator

NewResource

NEW RELEASE




Connectingthe Processto the Outcome

KimWerkmeister,RN,CPHQNationalImprovementAdvisor

[email protected]

ProcessImprovement


Connection Between Process and Outcome

Process–TechniqueorStrategy

Performance–SpecificStandard

Outcome–EndResult

ProcessImprovement




Initial stages of improvement:

• Focusisonrapidimprovementofanewprocess

• Processmaybemodifiedmultipletimesinashortperiodoftimetoachievesuccess

• Focusontheabilitytoperformthenewprocesseffectivelywithintheconstraintsoftheorganization

• Focusonhowtoimplementglobalevidence‐basedrecommendationsinthelocalsetting

ProcessImprovement


On-going Improvement Work

• Firstfocus– outcomesdata(Areweavoidingcatastrophicevents?)

• Secondaryfocus– completenessorcomplianceincarryingoutstepsintheprocess

ProcessImprovement




On-going Reliability Work

• Firstfocusstillonoutcomesdata,butnewshiftforprocessmeasures

• Focusnowonhowreliablythenewprocessisbeingcarriedout(Areweexceptionallyconsistent?)

ProcessImprovement


Example – Reducing Falls with Injury

DriverDiagram

Aim

PrimaryDriver

SecondaryDriver ChangeIdeas


PrimaryDriver


ProcessImprovement




Example – Reducing Falls Driver Diagram

AIM:Reducerateoffallswithinjury

PrimaryDriver#1:Assessriskforfallingandinjury

SecondaryDriver#1:Implementstandardizedrisk‐driveninterventions

ProcessMeasureforDriver#1:Percentageofpatientswhohaveariskassessmentcompleted

ProcessImprovement


But what if your outcomes data does not improve?

Theprocessmeasuresholdthekeytotellingyou:• Ifitisbeingperformedreliablyforeverypatient

• Ifitisbeingperformedaccuratelyforeverypatient

• Iftheinterventionsareeffectiveforthepatientpopulation

ProcessImprovement




Connection between High Reliability and Outcomes

Highreliabilityorganizationsareorganizationswithsystemsinplacethatmakethemexceptionallyconsistentinaccomplishingtheirgoalsandavoidingpotentiallycatastrophicerrors

ProcessImprovement


“Exceptionally consistent”

• Musthaveaprocessinplacetomeasure“exceptionalconsistency”

• Thedifferencebetween“yeswedothatforourpatients”and“yeswedothatreliablyfortherightpatientsattherighttimes”

ProcessImprovement




How can we do this with our current process measures?

• Readmissions/ADE/VTE– Processmeasure:dischargeinstructionsanddischargeteaching

• C.diffandotherinfections– Processmeasure:handhygienecompliance

ProcessImprovement


Discharge Instructions / Discharge Teaching:

AIM:Reductionofavoidablereadmissions/reductionofadversedrugeventsrelatedtowarfarin/reductionofhospitalacquiredvenousthromboembolism(VTE)

Primarydriver:Patientandfamilyengagementintheirowncare

Secondarydriver:Providethepatientwitheducationrelatedtoanticoagulationmedication– THISISTHEPROCESSMEASURE

ProcessImprovement




Measuring for Improvement:

• ForReadmissionprevention– auditepisodesofteachbackdocumentedinthemedicalrecord

• ForADE/VTEprevention– auditdocumentationinthemedicalrecordthatdischargeinstructionsincludedspecificdetailsaboutanticoagulationmedication

• Continuemonitoringoveralloutcomesdata

ProcessImprovement


Measuring for Reliability and Effectiveness:

ForReadmissionsprevention• Interviewpatientswhoarereadmitted.Askspecificquestionsaboutdifficultieswithdischargemedications.Probetofindoutmoreaboutthepatient’sunderstandingofthedischargeinstructionsvs.theabilitytofulfillthedischargeinstructions• Conductsomedischargeteachingatshiftchangesoboththeoff‐goingandoncomingbedsidenursecanassesstheeffectivenessofteachback

ProcessImprovement




Higher Reliability Methods:

Taketheprocessastepfurther:• Useassessmenttoolstoassesspatient’shealthliteracypriortodischargeteachingandplanteachingaccordingtoassessment

ProcessImprovement


Hand Hygiene Compliance

AIM:Reductionofc.diffrates(orotherhospitalacquiredinfections)

Primarydriver:Provideadequatemeasurestoeliminateinfectiousorganisms

Secondarydriver:Providehandhygieneinbetweeneverypatientencounter‐ THISISTHEPROCESSMEASURE

ProcessImprovement




Measuring for Improvement:

• Rateofadequatehandhygieneepisodesobservedinamonth

• Continuemonitoringoutcomesdata

ProcessImprovement


Measuring for Reliability and Effectiveness

• Auditnotonlyifhandhygienedone,butifsoapandwater– howlong?

• Accessibilityofhandhygieneareas

• Availabilityofproduct

ProcessImprovement




How can we possibly complete all these process measures???

• Auditsaredonebythosewho“own”theprocess

• Disseminatedmodelofquality=QualityDepartmentisthecoach,notthewholeteam

ProcessImprovement


Contact:KimWerkmeister

NationalImprovementAdvisorCynosureHealth

[email protected]

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Thank you for what you are doing to keep patients safe!

ProcessImprovement




Measures & Data Update

RobRutherfordSeniorHealthCareDataAnalystKansasHealthcareCollaborativerrutherford@khconline.org

785‐231‐1326


Program Updates

Measures&DataUpdate

● KansasHENMeasuresDictionaryupdatedo ConsolidatesfallriskassessmentprocessmeasuretotheoriginaloneinplacesinceHEN1.0

o ChangesOBpreeclampsiaandhemorrhagemeasurestoalignwithrevisedCMQCCspecifications(allbirths,notjustbirths >20weeks)

● NewmeasuresavailableinQHi● Improvementcalculator/HABreleased● CAH/RuralDataCollectionToolreleased(notecaveats)● Feb29th – SurveyonPFE,CultureofSafety/WorkerSafety,andFailuretoRescue

● March9th – Final“lock‐in”dateforbaselinesubmission.




HRET HEN 2.0 MilestonesMilestone1:(Nov2,2015)● HospitalCommitments

Milestone2:(Feb8,2016)● Hospitalsitevisits● Baselinedata

Milestone3:(Mar31,2016)● MonitoringdataforalltopicsfortheperiodofOct1,2015throughFeb29,2016

Milestone4:(Aug31,2016)● Monitoringdata,andhospitalsreachingHEN2.0goalsforatleast5topics

Measures&DataUpdate


Milestone 2: Baseline SubmissionCore Topics

KansasHEN2.0Baselinesubmissionrate

ADE 96%CAUTI 97%CLABSI 97%EED 100%

OBharm 100% EED,62%pre‐eclampsiaFallswithInjury 94%

PrU 90%*SSI

(Colo,AbHyst,KPRO, HPRO)87%

VAE 92%Readmissions 99%

AllremainingbaselinedatamustbesubmittedbeforeMarch9“lockin.”

Measures&DataUpdate




HEN SustainabilityComparison of end of 2014 to new HEN 2.0 baseline

HarmtopicRate

EndofHEN1.0Rate

StartofHEN2.0

CLABSI 0.4 0.5EED 4.4 4.8

SSI– COLO 5.0 6.0

SSI– HYST 1.4 1.2

Readmissions 7.0 7.8

• Fairlystablewithlargenumberofadditionalhospitalsreporting.

Measures&DataUpdate


Looking forward: Milestone 3● March:

o UpdateKansasHENdashboardreportstoreflectmonitoringdatasubmissionprogress• (FebruarydatadueMarch31.)

o Addnewmeasurestoreports

● UpNext:o Create/updatenewanalyticreportstoreflectimprovementprogress

Measures&DataUpdate




Milestone 3:Monitoring Data Submission

Core TopicsKansasHEN2.0

Monitoringsubmissionrate(todate)

ADE 73%CAUTI 75%CLABSI 74%EED 64%

OBharm 52%FallswithInjury 67%

PrU 59%SSI

(Colo,AbHyst,KPRO, HPRO)54%

VAE 53%Readmissions 69%

Measures&DataUpdate


UpdatedDataFlow

ComprehensiveDataSystem(CDS)

NHSN

QHi

ADECAUTICLABSIFallsHAPUEED

ReadmitsSSIVTEC.diff.

Addl.TopicsProcessesH

CAUTI*CLABSI*SSI*VAEC.diff.

DataEntryDataTransfer(byKHC)ReportbacktoHospital

*NHSNPreferred

KHC

ProgramEvaluation

• DataAnalysisTools&Templates• ComparativeReports• AggregateComparisons• ProgressTowardGoals

KSSIDAHRQPSIMeasures

SurveyMonkeyGapAnalysisResponseTeams




DataSystems

ADE CAUTI CLABSI Falls OB

PrU Readmits SSI VTE

C.difficile Sepsis FailuretoRescue CultureofSafety ProcessMeasures

WhatifIneedhelp?(Passwords,addingusers,measureselection,reports,etc.)

StuartMooreQHiProgramManager

785‐276‐3104Smoore@kha‐net.org

SallyOthmerSr.DirectorofDataServicesandQuality

785‐276‐3118Sothmer@kha‐net.org


DataSystems

NHSN

CAUTI CLABSI

SSI VAE

C.diff.

WhatifIneedhelp? RobertGeistKDHEHealth.Assoc.InfectionsProgram

785‐296‐[email protected]

NHSNtechnologysupport:[email protected]

TheCDChasextensivetrainingdocumentsandvideoshere:http://www.cdc.gov/nhsn/training/index.html




DataSystems

State Inpatient Discharge Database

SID/AHRQ OBTraumaw/Instrument OBTraumawo/Instrument Stage3+PressureUlcers Post‐OpPE/DVT

Post‐Opsepsisrate FtR Deathfromserioustreatablecomplicationsamongsurgicalinpatients

CurrentlycalculatedbyKHCfromKHA’sInpatientDischarges

DataentryintoQHiisOPTIONAL(Midas)

Measuredetails(DRGs,ICDcodesetc.)maybefoundhere:www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec_ICD10.aspx


Kansas HEN 2015-2016Data Submission Schedule

Outcome&ProcessMeasuresforHACsoccurringin:

Readmissions forindexdischargesin,andSSIforproceduresperformedin: SubmissionDue

October,2015 September,2015 November 30,2015

November,2015 October,2015 December31,2015

December,2015 November,2015 January31,2016

January, 2016 December, 2015 February29, 2016

February,2016 January,2016 March30,2016

March,2016 February,2016 April30,2016

April,2016 March,2016 May31,2016

May,2016 April,2016 June30,2016

June,2016 May,2016 July31,2016

July,2016 June,2016 August31,2016

August,2016 July,2016 September30,2016

DataandMeasuresUpdate




Resources & Upcoming Events

MicheleClarkProgramDirector

[email protected]

785‐231‐1321


“Applyingthe2016ChangestoAccuratelyReportHAIs”February29throughMarch4,2016

Seetheagenda andinstructionsonhowtoviewthe webstreamat:www.cdc.gov/nhsn/training/2016training.html

▫ HostedbyNHSN.

▫ Noregistrationrequired.

*SessionswillberecordedandarchivedontheNHSNwebsiteforfutureviewingatalaterdate.

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NHSN Training: Live Webstream

NHSNEnrollment





HRET HEN LISTSERV®

Topics:

AdverseDrugEvent(ADE) DataInformatics Infections– includesCAUTI,CDI,CLABSI,SSIandVAE EarlyElectiveDeliveryandObstetricalAdverseEvent Patient&FamilyEngagement/HealthCareDisparities PressureUlcers&Falls Readmissions Rural/CriticalAccessHospitals Sepsis

Subscribeatwww.hret‐hen.org/inc/dhtml/listserv.dhtml


HospitalEngagementNetwork(HEN2.0)

HRET HEN 2.0Action Leader FellowshipLead by Institute for Healthcare Improvement

March9 April13Datestobeannounced:May,June,July,August

September:Showcaseandsharingofimprovementprojects

Twotracks:Foundational Experienced

11:00a.m.to12:00pm 12:30to1:30p.m.

Registeratwww.hret‐hen.org/events/.NextQIOfficeHours:

March2,11amto12pm





Curriculum ScheduleAHA/HRET Action Leader Fellowship

FoundationalFellowship ExperiencedFellowship

March9 Partnerwithpatientsandproviders

DevelopandCultivateTeamwork:Leveragecontributionsfromptsandfamilies,whileengagingfront‐line staff

April13 Practiceimprovementessentials

Manage theMeso‐system

May Guidefrontlinestaffindevelopingideasforchange

Usecoachingskillstogetresults

June Createstructuresthatsustainimprovement

Createsupportivestructuresthatsustainimprovement

July Spreadsuccessfulimprovement Developsoundspreadplansthatgetresults

August Expandondata:QualitativeandQuantitative

Expand ondata:Qualitativeandquantitative

September Showcasingandsharingofimprovementprojects


Thursday,February25• 11to12:30p.m.CTOB:“Notimetowait!Earlyrecognitionandtreatmentofseverepreeclampsia”Pre‐registerathttps://hret.adobeconnect.com/obharm/event/registration.html

• 2to4p.m.CTSSI:“ImprovingSurgicalSafety:StrategiesforIdentifyingandAddressingHarm”Pre‐registerathttps://secure.confertel.net/tsRegister.asp?course=6860818

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Featured national webinars

EducationalOpportunities




Thursday,March3 11:00to12:30p.m.CTVAE:Ventilator‐AssociatedEventsWebinarPre‐registerat:https://events‐na12.adobeconnect.com/content/connect/c1/1309328635/en/events/event/private/1428030449/1431616098/event_registration.html?sco‐id=1463995480&_charset_=utf‐8

Monday,March7 11:00to12:30p.m.CTRural/CAHAffinityGroupWebinar:HighRisk/LowVolume:ATickingTimeBomb?Pre‐registerat:https://hret.adobeconnect.com/ruralcahaffinitygroupwebinar/event/registration.html

Wednesday,March9 12:00to1:00p.m.CTTeamSTEPPS® toImprovePatientTransfersfromtheORtotheICUPre‐registerat:https://www.onlineregistrationcenter.com/register.asp?m=347&c=220&usc=march

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Featured national webinars



CLABSI“NailingCLABSIPrevention!”(Feb.18webinar)www.hret‐hen.org/resources/display/hen‐20‐clabsi‐webinar‐nailing‐clabsi‐prevention

SSI“SurgicalSiteInfectionRiskReduction”(Feb.9webinar)www.hret‐hen.org/resources/display/surgical‐site‐infection‐ssi‐risk‐reduction

CultureofSafety/WorkerSafety(Jan.29webinar)www.hret‐hen.org/resources/display/hen‐20‐culture‐of‐safety‐webinar

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New resources in HRET HEN education archives


https://events-na12.adobeconnect.com/content/connect/c1/1309328635/en/events/�event/private/1428030449/1431616098/event_registration.html?sco-id=1463995480&_charset_=utf-8




PatientandFamilyEngagement

TheAmericanInstitutesforResearch(AIR)haspublishedaStrategicVisionRoadmapforPFE.

Hospitalscanusethisdocumentto:• PromoteasharedunderstandingofPFE,

• LearnhowtomoreeffectivelyimplementactivitiesassociatedwiththefivePFEmetrics,

• Identifycross‐cuttingkeystosuccessfulPFEimplementation,

• Identifyresourcesthatcorrespondtobestpractices,and

• Improvesustainability.

www.hret‐hen.org/topics/pfe/FINALPFEStratVisionRoadmap.pdf


• AllHEN2.0dataarecurrent(throughFebruary)byMarch31,2016.

PleasehelpuscollectivelymeetthistargetonourwaytoachievingHEN2.0goals.

KansasHEN2.0hospitaldataanalyticreports willbeProducedforyoufollowingthismilestone.

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Our Next HEN 2.0 Milestone (#3)

KansasHEN2.0




Thanks for all your hard work!

DataandMeasures

Questions?

Discussionitems?


YourKHCTeam 785‐235‐0763

RosanneRutkowskiProgramDirector

[email protected]

MicheleClarkProgramDirector

[email protected]

KendraTinsleyExecutiveDirector

[email protected]

EricCook‐WiensDataand

[email protected]

MaryMonasmithQualityImprovement

[email protected]

KarlenHauryQualityImprovement

[email protected]

RobRutherfordSeniorHealthCare

[email protected]

[email protected]

SusanRunyanProgramDirector

[email protected]

RhondaLassiterExecutiveAssistant

[email protected]

JonathanSmithQualityImprovement

[email protected]

JoshMosierQualityImprovement

[email protected]

[email protected]

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