Montana Regional MeetingGlendive Medical Center
AHA/HRET Hospital Engagement Network
Charisse Coulombe, MS, MBA, CPHQ; Senior Director, HENHospital Engagement Network
Health Research & Educational TrustAmerican Hospital Association
Hospital Leadership
Clinicians & Front Line Staff (Teams)
THE PATIENT
• ACA considerable focus on quality• Created the CMS Innovation Center • Public-private partnership
• Set 40/20 goal• Tool: Hospital
Engagement Networks• 26 contracts awarded
• Contracted with 31 state and regional hospital associations
• 1,600 + hospitals
Hospital Engagement Network
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Partnership for Patients
The 40/20 Goal
• Keep patients from getting injured or sickerReduce preventable hospital-acquired conditions by 40 percent 1.8 million fewer injuries to patients, with more than 60,000 lives
saved over the next three years
• Help patients heal without complication Reduce all hospital readmissions by 20 percent 1.6 million patients will recover from illness without suffering a
preventable complication requiringre-hospitalization within 30 days of discharge
Progress to DateEEDs/OB Adverse Events• 36%: Average percent reduction in EED > =37 weeks and <39 weeks for 612 hospitals (68%)• 2,673 EEDs prevented (all hospitals)• $1.9 m Estimated cost savings for avoided EED NICU admissions (all hospitals)• Also tracking hard stop policies implemented across all birthing hospitals
CAUTIs• 9%: Average CAUTI percent reduction in all tracked units for 985 hospitals • 359 CAUTIs prevented (all hospitals)• $269,000 Estimated cost savings for avoided CAUTIs
CLABSIs• 11%: Average CLABSI percent reduction in all tracked units for 823 hospitals • 308 CLABSIs prevented (all hospitals)• $5.8M Estimated cost savings for avoided CLABSIs
Progress to DateADEs and Falls• Focus area for all HENs and all of the states within our HEN• Participate in the Boot Camps!
PRESSURE ULCERS• 2.52 Percent reduction in patients with at least one Stage II or greater
pressure ulcer for 399 hospitals• 8.18 Percent reduction in CMS HAC Pressure Ulcers for 367 hospitals• Need more data submission from our hospitals!• 34 Stage III/IV Pressure Ulcers prevented (all hospitals)• $1.4M Estimated cost savings for avoided Stage III/IV Pressure Ulcers
SSIs• <0.81% Average surgical site infection rate (in hospital) for 808 hospitals • <1.26% Average SSI rate (within 30 days of procedure) for 752 hospitals
Progress to DateVTEs• 0.57 Average percent reduction in Post-op PE/ DVT (AHRQ PSI 12) rate
for 360 hospitals• 12.7 Average percent reduction in Potentially Preventable VTE for 330
hospitalsVAPs• 21 Average percent reduction in ventilator-associated pneumonia rate in
ICU for 486 hospitals• 152 ICU VAPs prevented (all hospitals)• $6.5m Estimated projected cost savings for avoided ICU VAPs (all
hospitals)READMISSIONS• 1.8 Average percent reduction for 30 day all cause readmission rate
for 829 hospitals • 2.7 Average percent reduction for Heart Failure 30 day all cause
readmission rate for 258 hospitals
Montana Summary TableTopic Most Popular
Outcome Measure
Avg # Hospitals Reporting
Total Eligible Hospitals
Percent Reporting
Baseline Last 3 monitoring months
Percent Reduction
ADE Med Errors Req Pharma Intervention
8 26 31% 1.82 0.78 57%
CAUTI Pts Treated with Abx for UTIs
7 26 27% 0 0 None
CLABSI CLABSI Infection Rate
7 13 54% 0 0 None
EED TJC EED 4 13 31% 8.42 3.57 57%
OB C-section Delivery Rate
7 13 45% 31.87 35.19 N/A
Falls Falls after admission
9 26 35% 1.97 1.39 29%
Pressure Ulcer
Decubitus Ulcer 9 26 35% 0 0 None
Montana Summary TableTopic Measure Avg #
Hospitals Reporting
Total Eligible Hospitals
Percent Reporting
Baseline Q4 2012 or last 3 monitoring months
Percent Reduction
Readmission Readmission with same dx
21 26 81% 3.73 3.96 N/A
SSI SSI Rate (in hospital)
8 13 62% 1.23 0.67 45%
VAP *
VTE Post Op PE/DVT
8 26 31% 1.53 3.55 N/A
* Not enough monitoring data submitted to evaluate
What Data is Needed and How Much?
• CMS’ focus is on outcome measures to track progress of the HENs
• In order to be included in the HEN/state level analysis, need to submit at least 4 data points
• Baseline and Monitoring periods are compared
• Baseline is defined as pre-2012; if you started collecting data after January 2012, we need that data!
• We will review your first month submitted and use as baseline reference to track your progress
Data Tools for Hospitals to Review Progress
• Hospital Dashboard – Data Submission Status– Individual Measure Data– Run Charts
• Hospital CEO Dashboard– Summary of the Hospital Dashboard
• Both located under Reports in the Comprehensive Data System (CDS)
Intervention Tools Available
• www.hret-hen.org has many resources• Topic specific change packages• Topic specific checklists• Reference articles• Previous recordings of webinars and meetings• Leadership, physician, patient/family
engagement resources
Next Steps
• Continue to work towards 40 percent harm reduction and 20 percent readmission reduction
• Continue to submit data on your measures• Continue to track your progress on all topics
through the progress reports • Continue to share your ideas and tools with
others on the LISTSERVs• Continue to share your success stories with us,
your states and your fellow hospitals
Thank You!
• AHA/HRET HEN is proud of the accomplishments that have occurred to date and continue to look forward to accelerating the improvement across all topics!
• We are here to support you in any way possible– General Email: [email protected]– Data Specific Questions: [email protected] – Check in with Casey Brewington!
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